Mental Health Consequences
Following Release from 

Long-Term Solitary Confinement 

in California
Consultative Report Prepared for the 

Center for Constitutional Rights

Human Rights in Trauma Mental Health Lab, Stanford University



Table of Contents
Executive Summary	 2
Introduction 	 4
Methodology	 4
Mental Health Consequences of Long-term Isolation	

7

Experiences in the General Population Following Release from SHU	

15

Considerations for Improving Post-SHU Experiences and Functioning 	

25

Conclusion	

28

About the Human Rights in Trauma Mental Health Lab	 30
References 	

31

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Executive Summary
In Spring 2017, members of Stanford University’s Human Rights in Trauma Mental Health
Laboratory (the Stanford Lab) were invited to consult with attorneys from the Center for
Constitutional Rights (CCR) representing class members in the federal class action lawsuit Ashker
v. The Governor of California (Ashker). The Stanford Lab was asked to gather narratives from Ashker
class members in order to glean insight into what psychiatric sequelae directly related to
prolonged, indefinite isolation in the Security Housing Units (SHU) at California prisons are
present, and to determine whether that harm continues to impact prisoners following their
release from SHU into the general prison population (GP).
As aggregated, the class member narratives indicated that most of the men experienced severe
psychological disturbances with lasting detrimental consequences as a result of their experience
in SHU. The Stanford Lab’s interviews revealed a range of common impairments and adverse
consequences associated with long-term, indefinite incarceration. The majority of class members
endorsed mood symptoms consistent with the Diagnostic and Statistical Manual of Mental
Disorders (DSM 5) diagnosis of Major Depressive Disorder, including depressed mood,
hopelessness, anger, irritability, anhedonia, anger, fatigue, feelings of guilt, loss of appetite, and
insomnia. Nearly all class members also endorsed anxiety symptoms characteristic of DSM 5
diagnoses of panic disorder, traumatic stress disorders, and/or obsessive-compulsive disorders,
such as nervousness, worry, increased heart rate and respiration, sweating, muscle tension,
hyperarousal, paranoia, nightmares, intrusive thoughts, and fear of losing control. Psychiatric
symptoms and diminished capacity for socialization continue to cause psychological suffering and
problems with social function for most of the men now in GP.
Class members cited emotional numbing and desensitization as the some of the most common
responses to living in SHU. This sense of emotional suppression and dysregulation continues to
be problematic for prisoners following the transition to the general population. Class members
also reported significant alterations in cognition and perception. Problems with attention,
concentration, and memory were common, and described as persistent and worsening. Some of
the most pronounced and enduring effects of long-term isolation appeared to have resulted from
relational estrangement and social isolation; interviewees frequently reported losing, over time,
the motivation to seek social connection.
These psychiatric and social difficulties were reported to have persisted throughout the transition
to GP. Class members commonly reported ongoing anxiety and posttraumatic stress symptoms.
Specific difficulties endorsed by class members include pervasive hypervigilance, worry, and
nervousness; they described experiences of being on constant alert and chronically feeling under
threat or danger. Many class members endorsed sensory sensitivity following their transition to
GP, noting experiences of distress, anxiety, paranoia, and irritability particularly in response to

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the “chaotic” environment of GP with an influx of new activities, interactions, and sounds.
Furthermore, class members report that periods of lockdown in GP are triggering and retraumatizing, and that they invoke re-experiencing symptoms of posttraumatic stress disorder.
These social and psychological responses to SHU are consistent with the majority of current
literature on prolonged isolation.
In considering opportunities to improve post-SHU experience and functioning for prisoners, the
Stanford Lab noted that class members generally felt overwhelmed by and underprepared for the
post-SHU experience in GP.  Class members described the experience of GP as totally foreign
and overwhelming; these experiences appeared to stem from the drastic contrast between the
physical, social, and sensory environments of SHU and GP, as well as the absence of an effective
transition program. The loss of routine and stability in daily functioning, and the related lack of
predictability and demand for flexibility, was jarring and distressing for many interviewees,
resulting in feelings of anxiety, nervousness, irritability, and a sense of isolation and
disconnection, exacerbated by the lack of any transition preparation.  
The mental health professionals in the Stanford Lab are well versed in treatment modalities and
useful interventions for persons with mental health disorders and/or symptoms. Based on the
information summarized in this report, the Stanford Lab recommends reparative services in the
form educational, occupational, and social programming opportunities to help address the lasting
consequence of the long-term SHU experience. Emotional and psychological support services
are also needed. For transition, it is clear that improved, earnest access to mental health
treatment is necessary, and that such access should come from non-CDCR sources for a number
of reasons elucidated in the full report. The Stanford Lab recommends that class members be
offered mental health and psychological services in the form of independent psychiatric care
and/or peer-led or peer-facilitated support groups. Moreover, interviews indicate that prisoners
seem to derive a sense of fulfillment and self-worth from opportunities to mentor their peers; such
programming could be helpful in combatting some of the detrimental effects of time in SHU,
including by diminishing anxiety and depression.
Furthermore, class members’ requests for greater access to jobs and other out-of-cell activities, to
programs, and to therapeutic groups are wise interventions for their symptom profiles and are
likely to improve their transitions and the long-term prospects for functioning and contribution to
society. The Stanford Lab found the men interviewed to be resilient, self-educated, intellectually
curious individuals, many of whom have implemented therapeutic coping mechanisms on their
own. The Stanford Lab recommends that CDCR and other prison authorities seek to offer
adequate and enriched programming opportunities as a means of providing reparative services
and personal, community, and societal healing following long-term isolation in SHU.  

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Introduction
In the spring of 2017, members of Stanford University’s Human Rights in Trauma Mental
Health Laboratory (the Stanford Lab) were invited to consult with attorneys from the Center for
Constitutional Rights (CCR) representing class members in the federal class action lawsuit
Ashker v. The Governor of California (Ashker). The Stanford Lab is a multidisciplinary collaboration
between Stanford University’s School of Medicine, Law School, and the WSD Handa Center for
Human Rights and International Justice, and is composed of faculty and students including
academic clinicians, lawyers, and policy experts with special knowledge in the area of trauma
mental health. Moreover, the team has practical experience in clinical psychiatry and mastery of
the science of the effects of adverse conditions on human psychology, as well as significant
experience performing interviews and qualitative research in adverse conditions. As indicated,
the Stanford Lab was approached by attorneys from CCR to consult on the question of how
psychological changes acquired in long-term situations of isolated incarceration affect transition
into a general prison population. The Stanford Lab was asked to gather narratives from Ashker
class members in order to glean insight into what lasting psychiatric sequelae are present and how
the acquired psychological changes affect the transition from solitary confinement to the
mainline, as well as to review the science of the consequences of isolation for human psychology.
The focus of the endeavor was to investigate the extent of psychological harm directly related to
prolonged, indefinite isolation in the Security Housing Units (SHU) at California prisons and to
determine whether that harm continues to impact prisoners following their release from SHU.
Of note, the experiences of class members in SHU were consistent with conceptualizations of
solitary confinement, which is widely accepted as being held in isolation for 22 - 24 hours each
day. Given the specific focus on class members in the Ashker settlement, the purpose of the
current analysis and report was not to review all applications of solitary confinement (for
example, the impact of isolation for periods of less than 10 years); however, the present
considerations and outcomes have relevant implications for those held in the SHU or similar
conditions for any duration of time.

