Reducing the Use of Segregation for People with Serious Mental Illness

Abstract

This study, using data from a state correctional agency, examines the use of segregation for people with serious mental illness in prisons. Our investigation shows deviations from departmental policy regarding the housing of individuals with serious mental illness (SMI); frequent use of segregation as a response to self-harm episodes and suicide attempts; and that people determined to be most impaired by a serious mental illness were typically placed in segregation. These findings suggest that correctional staff need to decouple disciplinary actions and responses from mental health symptoms, and avoid a punitive approach to incidents of self-harm or suicidality.

Keywords

serious mental illness segregation in prison suicidality self-harm

Introduction

The widespread use of segregation, or solitary confinement in prisons is a topic of increasing debate and reform (Anthony-North et al., 2017). There are varying definitions of segregation, and specific instances of this correctional system’s use of restrictive environments are discussed in the methods section of this article. Segregation is defined by the American Correctional Association (ACA) as spending 22 or more hours in a single cell for extended periods, with little to no stimulation or social contact (American Correctional Association, 2018). A report published by the Association of State Correctional Administrators and Yale Law School defines restrictive housing as separating incarcerated persons from the general population, and confining them to their cells for an average of 22 hours a day or more, for at least 15 days at a time (The Association of State Correctional Adminsitrators, 2018). Differences in terminology also reflect differences in correctional agencies’ attempts to define the intent and purpose of different forms of restrictive housing (e.g. Treatment Units, Intensive Management Units, Security Housing Units) (Labrecque, 2016).

Segregation is present in every form of correctional custody, and the situations described by segregation or restrictive housing vary considerably. Three categories often used to differentiate types of segregation are disciplinary segregation (used as punishment for in-prison infractions), administrative segregation (often used to separate individuals who are presumed to be dangerous), and protective segregation or protective custody (used to separate individuals who are presumed to be likely victims) (Browne et al., 2011). The use of administrative segregation in particular grew exponentially since the mid-1980s (Frost & Monteiro, 2016), with its use initially designed as a way of maintaining control over those who posed the “worst” threat to prison management (Browne et al., 2011). However, its use has become institutionalized, and it is applied to respond to a range of situations. This growth has been followed by concern about the short- and long-term mental and physical effects of holding someone in isolation. There is scientific consensus that segregation aggravates and incites mental health symptoms like suicidality and depression, and a recent study found that social isolation was a primary risk factor for suicide and other suicide-related outcomes (Calati et al., 2019).

The link between use of segregation and mental health impacts on incarcerated people is particularly concerning to some clinicians and researchers because data also document the increasing prevalence of serious mental illness (SMI) in the criminal justice system (Prins, 2011). Definitions of SMI vary, but generally SMI means: 1) diagnosis of a major mental disorder such as schizophrenia or bipolar disorder, and 2) impacted daily life because of this diagnosis (Metzner & Fellner, 2010). Federal regulation defines SMI as “a mental, emotional, or behavioral disorder, excluding substance use and developmental disorders, that causes serious functional impairment to major life activities” (Substance Abuse and Mental Health Services Administration, 2013, p. 11).

Individuals with SMI have more difficulties navigating a correctional environment, and they are more likely to accumulate infractions that lead to placement in restrictive housing (American Psychiatric Association, 2012). Mental health symptoms themselves may be treated as infractions—for example, several jurisdictions include self-harm among the behaviors punished by disciplinary restrictive housing (Federal Bureau of Prisons, 2011). These realities have contributed to an established trend: mentally ill incarcerated people are placed in restrictive housing at disproportionally higher rates (Gilligan & Lee, 2013).

Previous research has shown that in correctional settings, policy may be different from practice (Resnik et al., 2016). Therefore, to align policy and practice, correctional staff members must be essential partners in reform. Correctional officers, forensic healthcare staff, and prison administrators systematically determine the decision points and standards that lead mentally ill people to restrictive housing. The policies that formally shape these checkpoints are influenced by federal standards, but they are also reflective of each agency’s culture and priorities. This study analyzes the administrative decisions made regarding incarcerated people with SMI, with the goal of influencing correctional staff at all levels to eliminate their use of segregation for people with SMI.

We present a case study of a single U.S. state correctional system to illustrate problems with the current use of segregation and discrepancies between Department of Corrections (DOC) policies and placement of persons with SMI. We analyzed housing classification policies, administrative data, and movement data between facilities to examine connections between SMI and placement in restrictive housing. Based on the findings, we make recommendations to safely reduce the use of segregation for incarcerees with SMI.

In the next section, we describe the history of policy changes that have led to the growing prevalence of people with SMI in prisons, and the increased use of isolation to manage mental illness. We briefly describe our methods and data, followed by a summary of our findings. Finally, we end with a discussion of the results, and give evidence-based policy recommendations based on other jurisdictions.

