RESEARCH AND PRACTICE

Solitary Confinement and Risk of Self-Harm Among
Jail Inmates
Fatos Kaba, MA, Andrea Lewis, PhD, Sarah Glowa-Kollisch, MPH, James Hadler, MD, MPH, David Lee, MPH, Howard Alper, PhD,
Daniel Selling, PsyD, Ross MacDonald, MD, Angela Solimo, MS, Amanda Parsons, MD, MBA, and Homer Venters, MD, MS

Self-harm is a prevalent and dangerous occurrence within correctional settings.1 Inmates in jails and prisons attempt to harm
themselves in many ways, resulting in outcomes ranging from trivial to fatal. Suicide
is a leading cause of death among the incarcerated; however, suicide and suicide attempt represent a small share of all acts of
self-harm.2 The motivations of inmates who
harm themselves are complex and often
difficult to discern.3 Inmates often arrive in
correctional settings with significant preexisting mental illness and histories of selfharm, but they may also be influenced by
environmental stressors within correctional
settings or aim to avoid certain situations or
punishments. 4
Approximately one third of those admitted
to the jail in New York City (NYC) receive care
for mental health services during their incarceration, a proportion that has been increasing
over time. Inmates who harm themselves
become patients in the mental health service.
Those who harm themselves while in solitary
confinement may be diverted from that punitive setting to a therapeutic setting outside
solitary confinement, which may provide an
incentive for self-harm. The purpose of this
analysis was to better understand the complex
risk factors associated with self-harm and
consider whether patients might be better
served with innovative approaches to their
behavioral issues.

METHODS
The NYC jail system is the nation’s secondlargest, representing an average daily population
of approximately 12 000 persons and 80 000
annual admissions. Most inmates stay in this
system for days to months while awaiting trial
or serving relatively short sentences; those
sentenced to longer prison terms are transferred to the New York State prison system.

Objectives. We sought to better understand acts of self-harm among inmates
in correctional institutions.
Methods. We analyzed data from medical records on 244 699 incarcerations in
the New York City jail system from January 1, 2010, through January 31, 2013.
Results. In 1303 (0.05%) of these incarcerations, 2182 acts of self-harm were
committed, (103 potentially fatal and 7 fatal). Although only 7.3% of admissions
included any solitary confinement, 53.3% of acts of self-harm and 45.0% of acts
of potentially fatal self-harm occurred within this group. After we controlled for
gender, age, race/ethnicity, serious mental illness, and length of stay, we found
self-harm to be associated significantly with being in solitary confinement at
least once, serious mental illness, being aged 18 years or younger, and being
Latino or White, regardless of gender.
Conclusions. These self-harm predictors are consistent with our clinical
impressions as jail health service managers. Because of this concern, the New
York City jail system has modified its practices to direct inmates with mental
illness who violate jail rules to more clinical settings and eliminate solitary
confinement for those with serious mental illness. (Am J Public Health. 2014;104:
442–447. doi:10.2105/AJPH.2013.301742)

Within the NYC jail system, the Bureau of
Correctional Health Services (CHS) of the
NYC Department of Health and Mental Hygiene is responsible for providing all aspects of
medical and mental health care for inmates,
and the NYC Department of Correction is
responsible for all other aspects of custody
and security. Inmates in this jail system occasionally violate jail rules, ranging from refusal
to follow orders of security staff to acts of
serious violence against other inmates or
security staff. To maintain order and safety
within the jail, solitary confinement is used as
punishment for inmates who violate jail rules,
as it is in many jail systems throughout the
United States.
We analyzed data from all jail admissions
that occurred between January 1, 2010, and
October 31, 2012. We counted only acts of
self-harm committed during this time period,
with the exception of inmates admitted to the
jail system in the last 3 months of the study
period. For these inmates, we extended the
observation period for acts of self-harm to
3 months after their admission date with the

442 | Research and Practice | Peer Reviewed | Venters et al.

latest possible date of self-harm being January
31, 2013, for patients admitted October 31,
2012.
We abstracted data relating to inmate demographics, jail admission and discharge dates,
utilization of emergency services, and housing
placement to indicate solitary confinement
from the jail electronic health record. These
data are entered into the Department of Correction database by their staff as inmates are
processed and are directly fed into the electronic health record. Serious mental illness
(SMI) was defined with standardized criteria
followed by mental health professionals
throughout New York State, including
DOHMH.5
We defined self-harm as an act performed
by individuals on themselves with the potential
to result in physical injury, and potentially
fatal self-harm as an act with a high probability
of causing significant disability or death, regardless of whether death actually occurred.
We obtained information about the method,
severity, and outcome of self-harm acts from a
database kept by CHS to track acts of self-harm.