Methodology
In early 2017, Ashker class members received a letter (drafted by the attorneys in consultation with
the Stanford Lab) via U.S. Postal Service inquiring if they would be willing to participate in an
interview with Stanford Lab members. Ashker class members were all formerly housed in the
SHU at Pelican Bay State Prison and California State Prison, Corcoran for more than 10 years
(with some also spending time in similar units at additional facilities, including San Quentin State
Prison).
Forty-five Ashker class members now housed in California State Prison, Sacramento (SAC);
Salinas Valley State Prison (SVSP); and Kern Valley State Prison (KVSP) were randomly selected
by the Stanford team and invited for interviews. Thirty class members accepted the invitation
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and all but one of them were subsequently interviewed using a semi-structured and focused
interview format. The survey instrument was carefully designed by the Stanford Lab over a
period of several weeks to gain subjective, qualitative responses in three general categories of
information: mental health symptoms acquired in SHU; symptoms that persist and/or new
symptoms that have surfaced during the post-SHU period, in most cases while being housed in
the general prison population (GP); and insights into potentially beneficial resources for prisoners
following long-term isolation. The Stanford Lab also asked class members to reflect on how their
fellow SHU inmates fared. Each interview was conducted during prison visiting hours with the
class member, an attorney from the Plaintiffs’ monitoring team1, and an interviewer from the
Stanford Lab (interviewers included a licensed psychiatrist, licensed clinical psychologist, clinical
psychology doctoral student, and a human rights investigator).
Stanford Lab members drafted individual reports summarizing each interview. The team then
collectively reviewed the individual reports to identify common themes and notable aberrations
with a focus on making informed suggestions to improve outcomes for class members’ post-SHU
experience. The noticeable trends, which are discussed below in further detail, reveal that the
clients suffer a range of mental health consequences following their prolonged isolation, varied
responses to the post-SHU experience in GP, and ongoing psychiatric, medical, social, and
functional difficulties.

Acknowledgement of Limitations of the Consultation
By interviewing 29 prisoners, the Stanford Lab was able to investigate and capture a fair crosssection of the class members’ experiences so as to make credible generalizations of themes, while
allowing nuances to highlight the diversity of experience and opinion. Patterns were detected
across the class members’ narratives, and sound information could be gleaned about the mental
health symptoms associated with SHU, and how these symptoms hindered — and continue to
hinder — clients’ psychology and social capacity since release from SHU.
That said, the Stanford Lab recognizes that relying upon the consent and ability of the class
members to participate in interviews likely inserts some selection bias into the grouping, meaning
the perspectives and experiences of individuals interviewed do not likely represent those
prisoners who faced or face the most severe challenges from their time in isolation. This project
only represents narratives from class members who were able to affirmatively respond to a letter
sent by the Ashker attorney group; this excludes narratives from men yet to be released from SHU,
men who did not survive SHU, men who were transferred to a mental health unit, and/or men
who were either not able to answer the invitation or unwilling to consent. While this creates a
potential bias, it likely selects for persons with higher cognitive abilities and better mental health

1

Three interviews were conducted without a member of the legal team owing to an administrative complication.

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states. Therefore, the current report presents a summary of the psychological impact of SHU
among what are likely the most resilient and resourceful of the former SHU prisoners.
Another factor that may influence the quality and quantity of the information obtained is a
general reluctance among prisoners to acknowledge mental and emotional distress. While all
interviewees gave consent to participate and were willing to talk openly about their experience,
their stories might not capture the entirety of what they went through in SHU and during the
transition to GP, as prisoners may be hesitant to disclose the full extent of the psychological harm
they have experienced for a number of reasons. Mental health stigma is a problem in the general
community that appears to be exacerbated within the prison system.2 Multiple class members
explained that it is important to avoid appearing weak or vulnerable in front of other prisoners.
They also stated that emotional expression is often considered to be a sign of weakness in prison
culture. Some class members began the interviews by discussing their strengths and resilience,
and only opened up about emotional difficulties after getting comfortable with the interviewer
and being asked more specific questions.
Another potential challenge to using a voluntary interview format is emotional numbing and
minimization of distress. Nearly all class members reported experiencing emotional numbing
during their time in SHU. Many class members reported ongoing difficulties with experiencing
emotions, which might affect their ability to recall their emotional state in SHU and during the
transition. As noted by Stuart Grassian (2006), many prisoners view prolonged confinement as an
attempt to break them down, mentally and physically. In this case, prisoners may view
acknowledgement of psychological symptoms as evidence of being successfully “broken,” which
could cause even greater distress and damage to their sense of self.3 Finally, some class members
expressed a fear of being labeled as mentally ill and subsequently forced to receive psychiatric
medication or intervention from the California Department of Corrections and Rehabilitation
(CDCR).

2

"Furthermore, many inmates cite an undesirable degree of social risk in identifying oneself as being in need of
mental health intervention or taking psychotropic medication. They report that inmates and staff see such behaviors
as evidence of a weak or broken status.” (Cloyes et al., 2006, p. 762)
3

"Many inmates housed in such stringent conditions are extremely fearful of acknowledging the psychological harm
or stress they are experiencing as a result of such confinement. This reluctance of inmates in solitary confinement is a
response to the perception that such confinement is an overt attempt by authorities to ‘break them down’
psychologically, and in my experience, tends to be more severe when the inmate experiences the stringencies of his
confinement as being the product of an arbitrary exercise of power, rather than the fair result of an inherently
reasonable process.” (Grassian, 2006, p. 333)

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Mental Health Consequences of Long-term Isolation
As aggregated, the class member narratives indicated that most of the men experienced severe
psychological disturbances with lasting detrimental sequelae as a result of their experience in
SHU. The Stanford Lab’s interviews revealed a range of common impairments and adverse
consequences associated with long-term, indefinite incarceration in SHU. These include mood
deterioration and depression, intense anxiety, emotional numbing and dysregulation, cognitive
impairments, and modifications in perception of time. In addition, all the interviewees reported
distressful relational estrangement with family and/or friends. Psychiatric symptoms and
diminished capacity for socialization continue to cause psychological suffering and problems with
social function for most of the men now within the GP.

Inventory of Mental Health Impairments Acquired in SHU
Mood The majority of class members endorsed a number of negative mood symptoms such as
irritability, intense anger, anhedonia (an inability to feel joy), hopelessness, and depression.4 Class
members described their emotional experience in SHU as “desolate,” “stale,” and “like a robot.”
4

A study of 34 inmates in Kentucky by Miller and Young (1997) indicated that inmates in disciplinary solitary
confinement experience greater feelings of inferiority, withdrawal, and isolation than the general prison population,
and greater feelings and actions of aggression than both the general prison population and inmates held in
administrative segregation.

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Nearly all class members reported sleep difficulties including severe insomnia and inability to fall
asleep owing to intrusive thoughts.5 Class members also reported experiencing fatigue, loss of
appetite, and feelings of guilt. A number of class members reported having thoughts of ending
their life.6 Some class members also witnessed the suicide or self-harm of others. These
symptoms are consistent with the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) diagnosis of Major Depressive Disorder (American Psychiatric Association, 2013).7
Also, while some class members were able to remain hopeful, many became despondent and
believed that they would die in SHU. Class members recalled thinking that the only way they
would get out of SHU prior to the Ashker settlement was to “debrief, parole, or die.”

Anxiety Nearly all class members reported experiencing anxiety8 symptoms characteristic of
DSM-5 diagnoses of Panic Disorder, traumatic stress disorders, and/or obsessive compulsive
disorders (American Psychiatric Association, 2013). Symptoms included nervousness, worry,
increased heart rate and respiration, sweating, muscle tension, hyperarousal, paranoia,

5

Andersen, et al. (2000) found, through repeated measurements over four months of Danish prisoners without prior
mental illness, that SHU prisoners were significantly more likely than those in general population to develop
psychiatric disorders, particularly related to anxiety, depression, irritability, worrying, insomnia, difficulty
concentrating, and passivity.
6

Single-cell SHU housing has been found to be a significant suicide and self-harm risk factor in other studies (Kaba,
et al., 2014; Kupers, 2008; Patterson & Hughes, 2008; Roma, et al., 2013; Reeves & Tamburello, 2014; Way et al.,
2005).
7

A longitudinal study comparing Danish prisoners in solitary confinement and those not in solitary confinement by
Andersen, et al. (2003), found that scores of psychopathology (including anxiety and depression) decreased for nonSHU inmates over the first 2-3 months of imprisonment, but remained the same for SHU inmates (improvement was
likely due to being removed from drugs, alcohol and treatment of withdrawal). Once inmates were moved from SHU
to non-SHU their psychopathology scores improved.
8

In his study of 100 Pelican Bay inmates in SHU, Haney (2003) found that 91% reported anxiety, 84% chronic
lethargy, 84% difficulty sleeping, 70% impending nervous breakdown, 68% heart palpitations, 63% loss of appetite
and 55% nightmares.

