Over the last year, our collective minds have been captivated by stories about child and family separation, detainment of citizens and immigrants, and the quality of the health care within detention facilities. These stories have been jarring and traumatic, and have also awoken an important level of national consciousness about the nature of detention. 

What has not received as much coverage in recent discourse is the ongoing nature of solitary confinement in our justice system. Many of us have heard about it colloquially in books, movies or television shows, but are not aware of its prevalence. 

While this piece focuses primarily on the use of solitary confinement among adults, it also aims to open a conversation about the nature of solitary confinement, its utilization, and whether there is evidence to suggest that there are notable impacts on health, be they benign or deleterious. It is my hope that we can open a conversation here at in-House about the role of the physician in settings where such structure exists, and whether we have an obligation to speak out on these topics, by virtue of our charge to “do no harm.”

What is solitary confinement?

Solitary confinement is defined as a type of incarceration in which individuals are maintained for roughly 23 hours a day in individual cells. You may have heard about solitary confinement, often referred to as ‘the hole,’ ‘ad seg,’ protective housing, disciplinary segregation or ‘supermax.’ If you watch Orange is the New Black, you know many of the characters have been taken to ‘the hole’ when they commit various infractions in the jail and are often deprived of social contact during that time frame. According to the National Commission on Correctional Healthcare, solitary condiment subjects the punished to “minimal to rare meaningful contact with other individuals.” What separates solitary confinement from other sorts of incarceration is that not only are individuals reduced in their ability to interact with others, but they also lose access to programs intended to be rehabilitative including educational and vocational efforts. A recent article from The Economist revealed that nearly 2,000 individuals in the United States have been in solitary confinement for six years or more.   

Okay, but what does this mean?

Solitary confinement is a state that may be transient — hours to days for a minor infraction — or may be a longer state ranging from weeks to months or even years depending on a multitude of factors including why the individual was sent to solitary confinement, what the available housing units are in the facility and the nature of their sentencing. In fact, in the United States, the use of solitary confinement for both protective and punitive purposes has been on the rise. While these purposes are cited, they are not well-studied, so we do not really know if solitary confinement is achieving its goal to safely house individuals while preventing violence. What we do know is that there are a number of unintended adverse health outcomes associated with its use.

Who gets placed in solitary confinement?

As with many aspects of health care, there are notable disparities in which individuals are often placed in solitary confinement. Drs. Ryan Labrecque and Paula Smith noted that younger males particularly with severe mental illnesses are more likely to be placed in solitary confinement than the general population of incarcerated individuals. Drs. Daniel Mears and William Bales, also criminologists, found that in Florida, individuals in solitary confinement did not have statistically significant differences in their “offending record” as compared to individuals in the general population.

So what are the health effects?

Perhaps the most shocking result hails from a study of New York City jails. While individuals who experienced solitary confinement only accounted for 7% of the population, they experienced nearly 50% of the self-harm attempts with potentially lethal means. While this cannot be directly attributed to the experience of solitary confinement, aggregate studies have found that individuals who experience solitary confinement are more likely to endorse symptoms including anxiety, paranoia and confusion. In fact, a 2003 study by Craig Haney found that 70% of individuals in solitary confinement endorsed an impending nervous breakdown, 84% endorsed lethargy and chronic fatigue, and more than 90% reported feeling anxious. 

Many studies indicate that individuals who have been housed in solitary units are more likely to experience increased sensitivity to stimuli such as noise. Physical health effects include nearly 90% of individuals in Haney’s study having “headaches,” and multiple studies noting increased rates of abdominal pain, distress and muscle pain. Palpitations, tingling, trembling, fainting and dizziness are also common. Studies also reveal increased rates of chronic neck and back pain likely from the small quarters of the housing and its accommodations,in addition to deconditioning. 

It has also been documented that salivary cortisol elevates after experiencing solitary confinement. Further, studies indicate that the lack of social contact can be associated with increases in aggression and social withdrawal. A study of seclusion in psychiatric hospitals found that this genre of isolation can cause its own form of trauma. Coping skills are altered, and individuals can become conditioned to feeling that they do not need social interaction or that it is harmful. The changes formed in solitary confinement are not erased when people transition to the general population or are released. In fact, it likely impedes these transitions due to the sudden increase in social expectation. Attorney Shira Gordon found that people struggle with “adjusting to natural light, the noise of traffic, and physical, human contact.” There also are challenges with managing emotions which can place individuals at increased risk of recidivism.

Long-term consequences can even include alterations in behavior patterns. Haney’s work discusses several social pathologies that stem from this sort of isolation. First, he describes dependence wherein individuals who have experienced solitary confinement by virtue of their separation are solely reliant on external sources for their basic needs. They also are unable to choose activities, and therefore cannot organize their daily lives around basic needs. This is along the same lines as individuals with depression who are experiencing anhedonia coupled with the intrinsic lack of access to choice. 