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RESEARCH AND PRACTICE

This database is updated as soon as the selfharm reports are electronically cosigned by the
supervising psychiatrists and faxed to CHS. All
identification and recording of self-harm is
done by clinical staff—clinical social workers,
psychologists, or psychiatrists. The potentially
fatal self-harm was assessed by 2 physicians
and 1 physician assistant from CHS leadership;
the reviewers had only self-harm information
and were blinded to solitary confinement
status. Examples of potentially fatal self-harm
included ingestion of a potentially poisonous
substance or object leading to a metabolic
disturbance, hanging with evidence of trauma
from ligature, wound requiring sutures after
laceration near critical vasculature, or death. As
nearly two thirds of all self-harm acts and 85%
of potentially fatal self-harm act were initial

occurrences, we focused on timing, incidence,
and risk factors for initial self-harm acts during
each jail admission.
The dependent variables, self-harm and
potentially fatal self-harm, were dichotomous
variables (0 = no; 1 = yes). The independent
variables included ever being in solitary confinement during their incarceration, SMI, age
18 years and younger, gender, length of stay,
and race/ethnicity. We identified patients who
were in solitary confinement from housing
placement, thus creating a dichotomous solitary confinement variable (0 = no; 1 = yes).
We created another binary variable to indicate
inmates aged 18 years and younger (0 = older
than 18 years; 1 = 18 years and younger),
based on the classification used by Department of Correction. Gender was another

dichotomous variable (0 = male; 1 = female).
We calculated length of stay (in 6-month increments) from jail admission and discharge
dates, creating a dummy discharge date for
those patients who were still in jail by January
31, 2013. The race/ethnicity was categorized
as Hispanic, non-Hispanic White, non-Hispanic
Black, non-Hispanic Asian/Pacific Islander, and
other or unknown.
We calculated self-harm risk as number of
self-harm acts per 1000 inmate days. We
calculated risk ratios (RRs) of self-harm by
gender, age group, race/ethnicity, mental illness status, assignment to solitary confinement,
and length of jail stay. We examined the
relationship between self-harm and solitary
confinement first by comparing self-harm acts
at any time to whether an inmate was ever in

TABLE 1—Risk and Relative Risk of a First Self-Harm Incident by Person-Days of Exposure in New York City Jail System: January 1,
2010–January 31, 2013

Characteristics
All persons
Serious mental illness
Yes

No. Person-Days

No. of Incarcerations
With Any Self-Harm

Risk per 1000
Person-Days

15 658 050

1303

0.083

RR Self-Harm

No. of Incarcerations
With Potentially Fatal
Self-Harm

Risk of Potentially Fatal
Self-Harm per
1000 Persons

RR of Potentially
Fatal Self-Harm

...

89

0.006

...

984 152

259

0.26

3.70**

25

0.025

6.30**

14 685 839

1043

0.071

1.00

64

0.004

1.00

3 154 403

373

0.112

2.11**

31

0.010

2.50**

919 782

322

0.35

6.6**

9

0.009

2.26*

11 466 081

608

0.053

1.00

49

0.004

1.00

< 19
19–24

1 280 296
3 747 687

478
266

0.373
0.071

12.86**
2.45**

5
26

0.003
0.006

1.23
2.30*

25–34

4 290 543

310

0.072

2.48**

27

0.006

2.39*

35–44

3 138 083

157

0.050

1.72**

23

0.007

2.63*

> 44 (Ref)