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nightmares, intrusive thoughts,9 and fear of losing control. Multiple class members reported
experiencing akathisia, or the feeling of “wanting to crawl out of one’s skin.” Class members
reported feeling compelled to engage in repetitive behaviors in order to reduce their anxiety.
These behaviors include obsessively organizing their belongings, keeping strict daily routines, and
excessively cleaning their cells.10 Individuals who endorsed obsessive compulsive spectrum
symptoms reported feeling highly distressed when their routine was interrupted or their
belongings were disturbed. Additionally, some class members reported experiencing hyperarousal
and paranoia. These individuals became increasingly suspicious of others and bothered by
benign noises.

Emotional Numbing Class members cited emotional numbing and desensitization as the
most common responses to SHU living. Many class members described becoming “emotionless,”
numb, or detached during their time in SHU.11 They expressed a need to intentionally suppress
9

Cloyes, et al. (2006) found that 69% of those surveyed show psychosocial impairment and/or meet criteria for
serious mental illness. Authors highlight “thought disturbances,” which include “conceptual disorganization,
hallucinatory behavior, unusual thought content,” and are the subscale equated with with “serious psychotic illness.”
10

Grassian (2006) found obsessive thoughts common and notes the prevalence of obsessive behaviors in prisoners
of war held in solitary confinement and postoperative, bed-confined heart surgery patients; granted, the conditions
of SHU inmates are very different.
11

In their studies of social exclusion with nonincarcerated populations, subjects in Twenge, Catanese, & Baumeister
(2003) displayed emotional numbness, reduced empathy, passivity, and lethargy.

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their emotions in order to cope with their experience.12 They reported feeling disconnected from
emotional experiences (particularly for emotions involving a level of vulnerability, such as sadness
or fear) and also reported an inability to control or regulate certain emotional responses, such as
anger. Class members indicated that displays of emotion were considered a form of weakness in
SHU culture. Additionally, many class members reported that the act of suppressing emotions
was a necessary coping strategy in SHU. Many class members felt like they had to “shut
everything out.” Oftentimes, the only emotion class members allowed themselves to feel was
anger, which could erupt from seemingly benign encounters or interactions. This sense of
emotional overcontrol and dysregulation continues to be problematic for prisoners following the
transition to GP.
Cognition Cognitive deficits appear to be some of the most pronounced consequences of longterm isolation. Problems with attention, concentration, and memory were some of the most
commonly reported responses to SHU. Most, if not all prisoners experienced changes in
attention span and memory deficits during their time in SHU. Multiple class members cited a loss
in ability to focus while reading and an inability to retain new learning. The class described
cognitive difficulties as persistent and worsening.13
Class members reported changes in thought content throughout the duration of their stay in
SHU.14 Some individuals had ruminative thoughts about the past, their feelings of guilt, or the
injustice of their situation. A number of interviewees also reported experiencing invasive or
unwanted thoughts. Moreover, they endorsed paranoid thought processes, and described feeling
anxious around and distrustful of correctional officers or any CDCR staff. Some class members
reported experiencing auditory hallucinations and delusions of a paranoid nature. Only one
interviewee reported visual hallucinations.15

12

This aligns with the findings of Haney (2001) that “emotional over-control, alienation, and psychological
distancing” are psychological adaptations that many SHU prisoners employ, often creating a “prison mask” of
emotional flatness. Emotional numbing, in combination with hyper-vigilance and suspicion, which are also common
psychological adaptations, often leads to social withdrawal.
13

Extrapolating from beyond the prison environment, a study of 823 elder adults by Wilson et al. (2007) found that
loneliness led to significant declines in global cognition, semantic memory, perceptual speed and visuospatial ability,
as well as increased risk of Alzheimer’s disease.
14

In a study of 152 Danish SHU prisoners and 193 non-SHU prisoners, Sestoft, et al. (1998) found that risk of
admission to the prison hospital for psychiatric problems was higher and increased in relation to amount of time
spent in SHU.
15

Grassian (1983) found that five of the 15 SHU inmates he interviewed reported experiencing auditory
hallucinations and three experienced visual hallucinations. Additionally, there exist several studies that indicate that
sensory deprivation and isolation induce hallucinations (Goldberger & Holt, 1961; Heron, Doane & Scott, 1956;
Lipowski, 1975), but the test subjects were mostly college students held in brief confinement.

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Alterations in Perception
One of the most common reported responses to long-term
isolation relates to lasting changes in perception. Class members consistently reported a marked
shift in their perception of time while in SHU, stating that in some cases days seemed longer,
while in other instances “time became a blur.”16 Additionally, class members reported becoming
highly sensitive to environmental stimuli, including loud noises and sudden movements.17
Moreover, they reported ongoing fear of crowded spaces.

Relational Estrangement Nearly all class members reported losing relationships with family,
friends, and significant others as a result of their isolation; several class members recalled that the
deterioration of relationships with parents, partners, siblings, and children marked some of the
most difficult experiences in SHU. According to most individuals interviewed, contact from their
personal networks outside the prison system was often limited to notification that a family
member had died. Class members reported being unable to properly grieve these losses, because
they could not allow themselves to feel emotions associated with grief. One individual stated that
he was unable to feel anything when his ex-wife, uncle, and nephew died within a short time
period, because he “just had to keep going.”

16

Drawing upon general research, Twenge, Catanese, & Baumeister (2003) found that time distortion, an indicator of
being in a “deconstructed state,” which is common in suicidal individuals, increased after experiencing social
rejection within the experiment.
17

Solitary confinement prisoners in Maine State Prison also reported that the slightest noise, such as knocking on a
cell door, resulted in feelings of uncontrollable anger. General prison population prisoners did not report such
feelings (Benjamin & Lux, 1997).

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Physical Health Several class members dealt with severe medical problems while in SHU;
some were treated successfully, others less so. In some cases, these physiological problems appear
to have developed as a result of the physical conditions of the SHU (for example, confinement to
small spaces, lack of exercise). These include chronic pain, vitiligo, joint problems, and visual
impairment, and many of these health consequences appear to continue well after transition out
of SHU. There are a few environmental factors that increase the risk of health problems for
people in long-term isolation. Lack of sunlight, for example, can lead to Vitamin D deficiency,
which increases the risk of bone fractures (Williams, 2016). Lack of exercise also contributes to
an increased risk of hypertension, arthritis, and heart disease (Williams, 2016).
Older prisoners may be particularly susceptible to chronic health problems and the health
consequences of reduced quality of medical care; the average number of chronic medical
conditions found in prisoners above the age of 55 is three (Williams et al., 2013). Research
suggests that prisoners are more likely to be functionally impaired by health problems compared
to non-prisoners. This means that prisoners have more trouble managing their illnesses and
adapting to worsening health. Physical difficulties are likely to be compounded by untreated
mental disorders and psychosocial impairment.