Next, social isolation can “undermine [the] sense of self.” Haney argues that identity is built through regular interpersonal interaction which is removed through solitary confinement. This pulls individuals away from their own feelings of identity and can create discord or even a feeling of loss of identity. Haney postulates that, over time, this can build fear surrounding social interaction. Additionally, he identifies that the frustration that people feel about being isolated likely compounds on itself and can manifest as significant anger and rage that may be uncontrollable. This is compounded particularly when individuals are expected to reintegrate into the general population or are released into the community. This is because the anger and distress associated with solitary confinement can confer additional risk of reoffending and returning not only to a correctional setting, but also to solitary confinement itself.

While one study seems to indicate that there are not significant psychological effects associated with solitary confinement, this study followed adult men who were required to meet study criteria for literacy in the English language thereby precluding a number of individuals who would be at high risk for decompensation in such a setting, including individuals with severe mental illness and immigrants.

As for solitary confinement’s indirect consequences?

Solitary confinement can reduce an individual’s access to health care. We have already discussed that people with behavioral health diagnoses are at an elevated risk of solitary confinement. Part of this may be due to symptoms consistent with their diagnoses that may make it even more challenging for them to adhere to the rules and expectations of a correctional setting. It’s not hard to imagine that this poses challenges for individuals with traumatic brain injuries as well and for those who impulsivity may be a sequela of their disease.

A study of Arizona supermax facilities found that despite representing only 16.8% of the general population, patients with behavioral health diagnoses received 26% of the write-ups; the implication being that symptoms consistent with these diagnoses are conflated with behavioral issues. This serves to perpetuate a system in which individuals who would benefit from further access to treatment are held in confined settings that reduce their access to care. Notably, some patients in solitary confinement are only required to be evaluated every 90 days.  

Is solitary confinement effective at preventing recidivism?

In short, it does not seem so. Multiple studies have found a modestly increased rate of recidivism among people who experienced solitary confinement. We observed that solitary confinement may actually increase the risk for recidivism by generating anxiety perhaps even paranoia around social interaction coupled with anger. We also know that a key factor in decreasing rates of recidivism is access to programs — something which is sharply decreased in the solitary setting. 

After the opening of the Supermax Pelican Bay facility in California, rates of violence within correctional facilities have not decreased; this article cites a nearly 20% increase. This is salient because as a Supermax facility, each cell is part of a secure housing unit, and it represents a large scale model of solitary confinement. The increased rate of violence is attributed to the “rage hypothesis.” This hypothesis postulates that individuals placed in solitary confinement feel significant distress and “anger” about their placement in solitary confinement. These symptoms may manifest as a desire to exact revenge on the society that placed them in confinement, or feelings of unfairness and feeling demeaned by the process that placed them in solitary confinement. The rage hypothesis suggests that these effects may contribute to more recidivism among individuals who have been in solitary confinement. In a sense, they would be seeking justice from what they view as an unjust experience.

The Vera Commission notably also indicates that the increasing use of solitary confinement in our society may be associated with more “antisocial tendencies” and more “tension” in facilities, which they believe may spur more violence over time. There are even states including Maine, Colorado and Mississippi where solitary confinement has been reduced, and they have not experienced increases in violence within their correctional facilities.  

Then what are the alternatives?

I do not have all the answers, but some researchers, policymakers and experts have weighed in with a few suggestions. A common theme is to remove individuals with behavioral health diagnoses from solitary confinement and to consider this an exclusion criterion because being in an isolated portion of a jail or prison decreases access to care and also removes the element of privacy in the clinician-patient interaction due to increased staff presence. The next recommendation is prioritizing social programs and stimulation for all inmates even those in maximum security settings. A maximum security prison in Minnesota cites natural light, exercise and keeping the absolute minimum number of individuals in its cells with maintaining an environment where there have not been on-site homicides.

Other facilities have imposed stipulations on the reasons why individuals can be placed in solitary confinement (i.e. only for the acute risk of harm to self and/or others) and to focus on the least restrictive housing option. The Vera Commission strongly recommends that the practice of sensory deprivation ends and that inmates be allowed access to their loved ones, treatment, programs and books. And in cases of solitary confinement, behavioral health providers should be involved in the assessment of the individual and to assist in de-escalating with the goal of discharge from solitary confinement. These stipulations would make solitary confinement into a placement for therapeutic evaluation and stabilization rather than a punitive arrangement even for violent behavior.

Why does it matter?

Regardless of what we each feel about the justice system and about incarceration itself, as physicians, we have a responsibility to vulnerable populations including our patients who are being incarcerated. As a psychiatrist-in-training who observes people with profound burdens of psychiatric disease who are being sentenced to conditions that will only further deteriorate the ability to cope and can worsen their symptoms, I feel obligated to speak up. I encourage my colleagues across all specialties to consider your position on this matter.

 If you would like to join me, here are some resources to take action:

• Contact your policymakers and remember to vote!
• Learn more about the history of solitary confinement.
• Check out the National Institute of Justice’s report on solitary confinement.

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Policy Prescriptions

Policy Prescriptions is dedicated to exploring and challenging contemporary health policy issues, especially in the fields of behavioral health, health care access, and inclusion.

Image credit: chair by Dean Hochman is licensed under CC BY 2.0.