A N A L Y S I S

A N D

C O M M E N T A R Y

Solitary Confinement and Mental
Illness in U.S. Prisons: A Challenge
for Medical Ethics
Jeffrey L. Metzner, MD, and Jamie Fellner, Esq.
In recent years, prison officials have increasingly turned to solitary confinement as a way to manage difficult or
dangerous prisoners. Many of the prisoners subjected to isolation, which can extend for years, have serious mental
illness, and the conditions of solitary confinement can exacerbate their symptoms or provoke recurrence. Prison
rules for isolated prisoners, however, greatly restrict the nature and quantity of mental health services that they
can receive. In this article, we describe the use of isolation (called segregation by prison officials) to confine
prisoners with serious mental illness, the psychological consequences of such confinement, and the response of
U.S. courts and human rights experts. We then address the challenges and human rights responsibilities of
physicians confronting this prison practice. We conclude by urging professional organizations to adopt formal
positions against the prolonged isolation of prisoners with serious mental illness.
J Am Acad Psychiatry Law 38:104 – 8, 2010

Physicians who work in U.S. prison facilities face
ethically difficult challenges arising from substandard working conditions, dual loyalties to patients
and employers, and the tension between reasonable
medical practices and the prison rules and culture. In
recent years, physicians have increasingly confronted
a new challenge: the prolonged solitary confinement
of prisoners with serious mental illness, a corrections
practice that has become prevalent despite the psychological harm it can cause. There has been scant
professional or academic attention to the unique ethics-related quandary of physicians and other healthcare professionals when prisons isolate inmates with
mental illness. We hope to begin to fill this gap.
Solitary confinement is recognized as difficult to
withstand; indeed, psychological stressors such as
isolation can be as clinically distressing as physical
torture.1,2 Nevertheless, U.S. prison officials have increasingly embraced a variant of solitary confinement
to punish and control difficult or dangerous prisoners. Whether in the so-called supermax prisons that
have proliferated over the past two decades or in segDr. Metzner is Clinical Professor of Psychiatry, University of Colorado
School of Medicine, Denver, CO. Jamie Fellner is Senior Counsel,
U.S. Program, Human Rights Watch, New York, NY. Address correspondence to: Jeffrey L. Metzner, MD, 3300 East First Ave., Suite 590,
Denver, CO 80206. E-mail: jeffrey.metzner@ucdenver.edu.
Disclosures of financial or other potential conflicts of interest: None.
104

regation (i.e., locked-down housing) units within
regular prisons, tens of thousands of prisoners spend
years locked up 23 to 24 hours a day in small cells
that frequently have solid steel doors. They live with
extensive surveillance and security controls, the absence of ordinary social interaction, abnormal environmental stimuli, often only three to five hours a
week of recreation alone in caged enclosures, and
little, if any, educational, vocational, or other purposeful activities (i.e., programs). They are handcuffed and frequently shackled every time they leave
their cells.3–5 The terms segregation, solitary confinement, and isolation will be used interchangeably
to describe these conditions of confinement.
Isolation can be psychologically harmful to any
prisoner, with the nature and severity of the impact
depending on the individual, the duration, and particular conditions (e.g., access to natural light, books,
or radio). Psychological effects can include anxiety,
depression, anger, cognitive disturbances, perceptual
distortions, obsessive thoughts, paranoia, and
psychosis.6
The adverse effects of solitary confinement are especially significant for persons with serious mental
illness, commonly defined as a major mental disorder
(e.g., schizophrenia, bipolar disorder, major depressive disorder) that is usually characterized by psy-