Social Impairments As previously noted, most class members lost contact with their personal
networks while in SHU. Moreover, they frequently reported losing, over time, the motivation to
seek social connection as well as a willingness to talk about their experience. Some became afraid
to communicate with others because of how this might be perceived by correctional officers or
Institutional Gang Investigators (IGI). Many class members expressed a belief that any personal
connection could be misinterpreted as gang association, which would likely lead to longer terms
in SHU. The majority of class members reported having highly negative relationships with
correctional officers.
Class members who were able to maintain supportive relationships throughout their time in SHU
appear to be outliers, though those who were successful in doing so seemed to show improved
mental health overall. In other words, maintaining social connection appeared to be a protective
factor against negative outcomes in SHU, meaning those with strong family ties demonstrated
enhanced resilience to their SHU experience. Also, class members who reported having external
social support or positive relationships with other prisoners, including cellmates, found themselves

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better able to cope. Additionally, class members who affiliated themselves with others who shared
the same political ideology, for example the New Afrikan Revolutionary Nationalism, or who
created opportunities for mentorship, perhaps of younger prisoners, reported a greater sense of
purpose and fulfillment.
Functional Deterioration It was the perception of most men interviewed that their overall
functioning in multiple spheres was damaged by their time in SHU. They report the capacity for
normal social interaction as the primary area of dysfunction after SHU. They also report lasting
and ongoing dysfunction in mood, anxiety, and cognition.
The Experience of Others in SHU Class members reported that other prisoners in their
SHU pods demonstrated evidence of mental disturbances, and that witnessing the suffering of
others was distressing. Class members reported losing friends in SHU due to suicide,
psychological deterioration, and death as a result of medical issues. Additionally, class members
saw others engage in self-harm and violence at a level that was described as “heart-breaking.”
Some class members reported that inmates in neighboring cells would talk to themselves, scream
constantly, and speak in non-linear patterns. Some class members reported that neighbors
attempted or completed suicide. Some neighbors were transferred to mental health units because
they were “too crazy.”
A number of class members stated that the primary purpose of SHU “is to break you.” They
reported feeling targeted by correctional officers, and being unable to communicate openly. Class
members explained that it was important to “keep thoughts to yourself ” in SHU. Conflict with
correctional officers and IGI appeared to be a significant source of distress among class
members. In a number of interviews, class members reported being treated unfairly by
investigators who were seeking reasons to validate their status as members of prison gangs. For
example, class members reported distress at having personal belongings, documents, and records
confiscated; these items were often alleged to be evidence of gang affiliation, though class
members stated that such claims were unsubstantiated and often interpreted such interactions as
forms of harassment or provocation.

Interview Results Consistent with Existing Literature
The social and psychological responses to SHU described above are consistent with the majority
of current literature on prolonged isolation. In one of the most notable publications, Grassian
(2006) described a specific syndrome associated with social isolation and sensory deprivation.
Similar patterns of psychological dysfunction have been documented in empirical literature on
prolonged solitary confinement. A number of researchers have observed the behavioral patterns
of individuals confined long-term and found consistent detrimental outcomes (Arrigo & Bullock,
2008; Cloyes et al., 2006; Grassian, 1983; Grassian & Friedman, 1986; Grassian, 2006; Haney,

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1993; Haney, 2003; Haney, 2006; and Lovell, 2008). Individuals in SHU exhibit increased risk for
a wide range of psychiatric symptoms and disorders including depression, impulse control
disorders, self-mutilation, and suicidal behavior (Haney, 2006). Prisoners in SHU also experience
disproportionately high rates of general anxiety, symptoms of panic disorder, and difficulty with
concentration, memory, and attention (Grassian, 1983; Grassian & Friedman, 1986; Grassian,
2006). Increased rates of psychotic symptoms, including paranoia, hallucination, and delusions
have also been correlated with long-term isolation (Cloyes et al., 2006; Lovell, 2008; Grassian,
1983, 2006).
Additional cited outcomes of long-term solitary confinement include insomnia, intense anger,
ruminations and intrusive thoughts, and social withdrawal (Cloyes et al., 2006; Haney, 2003;
Grassian & Friedman, 1986; Grassian, 2006). Psychiatric symptoms have been found to vary
based on the degree of sensory deprivation and social isolation (Arrigo & Bullock, 2008). The
writers of this report are familiar with Grassian’s concept of “SHU syndrome,” which is
comprised of “massive free-floating anxiety, hyper-responsivity to external stimuli, perceptual
disillusions, hallucinations, derealization experiences, difficulties with thinking, concentration,
memory, acute confusional states, aggressive fantasies, and paranoia” (Grassian, 1983, pp.
1452-1453). While the information obtained from the interviews does appear to align with
symptoms of SHU syndrome, making retrospective claims regarding the presence or absence of
SHU syndrome in Ashker class members is beyond the scope of the current report.
There is some conflict within the field and it is necessary to acknowledge critiques of these
studies, as well as assess the validity of conflicting literature. A report by Haney and Lynch in
1997 has been criticized as being overly reliant upon interviews and self-report as opposed to
scientifically rigorous experimentation (Kurki & Morris, 2001), while the reports of Grassian
(1983) and Grassian and Friedman (1986) have been challenged due to their reliance upon a
study population of only 14 inmates. A number of researchers contend that solitary confinement
is not conclusively detrimental (Bonta & Gendreau, 1990; O’Keefe et al., 2010; Suedfeld et al.,
1982; Zinger et al., 2001), but there are valid criticisms of these countering studies as well.
Primarily, the literature reviewed by Bonta and Gendreau (1990) relied heavily upon studies
involving volunteer subjects, short-term solitary (up to 10 days), and healthy subjects without preexisting conditions (Kurki & Morris, 2001). The authors emphatically make clear that they are
not arguing in favor of solitary confinement, and raise important questions: individual response
to the conditions of solitary confinement may be different, further research is necessary to
understand if solitary confinement effectively deters harmful behavior, and humane alternatives
must be explored (Bonta & Gendreau, 1990). O’Keefe, et al. (2010) presented controversial
findings that while both prisoners in solitary confinement and prisoners with mental illness in the
general population exhibited SHU symptoms, over time, 20% of SHU inmates improved. The
authors acknowledge not only that the results should not be generalized given the unique
conditions of Colorado SHU, but also that the research was limited due to the utilization of
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group averages and collection of psychological well being and behavior measures by prison
clinicians and correctional officers (Smith, 2011). The report by Suedfeld et al. (1982) was limited
by insufficient breadth of psychological measures and an inability to include subjects with severe
responses to SHU due to the fact that they could no longer be interviewed (Ogloff, 2008). They
did find that increased time in solitary was linked to anxiety, depression, hostility, and other
negative emotions, but that it was not “overwhelmingly adverse” (Suedfeld, et al., 1982). The
study is focused primarily upon the idea that responses to solitary confinement are individual and
not always deleterious, which is an important area of investigation. Lastly, Zinger, et al. (2001)
found that segregated inmates exhibited more depressive symptoms and anxiety than nonsegregated inmates, but did not find evidence that mental health had significantly deteriorated.
These longitudinal accuracy of these findings is challenged due to the fact that the experiment
lasted merely 60 days (Metzner & Dvoskin, 2006), and the attrition rate proved problematic given
that only 15% of 83 subjects completed all three phases of the testing and that ratios of
voluntary SHU subjects to involuntary were no longer accurate (Ogloff, 2008). Overall, the
literature indicates that solitary confinement negatively impacts the psychological well-being of
inmates (Pizarro & Stenius, 2004).

Experiences in the General Population Following Release from SHU
While the experiences and impact from time in SHU reported to Stanford Lab researchers are
consistent with the previous body of evidence regarding outcomes of prolonged isolation and
solitary confinement, the current analysis offers new important information regarding the lasting
impact of indefinite, long-term isolation following release. Little previous research or analysis has
been conducted with ex-SHU inmates following their release into GP or the general public at
large.18 At the time of these interviews, the amount of time elapsed since class members had
been released from SHU averaged approximately 14 months (ranging from 4 months to 2 years
since release). While many class members reported shock during their initial transition to GP
(described in greater detail below), this transition is not a finite process, and many class members
continue to experience significant difficulties up to two years post-SHU; many individuals are
likely to continue to struggle with the impact of the SHU experience into the foreseeable future.
General Responses to the Post-SHU Experience
In general, class members felt
overwhelmed by and underprepared for the post-SHU experience in GP. Class members
described the experience of GP as totally foreign and overwhelming (e.g., “like going to Mars”).
The class members reported no preparation or information offered by CDCR to explain the
18

"Presently, there are no published studies that answer such important questions as whether prisoners who spent
time in restrictive housing develop PTSD as a result of the experience. Likewise, no studies address whether
restrictive housing prisoners experience long-term changes in psychosocial functioning following release into the
community (e.g., getting a job, reconnecting with friends and family, finding stable housing)." (Kapoor & Trestman,
2016)

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transition; many thought this would have been helpful to set expectations. Class members’
reactions and adjustments to living in long-term SHU largely proved maladaptive within the
context of the general prison population.