3 184 631

92

0.029

1.00

8

0.003

1.00

14 692 524

1200

0.081

0.81

83

0.006

1.00

1 045 786

103

0.100

1.00

6

0.006

1.00

No (Ref)
Solitary confinement while incarcerated
Yes, but during time not in solitary
Yes, during time in solitary
No (Ref)
Age, y

Gender
Male
Female (Ref)
Race/ethnicity
Hispanic

5 307 329

478

0.090

0.90

45

0.008

0.59

Non-Hispanic White (Ref)

1 044 451

106

0.10

1.00

16

0.013

1.00

Non-Hispanic Black

8 782 431

691

0.077

0.77*

28

0.003

0.21**

Non-Hispanic Asian or Pacific Islander

152 603

5

0.034

0.34*

0

...

...

Other or unknown

318 156

21

0.066

0.66

0

...

...

Note. RR = risk ratio. The sample size was n = 14 732 259 person-days.
*P < .05; **P < .01.

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RESEARCH AND PRACTICE

solitary confinement during that incarceration,
and second by distinguishing acts of self-harm
that occurred during inmates’ time in solitary
confinement from those that occurred during
the incarceration but not while in solitary
confinement. We determined statistical significance of differences in rates by using the v2
test.
We conducted 4 logistic regression models
to estimate odds ratios (ORs) and 95% confidence intervals for predictors associated with
self-harm and potentially fatal self-harm. The
first model looked at the effects of solitary
confinement, SMI, age 18 years or younger or
older than 18 years, length of stay, gender, and
race/ethnicity on self-harm, and the second
model looked at the effects of the same independent variables on potentially fatal selfharm. The third model explored the impact of
gender, length of stay, race/ethnicity, and the
interaction of solitary confinement with SMI,
and age on self-harm, and the fourth model
investigated the association of these variables
and their interaction with potentially fatal selfharm. For persons who experienced solitary
confinement and also committed self-harm
during the same incarceration, we calculated
and graphed the timing of the first self-harm act
relative to the week of placement in solitary
confinement.

RESULTS
The study population consisted of 134 188
individuals who experienced 244 699 incarcerations. Of all incarcerations included in this
study, 4.0% involved inmates diagnosed with
SMI, 7.3% involved inmates who spent some
time in solitary confinement, 34.8% involved
inmates who spent more than 30 days in jail,
6.4% involved inmates who were aged 18
years or younger, and 90.8% involved male
inmates. By race/ethnicity, 56.1% were nonHispanic Black, 31.6% were Hispanic, and
8.4% were non-Hispanic White, with other
categories accounting for the remainder.
In 1303 of these incarcerations there were
2182 acts of self-harm; in 89 incarcerations
there were 103 acts of potentially fatal selfharm. The most common methods of self-harm
were laceration (34%), ligature (28%), swallowing a foreign body (15%), and overdose
(14%). In addition, 15% of acts of self-harm

were categorized as “other” (e.g., head banging
and setting self or cell on fire) and 6% of
incidents involved multiple methods. For the
103 acts of potentially fatal self-harm, common
methods included ligature (29%), swallowing
a foreign body (23%), laceration (19%), overdose (16%), other (21%), and multiple (8%). Of
the 2079 self-harm acts judged not to be
potentially fatal, 1715 (82%) were treated by
jail medical staff (physician or physician’s assistant) and 373 (18%) required transfer to
a higher level of care (emergency medicine
physician, inpatient admission, or diagnostic
imaging) for further evaluation or treatment.
The absolute risk for self-harm during an
incarceration was 0.5% and for potentially
fatal self-harm was 0.03% (Table A, available
as a supplement to the online version of this
article at http://www.ajph.org). The RRs for
self-harm increased sharply with the length of
stay in jail, from 0.02% for those with stays of
less than 8 days to 1.4% for those with stays
of 31 days or more. The RRs were highest for
inmates with SMI (6.0; P < .01), and those aged
18 years or younger (18.9; P < .01). Those
ever in solitary confinement had a far greater
risk of self-harm than did those never in
solitary (14.4; P < .01), but these inmates also
had longer lengths of stay. The RR for potentially fatal self-harm among inmates with SMI
was 9.5 (P < .01), and the RR for potentially
fatal self-harm among inmates ever in solitary
confinement was 10.2 (P < .01).
When we calculated the risk of self-harm as
per 1000 person-days (rather than per incarceration), the RR for self-harm was highest for
inmates with SMI (3.7; P < .01) and those aged
18 years or younger (12.9; P < .01; Table 1).
Inmates ever assigned to solitary confinement
were 3.2 times as likely to commit an act of
self-harm per 1000 days at some time during
their incarceration as those never assigned to
solitary (P < .01). These inmates assigned to
solitary were 2.1 times as likely to commit acts
of self-harm during the days that they were
actually in solitary confinement and 6.6 times
as likely to commit acts of self-harm during the
days that they were not in solitary confinement,
relative to inmates never assigned to solitary
confinement (P < .01 for each).
The RR for potentially fatal self-harm among
inmates with SMI was 6.3 (P < .01). The RR for
potentially fatal self-harm coincident with

