Related APHA Policy Statements
APHA Policy Statement 2004-08 – Correctional Health Care Standards and Accreditation
APHA Policy Statement 9123 – Social Practice of Mass Imprisonment
APHA Policy Statement 200029 – The Need for Mental Health and Substance Abuse Services for the Incarcerated Mentally Ill.
Thousands of prisoners and detainees in the United States are housed in conditions designed to maximize social isolation and sensory deprivation, often for years at a time. Such housing, commonly referred to as segregation, “supermax housing,” or solitary confinement, can cause significant mental suffering. In some cases, prisoners are punished with solitary confinement for behavior that is a product of serious mental illness. Such isolation creates barriers to providing necessary medical and mental health care, creating substantial risks that health will deteriorate. Multiple professional organizations and human rights bodies have taken positions supporting the restriction or abolition of solitary confinement. Patients whose medical or mental health conditions contraindicate placement in segregation should be categorically excluded from solitary confinement, as should juveniles. Correctional authorities should implement policies that eliminate solitary confinement for security purposes unless no other less restrictive option is available to manage a current, serious, and ongoing threat to the safety of others. Punitive segregation should be eliminated. Isolation for clinical or therapeutic purposes should be allowed only upon the order of a health care professional and for the shortest duration and under the least restrictive conditions possible. Prisoners who are separated from the general population for their own protection should be housed in the least restrictive conditions possible.
Housing prisoners (as used herein, “prisoners” includes incarcerated individuals who have been sentenced or who are in detention awaiting trial) in solitary confinement has become commonplace in correctional facilities in the United Sates. Many prisoners, including juveniles, in segregation housing units are locked alone in cells with minimal social interaction for 22 or more hours per day. Cells are designed to minimize human contact and environmental simulation and may have little, if any, natural light. Prisoners may be subjected to constant artificial illumination, punitively unpalatable diets, little personal property, and denial of opportunities to communicate with other human beings. Out-of-cell exercise, when provided, usually occurs in small individual rooms or cages. Most interaction with correctional staff occurs through bars or through lockable slots in solid metal doors. Prisoners may be kept in these conditions for years at a time with little opportunity to earn their way back into the general prison population. Some prisoners will remain in these conditions until their death sentences are carried out.2,3
Although total population data are difficult to obtain because of variations in nomenclature and conditions of confinement across jurisdictions, an estimated 20,000 to 25,000 prisoners are held in the harshest levels of solitary confinement.4,5 More than 80,000 are housed in restricted population units.6 A few jurisdictions have provided data on segregation stratified by race and national origin. In Kentucky, as of October 2012,African Americans accounted for 26.2% of the state’s 1,388 prisoners held in segregation; Whites accounted for 70.1% (written communication from the Kentucky Department of Corrections, October 11, 2012). Data from Minnesota show that African American, White, and American Indian prisoners account for 40.3%, 40.1%, and 17.8% of the population in isolated confinement, respectively (written communication from the Minnesota Department of Corrections, November 5, 2012). Additional impact on minorities is suggested by nationwide rates of incarceration according to race and ethnicity. As of December 31, 2011, the rate of imprisonment among African American males was 3,023 per 100,000 population, as compared with 1,238 per 100,000 population among Hispanic males and 478 per 100,000 population among White males.7
In some jurisdictions, juveniles may be held in solitary confinement for weeks or even months at a time. In addition to the harms associated with adults held in solitary confinement, juveniles may be denied educational opportunities or contact with their families, and they may suffer the onset of specific mental illnesses that first develop during late adolescence.8 The placement of juveniles in solitary confinement for disciplinary reasons is particularly problematic. Recent research suggests that the brain continues to develop into young adulthood and that adolescent risk-taking behaviors and lack of self-regulation may be a function of neurobiological factors.9,10 Such research may, in turn, inform the relative culpability of juvenile offenders. Indeed, courts in the United States have considered this diminished culpability in determining that the death penalty and certain adult sentencing schemes are inappropriate for juveniles.11