Class members reported a wide variety of transition experiences. Nearly half of individuals
reported participating in the “Step Down Program” (SDP), which is designed to change attitudes
and lead prisoners out of gangs. This program involves four stages that must be completed in
order to earn privileges and eventually be released from SHU.19 Prisoners who participated in the
SDP reported few benefits, and many class members found aspects of the program to be
unhelpful and disingenuous, particularly referencing the journals they were asked to keep. The
majority of class members who commented on the benefits of SDP credited the improvements to
increased social interaction and psychosocial education. A number of class members found
learning skills such as “cognitive restructuring” and similar therapeutic tools to be useful during
the transition. However, prisoners also reported problems with program implementation,
including coercion and conflicts of interest with correctional officers facilitating group discussion.
Prisoners did not report receiving any transitional support aimed at mitigating distress related to
the overwhelming nature of the transition to GP from SHU. The great majority of class
members denied any benefit of SDP in the absence of social interaction and mutual respect and
understanding.
19

In CDCR, the SDP occurs entirely within the SHU, and is not a transitional housing placement.

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Based on class member reports, experiences of feeling overwhelmed and underprepared
appeared to stem from the drastic contrast between the physical, social, and sensory
environments of SHU and GP, and the lack of an effective transition program. Class members
reported being shocked and overwhelmed by the cacophony of the GP environment, and they
reported hypersensitivity to the sounds and noises there. Many class members experienced
distress as a result of being “overstimulated” in GP. Routines and expectations regarding periods
of quiet and silence that had evolved over the many years in SHU were completely undermined
in GP, resulting in discomfort and disturbance for many post-SHU prisoners. Expectations
regarding cleanliness and organization were disrupted or unattainable in GP. Similarly, the highly
structured and closely supervised daily procedures and transitions in SHU were found to be
largely absent in GP. While many class members had developed rigid routines, daily schedules,
and expectations as a means of adapting to their time in SHU, living in GP required them to redevelop greater flexibility in their daily functioning. The loss of routine and stability in daily
functioning, and the related lack of predictability and demand for flexibility, was jarring and
distressing for class members, resulting in feelings of anxiety, nervousness, irritability, and a sense
of isolation and disconnection, exacerbated by the lack of any transition preparation. While class
members overwhelmingly asserted that GP was an improvement over life in SHU, the difficulties
experienced post-SHU are indicative of the impact of long-term isolation on normal functioning
and the extent to which adaptations to the SHU environment prove maladaptive in other
contexts, underscoring the need for programs and supports to assist in adapting to life post-SHU.
Class members also reported being unprepared for the increase in social and physical interaction
in the GP environment. Many did not anticipate or realize the discomfort they would feel in
having to interact with unfamiliar prisoners, and in experiencing violations in their expectation
for personal space and physical contact. For example, multiple class members reported difficulty
and distress in making eye contact and greeting other prisoners in GP. One class member
reported feeling as though “bugs were crawling” under his skin, because he was so unfamiliar
with being around people. Some found the communication styles they had developed in SHU to
be problematic and maladaptive in the context of GP. Many class members also reported
difficulty with a perceived change in prison culture during the time they were in SHU. In
particular, they noted difficulty with the younger generation of prisoners, in which there is “no
moral code.” Overall, class members described a general sense of being “out of place” and
“unfamiliar” in GP, resulting in a failure to achieve a sense of belonging, security, or personal
identity in their life outside of SHU.
Class members described experiences that frequently and continually created the perception that
they were being targeted by prison officials, guards, and IGI, not to mention treated differently by
fellow prisoners, because of their post-SHU status. Class members report that they are viewed as
dangerous, treated with disrespect, watched closely and searched frequently, granted fewer
privileges, and intentionally pushed to instigate an anger response (e.g., through disruption of
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routines or living environment, or destruction of personal belongings). Class members reported
the perception that prison officials wanted them to be back in SHU and were looking for reasons
to put them there. Such themes of harassment and discrimination by prison officials were a focus
of over half of the class member interviews. Class members report that their sense of being
watched, scrutinized, and targeted because of the their post-SHU status leads to increased
anxiety, distress, anger, and paranoia.
In general, class member reports demonstrate that the post-SHU experience in itself had
negative psychological consequences, contributing to experiences of irritability, hypervigilance,
and anxiety (discussed in further detail below) particularly in the absence of appropriate
transitional or support programs that might have mitigated these impacts. This distress
experienced in GP compounded the already existing negative impact and functional impairment
caused by the many years of being held in long-term isolation.
Nonetheless, class members reported some positive responses and beneficial aspects of the postSHU experience, such as witnessing nature (seeing mountains and the moon, for example),
increased social interaction, increased physical activity, and having increased contact with family.
Clearly, living in GP provided an improvement in quality of life over SHU, despite class members
living with the lasting psychological insult and functional impairment related to their many years
in SHU. However, the lack of programming, significant restrictions, limited mobility, and
repeated distress and disruptions experienced by ex-SHU prisoners in GP led some class
members to describe their experience in GP as a “modified SHU.”

Ongoing Psychiatric Problems Post-SHU Class members endorse lasting and ongoing
psychological difficulties since being released from SHU. These include anxiety and posttraumatic stress, obsessive and compulsive behaviors in an effort to re-impose order, and
continued mood dysregulation, emotional numbing, and cognitive impairment. Class members
coming out of SHU also report the emergence of metacognitive reactions, which is to say they
become aware of their own psychological impairments vis-à-vis others around them; this itself
becomes a source of additional anxiety. Class members also report psychosomatic complaints as
well as renewed substance abuse.
While some class members report that their psychiatric symptoms and psychological difficulties
(including anxiety, mood instability, obsessions/compulsions, and cognitive impairment) have
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gradually declined over time as they have adjusted to living in GP, others report sustained severity
and frequency of such symptoms even after periods of over two years since release from SHU.
Anxiety, Post-Traumatic Stress, and Hypervigilance Class members commonly reported
ongoing anxiety and posttraumatic stress symptoms in their post-SHU experiences. Nearly all
class members reported experiences consistent with an ongoing anxiety or trauma-related
psychiatric disorder (such as panic disorder, generalized anxiety disorder, and posttraumatic stress
disorder (American Psychiatric Association, 2013). Specific difficulties endorsed by class members
include pervasive hypervigilance, worry, and nervousness; some described experiences of being
on constant alert and chronically feeling under threat or danger. In the post-SHU experience in
GP, class members report living in an perpetual state of fear, in which they feel their safety and
well-being is under threat, and some report ongoing intrusive worries and re-experiencing
symptoms (such as nightmares).
While such feelings may generally be expected for any inmate in GP, class members’ experience
of anxiety and hypervigilance appeared to be exacerbated by the SHU experience: following a
prolonged period of incarceration in a highly structured and contained environment, exposure to
the chaotic, disorganized, and unpredictable GP environment leads to a heightening of
symptoms and distress. Class members described that, when in SHU, any time out of the cell and
in common areas was associated with potential threat or danger (e.g., due to potential attack from
other inmates). Therefore, the post-SHU experience involved increased exposure to contexts and
environments associated with threat or danger, thereby exacerbating anxiety symptoms. Class
members report particular anxiety in social situations and/or crowded settings: they report
feeling uncomfortable, nervous, and jittery when around groups of people, and find themselves
constantly scanning their surroundings. They avoid situations and settings in which they do not
have a clear view of, or cannot closely monitor, their surroundings and the movements of others.
Many class members endorsed sensory sensitivity following their release into GP, noting
experiences of distress, anxiety, paranoia, and irritability particularly in response to the noise and
sounds of GP. In addition, class members report sensitivity to physical touch, which continues to
elicit exaggerated startle and discomfort for many class members.
In addition, class members report that periods of lockdown in GP are triggering and retraumatizing, and that they invoke re-experiencing symptoms of posttraumatic stress disorder
(such as flashbacks in which one feels that he is reliving the traumatic experience, in this case, the
experience of being held in SHU). Many class members report a pervasive and ongoing fear of
returning to SHU, which is often exacerbated by their interactions with prison officials. In some
cases, class members reported ongoing paranoia stemming from their anxieties and worries.