444 | Research and Practice | Peer Reviewed | Venters et al.

actual solitary confinement was 2.3 and for
potentially fatal self-harm during the jail admission but not coincident with solitary confinement, RR was 2.5 (P < .01 for both values).
The first 2 logistic regression models demonstrated that self-harm and potentially fatal
self-harm were significantly associated with
being in solitary confinement, SMI, length of stay,
and race/ethnicity. In other words, inmates who
were ever in solitary confinement, had SMI,
stayed in jail longer, and were White or Hispanic
compared with Black were more likely to selfharm and commit potentially fatal self-harm.
Inmates who were aged 18 years and younger
were significantly more likely to self-harm, and
older patients were more likely to do potentially
fatal self-harm, but this relationship was not
statistically significant (Table 2).
The third and fourth regression models introduced the interactive terms. We wanted to
understand whether the interaction of solitary
confinement with SMI and age had stronger or
weaker associations with self-harm and potentially fatal self-harm than those variables on
their own. Table 3 shows the predictors of
self-harm and potentially fatal self-harm when
we included the interaction terms. Self-harm is

TABLE 2—Multivariate Analysis Results
for Predictors of Self-Harm in New York
City Jails, No Interactions: January 1,
2010–January 31, 2013
Variables

OR (95% CI)

Self-harm
Solitary confinement

6.89 (6.07, 7.82)

SMI

7.97 (6.85, 9.29)

Age £ 18 y
Length of stay (6 mos)

7.50 (6.61, 8.52)
1.43 (1.38, 1.48)

Hispanic vs Black

1.43 (1.26, 1.61)

White vs Black

1.83 (1.48, 2.27)

Potentially fatal self-harm
Solitary confinement

6.27 (3.92, 10.01)

SMI

8.15 (5.5, 13.16)

Length of stay (6 mos)

1.43 (1.28, 1.69)

Hispanic vs Black
White vs Black

3.09 (1.93, 4.97)
4.92 (2.63, 9.17)

Note. CI = confidence interval; OR = odds ratio; SMI =
serious mental illness. All variables were significant at
P < .001.

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RESEARCH AND PRACTICE

TABLE 3—Multivariate Analysis Results for Predictors of Self-Harm in New York City Jails,
With Interactions: January 1, 2010–January 31, 2013
Variables

OR (95% CI)

Self-harm
Solitary confinement and not SMI and aged > 18 y

10.15 (8.53, 12.08)

Solitary confinement and not SMI and aged £ 18 y

5.89 (4.80, 7.20)

Solitary confinement and SMI and aged > 18 y

4.03 (3.10, 5.24)

Solitary confinement and SMI and aged £ 18 y
SMI and solitary confinement

2.34 (1.65, 3.31)
4.71 (3.72, 5.97)

SMI and not solitary confinement

11.68 (9.78, 14.40)

Aged £ 18 y and solitary confinement

5.73 (4.85, 6.77)

Aged £ 18 y and no solitary confinement

9.88 (8.21, 11.89)

Length of stay (6 mo)

1.40 (1.36, 1.46)

Hispanic vs Black

1.43 (1.27, 1.61)

White vs Black

1.84 (1.49, 2.28)