Segregation of the Seriously Mentally Ill

Although researchers disagree on the exact blend of factors leading to mass incarceration of the mentally ill, the results are the same. The three largest psychiatric facilities in the country are jails (Cook County Jail, Los Angeles County Jail, and Rikers Island). At least 40% of individuals with SMI have been in jail or prison during their lifetime (Torrey et al., 2010). Additionally, a 2005 Bureau of Justice survey found that over half of all prison and jail inmates had symptoms of a mental health disorder within the past year, yet only 24% of federal prisoners and 34% of state prisoners had received treatment since their admission (James & Glaze, 2006).

Restrictive housing is now routinely employed as a response to an array of situations, such as: assisting another person with litigation, trading possessions, possession of excess stamps, getting up during the night without securing permission, possessing an electronic device, belonging to a gang, lying, participating in an unauthorized meeting or gathering, circulating a petition, and unauthorized physical contact (e.g. kissing, embracing) (Federal Bureau of Prisons, 2011; Indiana Department of Correction, 2012; North Carolina Department of Public Safety, 2014). Keramet Reiter (2016), a legal scholar and author of the book 23/7: Pelican Bay State Prison and the Rise of Long-Term Solitary Confinement, cites security concerns, racist treatment of Black civil rights leaders, court rulings, and public indifference as factors that allowed for isolation policies to flourish. While courts have generally defended attacks on solitary confinement, some courts have declared particular usages unconstitutional (Rudovsky, 1988).

Many researchers, psychologists, and psychiatrists believe that segregation can generate mental problems, and that it is “psychologically traumatizing” notwithstanding other prison conditions (Cloud et al., 2015, p. 12). Denial of stimulation and social contact is likely to exacerbate preexisting mental health symptoms in some individuals, and initiate symptoms in others (Haney, 2003). Dr. Stuart Grassian, a psychiatrist who evaluated hundreds of incarcerated men at California’s Pelican Bay Prison, reported the symptoms of what he called “SHU (Special Housing Unit) syndrome” as including: inability to tolerate external stimuli, hallucinations, panic attacks, difficulties with concentration and memory, paranoia, and difficulties with impulse control. Grassian argued that these symptoms, some of them rarely seen in psychiatry, formed a distinct and unique constellation endemic to segregation (Grassian, 2006). The American Psychiatric Association recommends that prolonged segregation be avoided for those with SMI (American Psychiatric Association, 2012).

At the same time, other researchers have pointed out the impossibility of conducting methologically rigorous experiments in a correctional setting, and the danger of drawing causal relationships between contemporaneous mental health symptoms and isolation and/or restriction (Kapoor & Trestman, 2016). Clinical data showing disturbances in individuals in restrictive housing are often impressional in nature and inherently individual-based. Gendreau and Labrecque (2018) argue that adverse mental effects from administrative segregation arise “primarily” from mishandling by prison staff members, meaning that they were prompted by a lack of transparency, accountability, and fairness from staff. Given the assumption that correctional agencies aim to produce a greater degree of pro-social behavior in incarcerated people, the research on the therapeutic alliance and the relational importance would seem to support an emphasis on the relationship between correctional staff and incarcerated people (Huffman, 2013; Newhill et al., 2003). Varying definitions of mental illness, segregation, measures of symptoms, and lengths of confinement further complicate the interpretation of mixed findings.

Although the evidence causally linking segregation and the deterioration of mental health is mixed, there is consensus among researchers that people in segregation have disproportionately higher rates of SMI, and long-term segregation causes long-term harm (Gendreau & Labrecque, 2018; Kapoor & Trestman, 2016; Smith, 2016). One study that did not find worsened psychological deterioration in segregation, as compared to a similar group in the general population, found that the symptoms associated with administrative segregation were in fact elevated for both groups (O’Keefe et al., 2011). Rather than showing that mental health was adequate for one group and worsening for the other, both groups demonstrated “high degrees of psychological disturbances” (O’Keefe et al., 2011, p. viii).

Due to severe overcrowding, the high staffing costs of increased supervision, compliance with national and international standards, and the negative psychological and physiological consequences of segregation, state agencies have made increased efforts to reduce their use of segregation (Anthony-North et al., 2017).

Why Are People with SMI in Prisons?

Correctional facilities’ attempts to address the changing needs of their populations has resulted in what Dr. Homer Venters, the former head of New York City’s correctional health services, labeled “a confused patchwork of punishment and treatment” (2019, p. 61).

The conflation of treatment and security may be even more pronounced in prisons. On a given day in 2017, federal prisons held 21.5% of the SMI population in high security custody, compared to 11.0% of the non-SMI population. Simultaneously, one-third of the people with SMI in federal prisons were identified as having two or more suicide attempts (U.S. Government Accountability Office, 2018). Incarcerated persons with any mental illness spent an average of 69 months in segregation at the Colorado U.S. Penitentiary (Office of the Inspector General, 2017). These numbers raise concerns about the threat federal prisons pose to the lives of people with SMI.