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Obsessive-Compulsive Behaviors
Class members report lasting obsessive-compulsive
thoughts and behaviors, primarily related to continued desire for cleanliness, order, and
organization in their living environment. The rigid routines, rituals, and compulsions that
developed while in SHU were also present for many class members following their transition to
GP; more than half of the class members interviewed endorsed ongoing difficulties in this area.
For example, many class members endorse experiences of irritability, anxiety, frustration, and
general distress when belongings are perceived to be out of order or unclean; they continue to
spend significant amounts of time and effort engaged in obsessive perseveration and compulsive
rituals. These obsessions, compulsions, and rigid routines sometimes result in interpersonal
conflict with others (cellmates, peers, prison officials).
Mood Dysregulation Class members describe lasting mood difficulty, typically marked by
anger, irritability, and emotional instability. Experiences of anger and aggression were often
linked with feelings of heightened anxiety, nervousness, and threat that are common in the GP
environment. Lasting mood impairments, which were endorsed by the majority of class
members, also include symptoms consistent with depression, including negative mood, lack of
motivation, anhedonia, and sense of isolation. Class members describe and exhibit continued flat
affect and signs of emotional numbing that arose while in SHU. In many cases, experiences of
anger, irritability, negative mood and affect, and other depressive symptoms carried over from the
distress and frustration that onset while in SHU; current interviews therefore confirmed this form
of distress related to the SHU experience to be lasting and pervasive following release. In
addition, class members’ heightened and ongoing experiences of anxiety and posttraumatic stress
in GP contribute to their experience of agitation, irritable mood, despair and hopelessness.
Cognitive Impairments Lasting cognitive difficulties experienced post-SHU and endorsed
by class members involve impairments with executive functioning, including attention,
concentration, and memory. Approximately two out of every three class members report current,
ongoing (at time of interview) difficulties with attention, concentration, and memory. Class
members report lasting difficulty in sustaining attention (e.g., while reading or writing),
comprehending information, remembering factual information and names, and the perception
and estimation of time. Some class members note feeling “slow” and “disorganized” in their
psychological and cognitive functioning. For some, these difficulties arose while in SHU, while
others note the onset of cognitive impairment only following their release from SHU, which they
attributed to the stress of being in GP and the overwhelming transition away from the highly
structured SHU environment. Lasting and pervasive impairment in executive and cognitive
functioning is common in response to chronic and traumatic stress exposure, due to the
biochemical impact of the stress response on brain structure and function (Polak et al., 2012).

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Metacognition Class members report varying meta-cognitive and meta-emotional reactions
during their post-SHU experience.20 While some class members report and demonstrate ongoing
emotional numbing and limited insight regarding their cognitive and emotional experiences
(which commonly onset while in SHU), others report increased awareness of their psychological
distress and functional impairment as they integrated into GP. Class members’ heightened
awareness of their own psychological impairment proved for many to be an additional source of
distress and despair, contributing to attributions that they are damaged and that their situation is
hopeless.
For example, as one class member became more aware of the atypical nature and the severity of
his obsessions with order and cleanliness, he became increasingly frustrated and distressed by his
compulsions and behavioral tendencies. In other cases, class members report distress and concern
in reflecting on their lack of emotional response to the death of close family members. In
addition, many class members struggle with feelings of guilt and shame about the emotional and
behavioral difficulties they experienced while in SHU. While difficulties with emotional and
behavioral regulation (e.g., anger outbursts) are a common and expected reaction to living in
SHU conditions, class members often internalized and personalized their difficulties. Class
members’ attributions of their difficulties often resulted in self-blame, rather than consideration
of the context in which they were living. The meta-cognitive and meta-emotional processes
described above and endorsed by class members are common core components of depression,
anxiety, and posttraumatic stress disorders.
Somatic Complaints Class members report numerous ongoing psychosomatic complaints
that are commonly associated with depression, anxiety, and posttraumatic stress. Such somatic
symptoms include chronic pain, fatigue, difficulty sleeping, and nausea/digestive irritability;
somatic difficulties were endorsed and discussed in nearly half of the interviews.
Substance Abuse Some class members report the onset or exacerbation of substance abuse
and substance dependence problems following their transition to GP. Incidences of new
substance abuse and addiction problems were attributed both to (1) the intensified anxiety and
emotion dysregulation associated with the transition to GP, and (2) increased availability and
access to alcohol and drugs in GP relative to SHU.
Other Health Problems and Difficulties
Class members report other ongoing health
difficulties during their post-SHU experience in GP. Many individuals report psychosomatic
complaints including chronic pain, fatigue, insomnia, psychomotor retardation, and weakness. In
addition to the psychological factors contributing to these health difficulties, the presence of such
20

Meta-cognition and meta-emotion refer to one’s own awareness of one’s thoughts, feelings, and ability to
function.