Potentially fatal self-harm
Solitary confinement and not SMI and aged > 18 y

6.16 (3.47, 10.96)

Solitary confinement and SMI and aged > 18 y

9.06 (4.03, 20.40)

SMI and solitary confinement

9.80 (5.02, 19.18)

SMI and not solitary confinement

6.67 (3.30, 13.50)

Length of stay (6 mo)

1.46 (1.30, 1.63)

Hispanic vs Black

3.08 (1.92, 4.95)

White vs Black

4.96 (2.66, 9.26)

Note. CI = confidence interval; OR = odds ratio; SMI = serious mental illness. All variables were significant at P < .001.

significantly correlated with patients who were
in solitary confinement, irrespective of SMI
status or age. The strongest correlations were
for patients in solitary confinement, not having
SMI, and older than 18 years (OR = 10.15) or
aged 18 years or younger (OR = 5.89). This
indicates the strong effect of solitary confinement on self-harm regardless of the SMI or age
status. Interaction of SMI and solitary confinement shows that the effect of SMI on self-harm
is quite strong regardless of simultaneously
being in solitary confinement (OR = 4.71) or
not (OR = 11.86). Finally, interaction of age
with solitary confinement demonstrated that
patients who were aged 18 years or younger
and were in solitary confinement were significantly likely to self-harm (OR = 5.73).
Potentially fatal self-harm was significantly
correlated with solitary confinement and being older than 18 years and having SMI
(OR = 9.06) or older than 18 years and not
having SMI (OR = 6.16). It was also significantly associated with having SMI and solitary
confinement (OR = 9.80).

Review of self-harm frequency revealed that
314 inmates (24.1%) who committed selfharm did so more than once. Among inmates
with a stay in solitary confinement, 1.1% had
multiple acts of self-harm, whereas only 0.1%
of inmates never in solitary confinement had
multiple acts of self-harm. Among inmates with
SMI, 0.9% committed multiple acts of self-harm
whereas 0.1% of the non-SMI inmates did so.
Similarly, 0.6% of inmates aged 18 years or
younger committed multiple acts of self-harm
whereas only 0.1% of those older than 18
years did so. Multiple potentially fatal self-harm
acts were done by 11 inmates; 6 inmates in the
multiple self-harm group had a low-lethality act
before they had a potentially fatal act.
To better understand the relationship between solitary confinement and self-harm, we
plotted the timing of initial acts of self-harm for
those who did enter solitary confinement relative to the day of admission to solitary confinement and those who did not relative to the
week of admission to jail. Once inmates are
given a sentence of solitary confinement for

March 2014, Vol 104, No. 3 | American Journal of Public Health

violation of jail rules, they may wait days or
weeks before being placed in these settings.
The histogram of self-harm among inmates by
week of jail stay shows that both those who did
and did not experience solitary confinement
had falling weekly rates of self-harm, although
this decline appears to be more pronounced
among those who did experience solitary confinement and this decline appears to stall
around week 41 for all groups (Figure A,
available as a supplement to the online version
of this article at http://www.ajph.org). The
histogram of self-harm among those who spent
some time in solitary confinement shows
a near-normal distribution, with the peak frequency shortly before entry into solitary confinement. The similar plot of potentially fatal
acts is not so tightly grouped around entry to
solitary confinement (Figure A).

DISCUSSION
We found that acts of self-harm were
strongly associated with assignment of inmates
to solitary confinement. Inmates punished by
solitary confinement were approximately 6.9
times as likely to commit acts of self-harm after
we controlled for the length of jail stay, SMI,
age, and race/ethnicity. This association also
held true for potentially fatal self-harm with
a slightly lower OR, 6.3. It is notable that acts of
self-harm often preceded the actual time spent
in solitary confinement. Both SMI (OR = 7.97)
and aged 18 years or younger (OR = 7.5) were
also predictive of self-harm; nonetheless, the risk
of self-harm and potentially fatal self-harm associated with solitary confinement was higher independent of mental illness status and age group.
The analysis showed that a small proportion
of inmates, those in solitary confinement, with
SMI, and aged 18 years or younger, accounted
for the majority of acts of self-harm. Approximately 7% of these acts were potentially fatal
self-harm. Our clinical experience with adolescents is that they have a much lower rate of
SMI and are very adaptive to jail rules. Inmates
often confide that their self-harm acts are used
as a means to avoid the rigors of solitary
confinement. The logistic regression analysis
with solitary confinement and SMI and age
interaction demonstrated that inmates who are
older and in solitary confinements were more
likely to commit potentially fatal self-harm