The Journal of the American Academy of Psychiatry and the Law

Metzner and Fellner

chotic symptoms and/or significant functional impairments. The stress, lack of meaningful social
contact, and unstructured days can exacerbate symptoms of illness or provoke recurrence.7 Suicides occur
disproportionately more often in segregation units
than elsewhere in prison.8 –10 All too frequently,
mentally ill prisoners decompensate in isolation, requiring crisis care or psychiatric hospitalization.
Many simply will not get better as long as they are
isolated.
Mental health professionals are often unable to
mitigate fully the harm associated with isolation.
Mental health services in segregation units are typically limited to psychotropic medication, a health
care clinician stopping at the cell front to ask how the
prisoner is doing (i.e., mental health rounds), and
occasional meetings in private with a clinician.7 Individual therapy; group therapy; structured educational, recreational, or life-skill-enhancing activities;
and other therapeutic interventions are usually not
available because of insufficient resources and rules
requiring prisoners to remain in their cells.11
The use of segregation to confine the mentally ill
has grown as the number and proportion of prisoners
with mental illness have grown. Although designed
and operated as places of punishment, prisons have
nonetheless become de facto psychiatric facilities despite often lacking the needed mental health services.7 Studies and clinical experience consistently indicate that 8 to 19 percent of prisoners have psychiatric
disorders that result in significant functional disabilities, and another 15 to 20 percent require some form
of psychiatric intervention during their incarceration.12 Sixty percent of state correctional systems responding to a survey on inmate mental health reported that 15 percent or more of their inmate
population had a diagnosed mental illness.13
Despite significant improvements in correctional
mental health services, often related to litigation and
development of standards and guidelines by the National Commission on Correctional Health Care
(NCCHC), the American Psychiatric Association
(APA), and other professional organizations, in
many prisons the services remain woefully inadequate. Relative to the number of prisoners needing
help, there is an insufficient number of qualified
staff, too few specialized facilities, and few programs.7 Mindful of budget constraints and scant
public support for investments in the treatment (as
opposed to punishment) of prisoners, elected offi-

cials have been reluctant to provide the funds and
leadership needed to ensure that prisons have sufficient mental health resources. Twenty-two of 40
state correctional systems reported in a survey that
they did not have an adequate mental health staff.13
Persons with mental illness are often impaired in
their ability to handle the stresses of incarceration
and to conform to a highly regimented routine. They
may exhibit bizarre, annoying, or dangerous behavior and have higher rates of disciplinary infractions
than other prisoners. Prison officials generally respond to them as they do to other prisoners who
break the rules. When lesser sanctions do not curb
the behavior, they isolate the prisoners in the segregation units, despite the likely negative mental health
impact. Once in segregation, continued misconduct,
often connected to mental illness, can keep the inmates there indefinitely.7,14
In class action cases challenging the segregation of
inmates with serious mental illness as unconstitutionally cruel because of the psychological harm it
can inflict, U.S. federal courts have either issued rulings or accepted settlements that prohibit or sharply
curtail the practice. According to one federal judge,
putting mentally ill prisoners in isolated confinement “is the mental equivalent of putting an asthmatic in a place with little air. . . .”15 Unfortunately,
except in the small number of prisons governed by
the outcome of such litigation, mentally ill prisoners
continue to be sent to segregation; indeed, they are
often disproportionately represented in segregation
units.16,17
International treaty bodies and human rights experts, including the Human Rights Committee,18
the Committee against Torture,19,20 and the U.N.
Special Rapporteur on Torture,21 have concluded
that solitary confinement may amount to cruel, inhuman, or degrading treatment in violation of the
International Covenant on Civil and Political
Rights22 and the Convention against Torture and
other Cruel, Inhuman, and Degrading Treatment or
Punishment.23 They have specifically criticized supermax confinement in the United States because of
the mental suffering it inflicts.19,20 Whatever one’s
views on supermax confinement in general, human
rights experts agree that its use for inmates with serious mental illness violates their human rights.
Principles of ethics regarding beneficence, nonmaleficence, and respect for the rights and dignity of all
patients have led international and national profes-