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problems may also be attributed to the limited physical activity, the nature of the physical
environment, and quality of care provided in SHU. For some class members, the quality of food
and health care in SHU contributed to and exacerbated existing health conditions. For example,
class members with poorly managed diabetes report worsening of neuropathy, which is
permanent. In addition, many class members attribute significantly elevated blood pressure and
cholesterol to their diet in SHU, though the chronic stress experienced in the SHU environment
is also likely to be a contributing factor with lasting consequences. Many class members reported
contracting Hepatitis C while in SHU.
Over half of all class members reported deterioration in their vision during their time in SHU,
which appears to be lasting and permanent. Many class members were not aware of the
deterioration in their vision until they were released from SHU. A majority of class members
now wear corrective lenses, and some report ongoing sensitivity to light.
Ongoing Social Interaction Problems
A primary lasting outcome of SHU and the
transition experience experienced by class members is the impairment in social functioning.
Over two-thirds of the class members interviewed endorsed ongoing anxiety and difficulty
functioning in social situations. As described above, class members noted difficulty and distress in
social interactions both while in SHU and while in GP post-SHU. Class members reported
feeling nervous and uncomfortable in social interactions, leading to behavioral avoidance of
social contact. They describe themselves as newly quiet, awkward, timid, and generally
overwhelmed by social experiences. They are unable to engage new relationships, as many report
lasting difficulty with basic greetings (e.g., making eye contact, shaking hands). In addition, class
members experience lasting anxiety and hypervigilance around social interactions, citing a
distrust for others, chronic perceptions of danger, and a pervasive fear of sharing information
about themselves. These fears have clear impact on their social interactions and functioning,
consistent with the negative impact of social anxiety disorders.
After getting accustomed to social isolation, and as a result of social difficulties experienced postSHU, class members demonstrate a lasting reluctance to engage or “be close with” others,
preferring the simplicity and familiarity of isolation. Class members feel disconnected from
others, and many prefer and envision a future in which they remain isolated and independent.
Many report a lasting loss of motivation, interest, or desire to connect or socialize with others.
As an exception to this common phenomenon, class members endorse an increased level of
comfort and interpersonal effectiveness with other ex-SHU prisoners, relative to other inmates
and/or family members and others on the outside.
Class members reported lasting impairment and dysfunction in relationships with family
members and individuals outside of the prison system. The “death” of family relationships that
occurred while in SHU continues for many class members, as they have been unable to repair
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damaged relationships caused by long-term separation. Class members report an inability to
tolerate the affective responses inherently involved in family interactions, leading to further
estrangement. Class members report complex and distressing difficulties in responding to contact
visits with family members, and they describe themselves as being unable to receive affection.
Commonly reported reactions included nervousness, joy, shock, dissociation, and numbing/flat
affect. Class members reported experiencing “sensory overload” and derealization — a sense of
one’s surroundings not being real — upon meeting with visitors. They reported not knowing how
to react to physical touch or displays of kindness during contact visits, and often found themselves
feeling uncomfortable and rejecting physical and social contact with family members, despite
having a desire to improve their relationships. Many class members are keenly aware of their
social impairments, leading them to be further distressed and upset by their inability to engage
with family and their lack of emotional response to family interactions.
Class members reported difficulties forming relationships with other prisoners in GP for a
number of reasons. As noted above, many prisoners experience heightened anxiety around
crowds of people. In order to cope with the overwhelming anxiety, some individuals described
standing with their backs against the wall, or in a place where they could view everyone around
them at all times. Others used self-talk to convince themselves that people would not attack them.
As noted earlier, some class members report that their behavioral rigidity, mood lability, and
expectations regarding cleanliness and order serves as a point of conflict and source of distress in
many of their interpersonal relationships (e.g., with new cellmates) in GP. Older class members
also experienced significant interpersonal stress related to cohort differences. They report feeling
“out of place” and “out of touch,” they have a limited sense of belonging, and their personal
identity as SHU inmates does not fit within the context of GP. These class members reported
feeling anxious about blending in and communicating with the younger generation. However,
some individuals relished their ability to mentor and advise younger prisoners.
In summary, class member difficulty with interpersonal and social functioning is characterized by
dysfunction and impairment due to: anxiety, irritability, and mood instability impacting
interpersonal interactions; emotional numbing affecting engagement; social and familial
withdrawal (isolation); poor communication and lack of conflict resolution skills; lack of
connection to others influencing personal identity and worldview; reduced sense of security;
limited support-seeking and social engagement; and low confidence and self-esteem. While some
class members report gradual reductions in social anxiety, irritability, and impairment over the
course of their adjustment to GP, many report sustained severity of symptoms and impairment
with little perceived prospect or hope for future improvement.
Other Ongoing Impairment in Functioning Class members describe alterations in their
personal identity following their release from SHU. Throughout the post-SHU experience, class
members continue to struggle to see their place and value in society and in the world, as they
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came to view themselves only as prisoners during their time in SHU. Many class members
reported that, after living in isolation for so many years and being treated only as an inmate with
no value or opportunity for contribution to society, they lost their sense of self and their
motivation for industry and productivity. An individual’s self-concept and personal identity play
major roles in his decisions and actions towards education, employment, and other contributions
to society; therefore, the impairment and alteration in class members’ sense of self and sense of
purpose is likely to impact their functioning in GP and in the outside community if unaddressed.
Additionally, the pervasive and perpetual anxiety, nervousness, and sense of threat experienced
following release from SHU contributes to a sense of hopelessness and despair regarding class
members’ well-being and prospects for the future.
Class members’ ongoing difficulties with mood instability, anxiety, depression, behavioral rigidity,
and cognitive functioning are likely to impair their functioning and performance in domains of
learning/education, vocation/employment, and independent functioning/self-care. Given these
difficulties, some class members reported concerns and anxieties about their ability to function
(i.e., obtain and retain employment) in both GP and society at large. Clearly, lasting difficulties
with social interactions will impact interpersonal functioning, including family relationships,
social relationships, and peer interactions in professional settings.
The impairments described above, while consistent with various forms of psychopathology and
psychiatric illness, are not thought to be generally rooted in an underlying psychopathology or
illness. Rather, the psychological, physical, and behavioral responses of class members represent
expected adaptations to the conditions of long-term solitary confinement. Any individual living
in long-term confined isolation is likely to manifest the symptoms and functional impairments
endorsed and demonstrated by class members. For example, undergoing a process of emotional
numbing and dampening may very likely be the best way of coping with the intense emotions
associated with long-term isolation, especially given the limited resources and outlets available to
class members. Or, developing rigid, highly structured routines (which eventually evolve into
obsessions and compulsions) around order and cleanliness likely served as the best possible means
to both maintain a sense of productivity and to exert some level of control and self-efficacy in an
otherwise helpless situation. Though these adaptations helped class members survive and cope
while in SHU, they proved largely problematic and maladaptive in the context of GP, as reported
and demonstrated by class members following their release from SHU. Clearly, class members’
psychological and behavioral adaptations to SHU will also be maladaptive in the context of
general society, and are likely to impair independent functioning, social functioning, and
vocational functioning.
As demonstrated by class members who had spent one to two years in GP at the time of the
interviews upon which this report is based, these impairments are pervasive and ongoing, and are
expected to continue, especially given the length of time that these emotional, cognitive, and
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behavioral response patterns became engrained (from 10 to over 20 years). While significant and
lasting, the impairments and difficulties endorsed and demonstrated by class members are not
irreversible in many cases, and may be amenable to intervention or support. There remain
opportunities for healing, for new learning, and for successful functional re-adaptation to the
contexts of GP and larger society. While some class members may experience a natural, gradual
reduction in distress and impairment, for others, if difficulties are not addressed, their
impairments are likely to continue and worsen over time.
The information provided by this report aligns with current literature on long-term isolation and
the subjective experience of SHU. Moreover, the trends in psychosocial and mental health
responses observed by the interviewers are consistent with those identified by SHU expert Terry
Kupers. Kupers (2016) developed the term “SHU post-release syndrome” to describe the
behavioral patterns of people who are re-introduced to social environments after experiencing
social isolation and sensory deprivation. Elements of SHU post-release syndrome that are salient
to the current report include anxiety in unfamiliar places, hyper-awareness of surroundings,
heightened suspicion of others, concentration and memory problems, and a sense of one’s
personality having changed. As noted above, these reactions were among the most commonly
endorsed by Ashker class members.

Considerations for Improving Post-SHU Experiences and Functioning
Many class members reported experiencing multiple restrictions in their activities in GP due to
their status as ex-SHU inmates. They reported limited opportunities for out-of-cell time,
employment, education, and contact with families and outside supports. Such restrictions placed
specifically on ex-SHU inmates are likely to be detrimental to their functioning and recovery, and
may exacerbate existing psychological difficulties and related distress stemming from their
experience in long-term isolation. Class members directly reported that with major restrictions
and little time out of cell, symptoms similar to those experienced while in SHU remained and did
not dissipate. Class members involved in out-of-cell activities and with less restriction reported a
subjective sense that there was a higher possibility for psychological improvement.
Class members repeatedly emphasized the importance of having jobs and other programming
opportunities in GP. Class members who are participating in jobs and educational programs
reported greater satisfaction and better outcomes in GP than those who are not. Class members
who are not working expressed frustration with their lack of program placement. Some
individuals perceived that they were being purposefully excluded from programming
opportunities due to their SHU history. Employment opportunities not only correspond with
greater out-of-cell time for class members,21 but they also provide class members with a greater
21

S. Miller, personal communication, September 15, 2017.

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sense of purpose, industry, and productivity. Involvement in occupational and educational
activities was observed to be a protective factor against distress during the post-SHU experience,
and appears to promote resilience in the face of the numerous adversities described above. Class
members who are denied opportunities for employment or education can be expected to
demonstrate greater levels of psychiatric distress, poorer general health, and poorer outcomes
with regard to functioning and performance.