Prisoners are placed in solitary confinement for a variety of reasons. Some prisoners are sentenced to finite periods of solitary confinement as punishment for disciplinary infractions. Others may be confined indefinitely owing to their status as alleged gang members or threats to institutional security. Some prisoners are isolated for their own personal security or for clinical or therapeutic purposes, including observation of self-injurious behavior and airborne precautions.12
Prisoners in long-term solitary confinement are subject to significant mental suffering and deterioration. They may develop anxiety, panic attacks, paranoia, cognitive impairment, social withdrawal, somatic symptoms, hypersensitivity to external stimuli, and perceptual disturbances.2,13–16 Long-term solitary confinement raises particular concerns for prisoners with serious mental disorders. Unable to abide by institutional rules, seriously mentally ill prisoners may be placed in segregation as punishment for behavior that is a product of their illness.17–19 Once they are placed in solitary confinement, some prisoners may deteriorate and experience an exacerbation of symptoms.13,20
Placement in solitary confinement may create barriers to accessing necessary medical and mental health care.2,21,22 Many systems require that prisoners in solitary confinement be escorted in restraints by 2 or more officers. This requirement often results in clinical encounters occurring at cellside through bars or through openings in solid metal doors. Consequences of this practice include limited privacy, impediments to physically assessing and communicating with patients, and hindrance of the therapeutic alliance. Security restrictions may result in prisoners being denied access to inpatient psychiatric treatment and modalities such as group therapy. Physical isolation from other prisoners and staff may result in life-threatening medical or psychiatric emergencies going undetected. Also, inactivity and lack of ready access to emergency medications may endanger prisoners with certain chronic conditions.23
Professional organizations can play a critical role in advocating against the overuse of solitary confinement and in support of its reform.24 In 2010, the American Bar Association published standards recommending that long-term isolated confinement for disciplinary or security purposes be significantly limited and that meaningful procedural and health safeguards be implemented.25 In 2012, the American Psychiatric Association issued a position statement that “[p]rolonged segregation of adult inmates with serious mental illness, with rare exceptions, should be avoided due to the potential harm to such inmates.”26 Similarly, the American Academy of Child and Adolescent Psychiatry opposes solitary confinement for juveniles.27
In recent years, use of solitary confinement has garnered significant attention from international human rights organizations and advocates.28–30 The Council of Europe proposes minimizing the use of solitary confinement and requiring significant safeguards to protect health and due process rights.31 In 2011, the United Nations Special Rapporteur of the Human Rights Council on Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment found that, depending on circumstances, the imposition of solitary confinement may constitute an act of torture as defined in the Convention against Torture. The Special Rapporteur recommended the complete abolition of indefinite solitary confinement and solitary confinement of any duration for juveniles and people with mental disabilities. He also urged that states replace solitary confinement for punitive purposes with alternative disciplinary sanctions.29
Proposed Recommendations Statement
Categorical exclusions and monitoring of health status: Prisoners with serious mental illnesses should be excluded from placement in solitary confinement. In addition, all juveniles under 18 years of age should be excluded from placement in solitary confinement regardless of whether they are held in adult or juvenile facilities. Prisoners should be closely monitored and removed from solitary confinement if continued placement becomes clinically contraindicated, if their physical or mental health deteriorates because of continued placement in solitary confinement, or if necessary medical or mental health services cannot be provided.
Solitary confinement for disciplinary purposes: Correctional authorities should eliminate solitary confinement as a disciplinary sanction and create alternative means of discipline. Prisoners with serious mental illnesses should be diverted into secure treatment programs.2,17
Solitary confinement for security purposes: Solitary confinement for security purposes should be permitted only in the most extreme cases when prisoners pose a current and serious threat to the safety of themselves or others. Prisoners should be housed in the least restrictive conditions possible, and correctional authorities should implement procedural safeguards to ensure that inmates are returned to general population when the immediate threat to safety is reduced or eliminated.