Venters et al. | Peer Reviewed | Research and Practice | 445

RESEARCH AND PRACTICE

(OR = 9.1), whereas inmates who were younger
and in solitary confinement were more likely
(OR = 5.73) to engage in the lower-lethality
acts of self-harm.
This analysis is consistent with our clinical
observations regarding self-harm. In addition
to the clear indication from patients with SMI
that they self-harm in response to the overall
stressors of the jail setting, adolescents appear
to commit lower-lethality acts of self-harm,
though with not infrequent unintended consequences. Regarding solitary confinement, many
inmates report to us that they have and will
continue to do anything to escape these settings. Mental health providers are in an ethically complex role with these inmates because
currently, they are asked to “clear” them for
solitary confinement. Those inmates who appear to self-harm to escape solitary confinement are often judged to exhibit “volitional” or
“goal-oriented” behavior, as opposed to suffering from psychosis, mania, or another more
recognized mental health symptom.6 This
judgment tracks loosely with the assessment of
security staff, who often refer to inmates who
self-harm as “bing-beaters,” with the “bing” as
the recognized term for solitary confinement.
The peak of self-harm around the time of
entry to solitary confinement (Figure 1)

suggests that these observations by clinical and
security staff are credible. Because it is difficult
or impossible to distinguish purely manipulative acts from those reflecting a true interest in
severe self-harm or suicide, and even “goaloriented” acts of self-harm can have severe
consequences. Related to these attempts to
escape solitary confinement, we have observed
some types of self-harm that occur exclusively
in these settings. One patient with relatively
mild mental illness inserted a deodorant canister into his rectum, requiring surgical removal, all in an attempt to be taken out of his
cell. Others set fire to their cells or smear their
own feces. In our experience, these are actions
that are solely associated with seeking to escape
solitary confinement.
An additional layer of complexity is that patients placed in solitary confinement, especially
those with mental illness, will often earn new infractions, resulting in even more solitary time.
In the most extreme type of example, a patient
held in solitary confinement may break off a
sprinkler head, use that metal to slash themselves,
and then earn not only a new infraction and more
solitary confinement time, but also a new criminal
charge for destruction of government property.
In addition to the clinical significance of selfharm, this practice represents a significant and
3.5

All

3

Highly lethal first self-harm

100

2.5
80
2
60
1.5
40
1
20

Highly Lethal, No.

Patients With Self-Harm Episodes, No.

120

0.5

49

43

37

31

25

19

7

13

1

-5

-11

-17

-23

-29

-35

-41

-47

0
< -52

0

Time to First Punitive Segregation Episode, wks
FIGURE 1—The distribution of first self-harm and potentially fatal self-harm relative to
the date of the first solitary confinement in New York City jails: January 1, 2010–January
31, 2013.

446 | Research and Practice | Peer Reviewed | Venters et al.

increasing drain on resources. When self-harm
occurs, inmates receive immediate medical and
mental health evaluations, and may require
transfer to a higher level of care, which also
requires 2 correction officers to escort them.
These transfers utilize local emergency medical
services, hospital emergency departments, and
inpatient wards. On the basis of these data,
we estimate that every 100 acts of self-harm
result in 36 transfers to a higher level of care
and 10 hospital admissions. Every 100 acts of
self-harm conservatively represent approximately 3760 hours of additional time by
correction officers (for hospital transport and
suicide watch) and approximately 450 excess
clinical encounters in the jail system.
Most of the published studies concerning the
health effects of solitary confinement have
focused on prison systems, which are quite
different from jails in that solitary confinement
in prisons may last for decades.7---9 Although
to our knowledge this is the first analysis of
these predictors of self-harm in a jail setting,
a previous study did observe a similar relationship between self-harm and solitary confinement among 132 inmates in a prison setting.10 One important area for future research is
a better understanding of how self-harm in
jail relates to overall mental health status
while in jail. In addition, the strong association
between SMI and self-harm suggests that
inmates with a history of mental illness are
susceptible to self-harm when facing the
solitary confinement in the jail setting.