Class members, particularly those without jobs, stated that they would benefit from more out-ofcell time. Numerous class members suggested that education around their transition would be
exceedingly helpful in improving outcomes and functioning. As mentioned above, some class
members found the group aspect of the Step Down Program to be thought-provoking and
helpful, while others found it to be coercive and threatening. Those who were unhappy with the
program would have preferred for the groups to be peer-facilitated or run by independent
professionals rather than correctional officers. Numerous class members emphasized the value of
gaining an improved understanding of their psychological reactions to living in SHU and their
difficulties in the post-SHU environment (including gaining knowledge that others experienced
similar difficulties), which they achieved through both formal and informal interactions with
other ex-SHU inmates.
It is understandable for class members to have reservations about participating in support groups
run by correctional officers, or anyone affiliated with CDCR. An overwhelming majority of class
members (over three out of every four interviewed) suggested and requested services and support
from non-CDCR officials. Bringing in outside facilitators to host supportive groups for prisoners

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transitioning from SHU to GP would allow for more genuine reflection and communication
among prisoners. Peer facilitation would be similarly beneficial.
Many class members spent the majority of their time in SHU studying, reading, and pursuing an
education. This appeared to be a source of resilience in the face of the adversity of the SHU
environment, as those class members that found ways to use their time productively and to
extract a sense of purpose from their time in SHU appeared to be better able to cope with the
psychological impact of the SHU experience. Many of these class members expressed the desire
to give back to the community by mentoring others. While many of these efforts were selfdirected and self-initiated, there exist ample opportunities for CDCR to offer programming and
facilitate opportunities; such efforts are likely to ameliorate the negative impact of long-term
isolation in SHU.

Concepts for Improved Post-SHU Transition
The mental health professionals in the Human Rights in Trauma Mental Health Laboratory at
Stanford University are well versed in treatment modalities and useful interventions for persons
with mental health disorders and/or symptoms. Much of the mental health pathology discussed
in the interviews with class members is amenable to intervention, but mental health interventions
must be sensitive to the needs and wants of the individual in order to be effective.
First, occupational, educational, and social programs are needed to address the lasting
consequence of the long-term SHU experience. Such services can be arranged and facilitated by
CDCR. Second, emotional and psychological support services are needed. The literature on
effective, evidence-based treatment for anxiety and depression is vast. Conventional medication
and psychotherapeutic interventions are proven to treat symptoms and improve functioning. In
addition, psychoeducation regarding psychiatric symptoms and expected reactions to adversity
and trauma is an important (and sometimes the most effective) element of evidence-based
intervention. Psychoeducation helps an individual to gain insight about his struggles, helps to
normalize distress, and leads to empowerment in managing symptoms. The importance of
psychoeducation is reflected in class member statements regarding the benefits of discussing their
experiences with other post-SHU inmates.
However, the class members have expressed concerns over the administration of traditional
mental health services through CDCR. Furthermore, many class members have made it clear
that they would not seek services through CDCR because of the stigmatizing effects of
identification with psychiatriatric illness. Some class members report that they would seek mental
health services if they were offered through providers from outside CDCR in a way that was
totally confidential. For transition, it is clear that improved, earnest access to mental health
treatment is necessary, and that such access should come from non-CDCR sources. Therefore, we

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recommend that class members be offered mental health and psychological services in the form
of independent psychiatric care and/or peer-led or peer-facilitated support groups. As noted
throughout the report, prisoners seem to derive a sense of fulfillment and self-worth from
opportunities to mentor their peers; such programming could be helpful in combatting some of
the detrimental effects of time in SHU, including by diminishing anxiety and depression.
Lastly, the feedback from the narratives offers greater understanding of what other interventions
class members want to improve their transitions from SHU. Their requests (detailed above) for
greater access to jobs and other out-of-cell activities, to programs, and to therapeutic groups are
wise interventions for their symptom profiles and are likely to improve their transitions and the
long-term prospects for functioning and contribution to society.

Conclusion
In interviewing Ashker class members undergoing the transition from long-term solitary into the
general prison population, members of Stanford Lab identified a number of trends related to
prisoners’ mental health, psychosocial adjustment, and general well-being. Class members
reported experiencing a number of psychological symptoms during their time in SHU, many of
which have persisted or even worsened while in GP (after being released from SHU). The sterile
environments common in GP, in which prisoners spend almost all of their day in their cell with
little productive activity, have contributed to many class members’ continuing psychological
symptoms. The most commonly reported symptoms included hypersensitivity to stimuli, anger/
irritability, anxiety, insomnia, paranoia, emotional numbing and/or dysregulation, obsessivecompulsive thoughts and behaviors, and problems with concentration, attention, and memory. In
addition to these symptoms, class members reported difficulties adjusting to the social
environment of GP. It is clear that placing ex-SHU prisoners in GP without additional supports
or programming is insufficient to remedy the outcomes stemming from long-term isolation in
SHU. In addition, the transitional programming that has been previously implemented for the
current class was largely ineffective and insufficient.
The majority of class members expressed a need for mental health care due to the psychological
harm they endured in solitary confinement. Class members reported high levels of continuing
distress and discomfort associated with social isolation and sensory deprivation. However, the
majority of class members also expressed a significant level of distrust for CDCR mental health
services. Interviewees recognized a stigma associated with seeking mental health care within the
prison system. They worried about being labeled as mentally ill and maintaining their
confidentiality. Class members expressed concerns of appearing weak to other prisoners and of
being medicated against their will. Among prisoners who did receive mental health services
provided by CDCR, there were mixed reports. Some reported benefitting from psychiatric
medication, but did not feel comfortable engaging in talk therapy. Others expressed

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dissatisfaction with the infrequency of the psychiatric care received, which was reportedly every
90 days.
Based on the information summarized in this report, the Stanford Lab recommends reparative
services in the form of externally based (non-CDCR) mental health care and psychological
support; meanwhile, continued and enhanced occupational and other programming should be
provided by CDCR.
The Ashker class members interviewed for this report are resilient, self-educated, intellectually
curious individuals, many of whom have implemented therapeutic coping mechanisms on their
own. Class members reported benefitting from mindfulness and meditation, as well as critical
thinking and other limited group-based therapeutic experiences. Additionally, class members who
were involved in jobs and other programming at the time of interview appeared to adjust to GP
significantly better than those who lacked similar opportunities. During the course of interviews,
it became apparent that when class members are offered opportunities for supportive
programming, education, and vocational training that are deemed relevant and are offered by
trusted sources, they capitalize on such opportunities towards the ends of personal development
and societal contribution. The Stanford Lab therefore recommends that CDCR and other prison
authorities seek to offer adequate and enriched programming opportunities (including vocational,
educational, and socio-emotional supports) as a means of providing reparative services and
personal, community, and societal healing following long-term isolation in SHU.

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About the Human Rights in Trauma Mental Health Lab
The Human Rights in Trauma Mental Health Laboratory is committed to advancing and
applying research on the physical and psychiatric impact of trauma on survivors of human rights
abuses with an eye towards informing transitional justice and judicial processes. The Lab focuses
on the science of the psychological changes and mental health pathology caused by trauma on
individuals, their families, and their communities, over time and between generations. Lab
affiliates and colleagues analyze and build upon the rich data available in the interdisciplinary
scientific literature and developed in specific conflict situations to clearly identify the impact on
human psychology of various forms of mass trauma, including genocide, mass killings, rape, and
torture. This analysis is used to clarify the science and/or advocate for the survivors’ human
rights and mental health in a whole range of settings, including criminal trials, civil suits for
money damages, and asylum proceedings. The Lab will participate in these transitional justice
processes in a range of ways, including by providing expert testimony and reports and consulting
with the legal teams prosecuting perpetrators or representing victims.
Learn more about the Stanford Lab at http://med.stanford.edu/psychiatry/research/
HumanRightsinTraumaMH.html

Report authored by Jessie Brunner, MA; Katie Joseff, BA; Ryan Matlow, PhD; Jessica Rahter,
MA; Daryn Reicherter, MD; and Beth Van Schaack, JD. Substantial research support provided
by Harika Kottakota.

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