Volume 38, Number 1, 2010

105

Solitary Confinement and Mental Illness

sional organizations to affirm that physicians are ethically obligated to refrain from countenancing, condoning, participating in, or facilitating torture or
other forms of cruel, inhuman, or degrading treatment.24 –27 Involvement of healthcare practitioners
in abusive interrogations recently prompted the
American Medical Association28 and the APA29 to
oppose the participation of physicians in interrogations. Two years ago, the NCCHC issued a position
statement that correctional health care professionals
“should not condone or participate in cruel, inhumane or degrading treatment of inmates.”30 To date,
however, the medical organizations have not formally acknowledged that prolonged isolation of the
mentally ill constitutes cruel or inhuman treatment
in violation of human rights, nor have they addressed
health professionals’ ethics-related responsibilities
when faced with such cases.
Correctional health care professionals struggle
with constrained resources and large caseloads that
limit the services they can provide their patients. It is
ethical for them to do the best they can under the
circumstances rather than resigning, which would
result in even fewer services for their patients. But
what are practitioners’ ethics-related responsibilities
when prison officials impose conditions of confinement that exacerbate the symptoms of a prisoner’s
mental illness?
The ethic-based calculus physicians face when
prisoners are isolated for disciplinary or security reasons is different than that created by the struggle with
limited resources. Segregation of mentally ill prisoners (or any other prisoner) is not an unintended consequence of tight budgets, for example. It reflects a
penal philosophy and the conscious decision by
prison officials about whom to isolate, for how long,
and under what conditions. If health professionals
simply do their rounds but say nothing, are they
implicitly legitimizing the segregation of mentally ill
prisoners and thereby contributing to the continuation of the harm? What must they do to avoid being
complicit in conditions of confinement that may
well constitute a human rights violation?
We believe it is ethical for physicians to treat prisoners who have been abused, but they must also take
measures to end the abuse. In addition to providing
whatever services they can to segregated patients,
they should advocate within the prison system for
changed segregation policies and, if that fails, they
should undertake public advocacy.31–33
106

Publically exposing and urging change in harmful
prison practices is difficult and, needless to say, can
threaten job security, but individual practitioners
should not have to wrestle alone with a prison practice that violates human rights norms. Their professional organizations should help them. Through the
organizations, health professionals collectively can
support colleagues who work in prisons in the quest
to ensure ethically defensible correctional policies.
The APA34 and the NCCHC35 have provided basic
frameworks for increased mental health monitoring
and treatment of segregated inmates. They must do
more, however.
Professional healthcare organizations should acknowledge that prolonged segregation of inmates
with serious mental illness violates basic tenets of
mental health treatment. The mental health standards of the NCCHC include the “optional recommendation” that mentally ill prisoners be excluded
from extreme isolation,35 noting in an appendix that
clinicians “generally agree that placement of inmates
with serious mental illnesses in settings with ‘extreme
isolation’ is contraindicated because many of these
inmates’ psychiatric conditions will clinically deteriorate or not improve (Working Group on Schizophrenia, 1997).”36,37 In light of that general consensus, shouldn’t the NCCHC make the exclusion
mandatory, instead of optional? The APA and AMA
should also formally adopt a similar position.
However, adopting a similar position is easier said
than done. Very few physicians in the APA and AMA
have experience or knowledge regarding correctional
mental health care, let alone correctional environments in general. They are not familiar with the differences between a general population housing unit
and a disciplinary segregation housing unit. Administrative segregation, supermax, rules infractions,
mental health rounds, and “kites” are terms most
noncorrectional physicians do not understand. In
short, we recognize that a serious educational effort
must be mounted so that noncorrectional mental
health practitioners have a better understanding of
the world in which their correctional colleagues work
and the unique challenges they face, including the
isolation of seriously ill patients for months, even
years, that would never be condoned in a noncorrectional mental health setting.
No doubt some correctional mental health clinicians will not agree with us. They may believe the
isolation of volatile mentally ill prisoners is necessary