Limitations
This study has several limitations. First,
because of the delay in placement in solitary
confinement for rules violations and because
jail is a short-stay setting, many inmates are
sentenced to solitary confinement but leave
before their punishment occurs. Some inmates
may have engaged in self-harm anticipating
stays in solitary confinement that never
occurred.
A second limitation is the lack of data regarding criminal charge or jail rules violations.
These nonclinical characteristics may have
some bearing on self-harm. The practice of
removing actively violent inmates from the
presence of others represents a legitimate
security act and information regarding why
inmates are placed into solitary confinement

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RESEARCH AND PRACTICE

may hold data that bear on self-harm. A third
limitation is that we have no systematic data on
self-harm from previous incarcerations and,
thus, cannot examine the extent to which previous acts might be independent predictors of
jail behavior or self-harm.

Conclusions
According to our analysis, length of stay in
jail, SMI, solitary confinement, and young age
appear to be important and independent predictors of self-harm in jail. These data support
the need to reconsider the use of solitary
confinement as punishment in jails, especially
for those with SMI and for adolescents. Recently, professional societies for adult and
adolescent mental health care have made
recommendations against the use of solitary
confinement as punishment for adolescents
and seriously mentally ill inmates.11,12
The NYC Department of Correction and the
Department of Health and Mental Hygiene
have recently announced a plan to eliminate
the practice of solitary confinement for inmates
with SMI. Instead, inmates with SMI who
violate jail rules will be placed in clinical
settings where they will receive a high level of
individual and group therapy aimed at promoting treatment adherence and prosocial
behaviors. This exchange of a punishment
model for a treatment approach will result in
clinical staff making decisions about how best
to respond to problematic behavior among
inmates with SMI. The plan also restructures
the approach to punishment for inmates with
mental illness whose illness is not categorized
as “serious,” such as those with mild to moderate behavioral problems and those with
personality disorders. These inmates will be
managed in a setting designed to provide
tangible incentives such as increasing time out
of cell and reduction in length of solitary
confinement sentence for engagement with
programming and following of jail rules. These
reforms provide an opportunity to evaluate the
effect of increased clinical management and
decreased reliance on solitary confinement as
a means to reduce self-harm and other behaviors among inmates with mental illness. j

About the Authors
All authors are with the New York City Department of
Health and Mental Hygiene, Queens, NY.

Correspondence should be sent to Homer Venters, 42-09
28th St, 10th Floor, Queens, NY 11101-4132 (e-mail:
hventer1@health.nyc.gov). Reprints can be ordered at
http://www.ajph.org by clicking the “Reprints” link.
This article was accepted October 17, 2013.

11. American Psychiatric Association. Testimony before
US Senate Judiciary Committee hearing on solitary
confinement. 2012. Available at: http://www.psychiatry.
org/advocacy–newsroom/advocacy/senate-committeeholds-hearing-today-on-solitary-confinement. Accessed
July 3, 2013.

Contributors

12. American Academy of Child Adolescent Psychiatry,
Juvenile Justice Reform Committee. Solitary confinement
of juvenile offenders. 2012. Available at: http://www.aacap.
org/cs/root/policy_statements/solitary_confinement_of_
juvenile_offenders. Accessed July 3, 2013.

F. Kaba assembled the primary data file used in this
report and she was assisted by A. Lewis, S. GlowaKollisch, J. Hadler, D. Lee, and H. Alper in all analyses. D.
Selling, R. MacDonald, A. Solimo, A. Parsons, and H.
Venters all worked on article writing and revision as well
as in collaborating with the data analysis team on
analytic design.

Acknowledgments
The authors would like to acknowledge the contributions
of Farah Parvez, MD, of the Centers for Disease Control
and Prevention.

Human Participant Protection
Institutional review board approval was not needed
because this analysis was assessed to be public health
surveillance, not research.

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