Isolation for clinical or therapeutic purposes: Isolation for clinical or therapeutic purposes should be permitted only upon the directive of a credentialed health care provider who is authorized, by virtue of licensure or credentials, to issue such an order. Patients should be isolated for the shortest duration and in the least restrictive conditions possible. The necessity for continued isolation must be reviewed frequently.
Isolation for personal safety: Prisoners who must be separated from the general population to protect them from being harmed by others must be housed in the least restrictive conditions possible and must be afforded a level of access to programs, treatment, education, recreation, visitation, and social interactions that is comparable to that afforded prisoners in the general population.
Defenders of solitary confinement argue that this practice is necessary to (1) maintain institutional order and security, (2) punish prisoners who fail to comply with prison rules, (3) protect vulnerable prisoners from harm, and (4) safeguard national security and legal processes by limiting communication with the outside world.
A yearlong longitudinal study of prisoners in a Colorado “supermax” facility revealed no significant deterioration among mentally ill and non–mentally ill prisoners placed in solitary confinement. However, the authors acknowledged that their findings may not be generalizable to other correctional systems or to longer periods of solitary confinement. They also noted that their results suggest that seriously mentally ill prisoners in segregation may be less likely to improve than their counterparts in the general population.32
Litigation against the use of solitary confinement is ongoing but faces major obstacles given the special restrictions placed on prisoners’ ability to challenge prison conditions in the courts, the high cost of litigation, and the fact that cases can take years to resolve. Furthermore, the United States Constitution sets a very high bar for proving that conditions of confinement violate prisoners’ rights. As one court held, “[t]he Eighth Amendment simply does not guarantee that inmates will not suffer some psychological effects from incarceration or segregation.”33 The first-ever congressional hearing on solitary confinement was held in 2012. At the international level, as noted above, the United Nations Special Rapporteur of the Human Rights Council on Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment condemned the practice. Human rights organizations also have addressed the use of solitary confinement.
APHA calls upon federal, state, and local correctional authorities to:
- Eliminate solitary confinement as a means of punishing prisoners and to develop alternative disciplinary sanctions and processes that accommodate prisoners with serious mental illnesses and chronic illnesses.
- Eliminate solitary confinement as a means of managing security threats except in the most extreme cases when no less restrictive option is available to mitigate a serious, current, and ongoing threat to safety. In such cases, prisoners should be confined in the least restrictive conditions possible and should be returned to the general population when the threat abates. Prisoners should be closely monitored and removed from solitary confinement if changing health circumstances so dictate.
- Exclude from solitary confinement prisoners with serious mental illnesses.
- Exclude juveniles from solitary confinement regardless of whether they are held in adult or juvenile facilities.
- Ensure that isolation for clinical or therapeutic purposes occurs only upon the order of a health care professional and that isolation be for the shortest duration and in the least restrictive conditions possible. Patients who are separated from the general prison population for their own safety should be housed in the least restrictive conditions possible.
- Knoll JL IV, Beven GE. Supermax units and death row. In: Scott CL, ed. Handbook of Correctional Mental Health. 2nd ed. Arlington, VA: American Psychiatric Association; 2010.
- Rhodes LA. Pathological effects of the supermaximum prison. Am J Public Health. 2005;95(10):1692–1695.
- Naday A, Freilich JD, Mellow J. The elusive data on supermax confinement. Prison J. 2008;88(1):69–93.
- Mears DP. Evaluating the Effectiveness of Supermax Prisons. Washington, DC: Urban Institute Justice Policy Center; 2006.
- Browne A, Cambier A, Agha S. Prisons within prisons: the use of segregation in the United States. Fed Sentencing Reporter. 2011;24(1):46–49.
- Carson EA, Sabol, WJ. Prisoners in 2001. Available at: http://www.bjs.gov/content/pub/pdf/p11.pdf. Accessed December 15, 2013.
- Human Rights Watch, American Civil Liberties Union. Growing Up Locked Down: Youth in Solitary Confinement in Jails and Prisons Across the United States. New York, NY: Human Rights Watch; 2012.