The Journal of the American Academy of Psychiatry and the Law

Metzner and Fellner

for security reasons. They may believe they are guests
in the house of corrections who have no business
addressing custody policies, or they may have become so accustomed to the extended use of isolation
that they have lost sight of its potential to cause psychological harm.
Experience demonstrates that prisons can operate
safely and securely without putting inmates with
mental illness in typical conditions of segregation.
Because of litigation, in some prisons, mentally ill
prisoners who would otherwise be locked in their cell
for 23 to 24 hours a day are given more time outside
their cells, including time in group therapy and other
therapeutic interventions.11 The improved clinical
responses of prisoners with mental illness have been
achieved without sacrificing needed controls or relinquishing the goal of holding those accountable,
whether mentally ill or not, who willfully violate
prison rules.
The professional organizations should acknowledge that it is not ethically defensible for health care
professionals to acquiesce silently to conditions of
confinement that inflict mental harm and violate human rights. They should affirm that practitioners are
ethically obligated, not only to treat segregated inmates with mental illness, but also to strive to change
harmful segregation policies and practices.31–33 Finally, the organizations should not be content with
clarifying the ethics-related responsibilities of individual practitioners in these circumstances. They
should actively support practitioners who work for
changed segregation policies, and they should use
their institutional authority to press for a nationwide
rethinking of the use of isolation. The medical professions’ commitment to ethics and human rights
would be well served by such steps.
References
1. Reyes H: The worst scars are in the mind: psychological torture.
Int Rev Red Cross 89:591– 617, 2007
2. Basoglu M, Livanou M, Crnobaric C: Torture vs. other cruel,
inhuman and degrading treatment: is the distinction real or apparent? Arch Gen Psychiatry 64:277– 85, 2007
3. Riveland C: Supermax prisons: overview and general considerations. Washington, DC: U.S. Department of Justice, National
Institute of Corrections, January 1999
4. Fellner J, Mariner J: Cold storage: super-maximum security confinement in Indiana. Human Rights Watch, October 1997
5. Commission on Safety and Abuse in America’s Prisons: Confronting confinement: a report of the Commission on Safety and Abuse
in America’s Prisons. Washington, DC: Vera Institute of Justice,
June 2006, pp 52– 61. Available at http://www.prisoncommission.
org/pdfs/Confronting_Confinement.pdf. Accessed May 12,
2009

6. Smith PS: The effects of solitary confinement on prison inmates:
a brief history and review of the literature. Crim Just 34:441–568,
2006
7. Abramsky S, Fellner J: Ill-equipped: US prisons and offenders
with mental illness. Human Rights Watch, 2003, pp 145– 68
8. Patterson RF, Hughes K: Review of completed suicides in the
California Department of Corrections and Rehabilitation, 1999
to 2004. Psychiatr Serv 59:677– 81, 2008
9. White T, Schimmel D, Frickey R: A comprehensive analysis of
suicide in federal prisons: a fifteen-year review. J Correct Health
Care 9:321– 43, 2002
10. Hayes LM: Prison guide: an overview and guide to prevention.
Washington, DC: U.S. Department of Justice, National Institute
of Corrections, 1995. Available at http://www.nicic.org/pubs/
1995/012475.pdf. Accessed May 13, 2009
11. Metzner JL, Dvoskin JA: An overview of correctional psychiatry.
Psychiatr Clin North Am 29:761–72, 2006
12. Metzner JL: Class action litigation in correctional psychiatry.
J Am Acad Psychiatry Law 30:19 –29, 2002
13. Hill C: Inmate mental health care. Correct Compend 29:15–31,
2004
14. Fellner J: A corrections quandary: mental illness and prison rules.
Harv CR-CL L Rev 41:391– 412, 2006
15. Madrid v. Gomez, 889 F. Supp. 1146, 1265 (N.D. Cal. 1995)
16. Lovell D: Patterns of disturbed behavior in a supermax prison.
Crim Just Behav 35:985–1004, 2008
17. O’Keefe M, Schnell MJ: Offenders with mental illness in the
correctional system. J Offend Rehabil 45:81–104, 2007
18. United Nations Human Rights Committee: CCPR General comment No. 20: replaces general comment 7 concerning prohibition
of torture, or other cruel, inhuman or degrading treatment or
punishment. New York: UNHRC, 1992
19. United Nations Human Rights Committee: Consideration of reports submitted by States parties under Article 40 of the Covenant, concluding observations of the Human Rights Committee,
United States of America. New York: UNHRC, UN Doc. CCPR/
C/USA/CO/3, 2006
20. United Nations Committee Against Torture: Consideration of
reports submitted by States parties under Article 19 of the Convention, Conclusions and Recommendations of the Committee
Against Torture, United States of America. New York: UN Committee Against Torture, UN Doc. CAT/C/USA/CO/2, 2006
21. Interim Report of the Special Rapporteur on Torture and Other
Cruel, Inhuman or Degrading Treatment or Punishment. UN
General Assembly. New York: United Nations, UN Doc. A/63/
175:18 –21, 2008
22. International Covenant on Civil and Political Rights. Available at
http://www1.umn.edu/humanrts/instree/b3ccpr.htm. Accessed
January 29, 2010
23. Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. Available at http://www1.
umn.edu/humanrts/instree/h2catoc.htm. Accessed January 29,
2010
24. World Medical Association: Guidelines for medical doctors concerning torture and other cruel, inhuman or degrading treatment or punishment in relation to detention and imprisonment. Adopted by the
29th WMA Assembly, Tokyo, Japan, October 1975
25. American Medical Association: Code of Medical Ethics. Opinion
2.067, Torture, 1999
26. The World Psychiatric Association: Madrid Declaration on Ethical Standards for Psychiatric Practice. Approved by the WPA
General Assembly, 1996
27. American Medical Association: H-65.997, Human Rights.
Health and ethics policies of the AMA House of Delegates.
Adopted December 1978

Volume 38, Number 1, 2010

107

Solitary Confinement and Mental Illness
28. American Medical Association: Code of Medical Ethics. Opinion
2.068, Physician participation in interrogation. Issued November
2006
29. American Psychiatric Association: Position statement: Psychiatric
participation in interrogation of detainees. Adopted May 2006
30. National Commission on Correctional Health Care: Position
statement: correctional health care professionals’ Response to Inmate Abuse. Adopted October 14, 2007
31. Dual loyalty and human rights in health professional practice:
proposed guidelines and institutional mechanisms. Physicians
for Human Rights and School of Public Health and Primary
Health Care, University of Cape Town, 2003. Available at http://
physiciansforhumanrights.org/library/documents/reports/report2002-duelloyalty.pdf. Accessed May 13, 2009
32. Nielsen NH, Heyman JM: Letter from the American Medical
Association President and Chair of the Board of Trustees (respectively) to the Honorable Barak Obama, April 17, 2009. Available
at http://www.ama-assn.org/ama1/pub/upload/mm/-1/obamaletter-torture.pdf. Accessed May 17, 2009
33. World Medical Association: Declaration concerning support for
medical doctors refusing to participate in, or to condone, the use

108

34.

35.

36.

37.

of torture or other forms of cruel, inhuman or degrading treatment. Adopted by the 49th WMA Assembly. Hamburg, Germany, November 1997. Available at http://www.wma.net/en/
30publications/10policies/c19/index.html. Accessed January 29,
2010
National Commission on Correctional Health Care: Standards
for mental health services in correctional facilities. Standard MHE-07, 2008
American Psychiatric Association: Psychiatric services in jails and
prisons: a task force report of the American Psychiatric Association (ed 2). Washington, DC: American Psychiatric Association,
2000, pp 4 –5
Metzner JL: Mental health considerations for segregated inmates.
Appendix E to Standards for Mental Health Services in Correctional Facilities. Chicago, IL: National Commission on Correctional Health Care, 2008, pp 129 –31
Work Group on Schizophrenia: American Psychiatric Association
practice guidelines: practice guideline for the treatment of patients
with schizophrenia. Am J Psychiatry 154(April Suppl.):1– 63,
1997

The Journal of the American Academy of Psychiatry and the Law