- Steinberg L. Adolescent development and juvenile justice. Annu Rev Clin Psychol. 2009;5:459–485.
- Burke AS. Under construction: brain formation, culpability, and the criminal justice system. Int J Law Psychiatry. 2011;34:381–385.
- Miller v. Alabama, 132 SCt 2455, 2464–2466 (2012).
- Schlanger M. Regulating segregation: the contribution of the ABA criminal justice standards on the treatment of prisoners. Am Crim Law Rev. 2010;47(4):1421.
- Grassian S. Psychiatric effects of solitary confinement. Wash Univ J Law Policy. 2006;22:325–383.
- Rhodes LA. Total Confinement: Madness and Reason in the Maximum Security Prison. Berkeley, CA: University of California Press; 2004.
- Haney C. Mental health issues in long-term solitary and “supermax” confinement. Crime Delinq. 2003;49(1):124–156.
- Grassian S. Psychopathological effects of solitary confinement. Am J Psychiatry. 1983;140(11):1450–1454.
- Fellner J. A corrections quandary: mental illness and prison rules. Harv Civil Rights Civil Liberties Law Rev. 2006;41:391–412.
- Metzner JL. Commentary: the role of mental health in the inmate disciplinary process. J Am Acad Psychiatry Law. 2002;30(4):497–499.
- Psychiatric Services in Jails and Prisons. 2nd ed. Washington, DC: American Psychiatric Association; 2000.
- Standards for Mental Health Services in Correctional Facilities. Chicago, IL: National Commission on Correctional Health Care; 2008.
- Burrow GF, Knox CM. Nursing in the primary care setting. In: Puisis M, ed. Clinical Practice in Correctional Medicine. 2nd ed. Philadelphia, PA: Mosby Elsevier; 2006:426–459.
- Knox CM, Shelton S. Sick call. In: Puisis M, ed. Clinical Practice in Correctional Medicine. 2nd ed. Philadelphia, PA: Mosby Elsevier; 2006:50–65.
- Puisis M, Appel H. Chronic disease management. In: Puisis M, ed. Clinical Practice in Correctional Medicine. 2nd ed. Philadelphia, PA: Mosby Elsevier; 2006:66–88.
- Metzner JL, Fellner J. Solitary confinement and mental illness in U.S. prisons: a challenge for medical ethics. J Am Acad Psychiatry Law. 2010;38(1):104–108.
- ABA Standards for Criminal Justice: Treatment of Prisoners. 3rd ed. Washington, DC: American Bar Association; 2010.
- American Psychiatric Association. Position statement on segregation of prisoners with mental illness. Available at: http://www.psychiatry.org/File%20Library/Learn/Archives/ps2012_PrisonerSegregation.pdf. Accessed December 15, 2013.
- American Academy of Child and Adolescent Psychiatry. Solitary confinement of juvenile offenders. Available at: http://www.aacap.org/cs/root/policy_statements/solitary_confinement_of_juvenile_offenders. Accessed December 15, 2013.
- DeMarco KD. Disabled by solitude: the Convention on the Rights of Persons With Disabilities and its impact on the use of supermax solitary confinement. Univ Miami Law Rev. 2012;66:523–567.
- United Nations General Assembly. Interim Report of the Special Rapporteur of the Human Rights Council on Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. New York, NY: United Nations; 2011.
- Smith PS. Solitary confinement: an introduction to the Istanbul statement on the use and effects of solitary confinement. Torture. 2008;18(1):56–62.
- Council of Europe. 21st general report of the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment. Available at: http://www.cpt.coe.int/en/annual/rep-21.pdf. Accessed December 15, 2013.
- O’Keefe ML, Klebe KJ, Stucker A, et al. One Year Longitudinal Study of the Psychological Effects of Administrative Segregation. Colorado Springs, CO: Colorado Department of Corrections, Office of Planning and Analysis; 2010.
- Madrid v. Gomez, 889 FSupp 1146, 1264 (1995).
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