A lack of data and transparency complicates the ability to move forward with proactive solutions for people with SMI. An oversight agency found that the federal Bureau of Prisons was not tracking cumulative time spent in segregation, and that mental health staff members were not consistently recording mental health diagnoses for incarcerated persons (Office of the Inspector General, 2017).

Some advocates argue that the symptoms of SMI and a correctional environment are fundamentally incompatible. Psychotic symptoms, disorganized thinking, and other aspects of SMI make it difficult to understand and follow the rules of a prison or jail (Lamb & Weinberger, 1998; Treatment Advocacy Center, 2016). At the same time, even though excluding people with SMI from correctional environments may be well-intentioned, it would be nearly impossible to execute. Flaws in record-keeping and the varying definitions of SMI between jurisdictions would complicate categorically diverting people with SMI from prisons.

Policy has failed to address the mental health burden placed on jails and prisons, and countless people have died as a consequence. Although correctional systems are not designed to be therapeutic, there are incentives both within the institution and for society-at-large to address mental health needs, including the legal right of incarcerated people to receive mental health treatment (Cohen & Dvoskin, 1992). Mears (2004) argues that there are at least two compelling reasons for correctional mental health to be a public policy concern: that treatment is a moral imperative, and that addressing mental health needs has pragmatic benefits for society. The politically conservative, “tough-on-crime” climate of the state in this study is generally resistant to lessened control over incarcerated people, and incarceration rates have remained stable despite a national decline. However, high recidivism rates, violent deaths in the prisons, overcrowding, and associated financial costs have prompted state legislators to make recent changes. These changes include diverting people with non-violent crimes from prison and shortening prison sentences.

Data and Methods

The Vera Institute of Justice, a criminal justice non-profit, provided technical assistance in 2017–2019 to five state Departments of Corrections (DOC) through Vera’s Safe Alternatives to Segregation Initiative. The purpose of this project was to significantly reduce the use of segregated housing by promoting safe and effective alternatives. Through a selective process, states applied to partner with the Vera Institute and receive data-driven findings and recommendations regarding their statewide use of segregation in their jails and prisons. Thus, each DOC worked with the Vera Institute towards the common goal of reduced use of segregation. The benchmark of an acceptable use of segregation was dependent on each state, but generally the goal was to limit its use to threats to institutional safety and security. The lead author worked for nine months with this team through a graduate fellowship, and was granted permission to use these data.

This report originated with the following questions:

How many people identified as having serious mental illness (SMI) are in segregation?

What counts as SMI, and how could this count be more accurate?

What is the relationship between self-harm or suicide attempts and segregation?

Is correctional mental health policy being followed?

These questions were addressed through analysis of administrative and movement datasets from a state DOC, as contractually provided to the Vera Institute of Justice. Administrative data includes demographic information and housing classification. Movement data is information on changes in housing status, including movement from one level of restriction to another, segregation status, or pending stays in disciplinary segregation.

This snapshot dataset consists of the state’s prison populationas captured on June 30th, 2016 (N = 20,824). These data represent the population as it existed on this date, with the exception of variables including date of entry into segregation and most recent mental health “flag.” Data are left-censored, meaning that anything occurring before 2014 is not captured. Quantitative data were analyzed using descriptive statistics.

Segregation status was coded using a definition agreed upon by the Vera Institute of Justice’s research team; as a current housing placement in a location known to be highly restrictive with 1–2 hours per day out-of-cell and reduced access to programing and other services; including extended lockdown, segregation cell blocks or segregation rooms, administrative segregation, and the mental health treatment unit (TU). For those placed in segregation on June 30, 2016, the total number of days spent in segregation was calculated using the date of entry into segregation when available, or the left-bound date of January 1, 2014, which was the earliest date available. This means the measure of time spent in segregation is an under-estimate and is limited to a maximum of 911 days (January 1, 2014–June 30, 2016).

Presence of SMI was coded using the DOC’s definition of SMI, which requisites a diagnosis of major depressive disorder, schizophrenia, schizoaffective disorder, bipolar disorder, psychotic disorder, severe anxiety disorder, or severe personality disorder. This diagnosis is made by a “duly licensed” mental health professional based on clinical information obtained at intake. Diagnosis with one of these disorders marks an incarcerated person with a “Level of Care” 1–3. The Department defines Level 3 as “offenders with SMI and who have been in remission or have been stable for at least six months.” Level of Care 1, the most severe, is defined as “significant disability primarily due to their mental health condition.”

Frequency tables were used to analyze mental health code by housing status and time spent in segregation. Presence of self-harm prior to entering segregation and while in segregation were assessed using clinical records.

This report’s aim was diverting people with SMI from segregation qua segregation.

Operationalizing segregation is difficult because this state DOC uses several varying definitions and situations that all function as highly restrictive. For example, some people are confined in the Mental Health Unit in conditions that qualify as restrictive housing, or someone may be put on in-cell lockdown even if their cell assignment is in general population. The variety of possible housing configurations, and the tendency to use in-cell restriction as punishment or protection mean that people with SMI will probably still end up in highly restrictive and deleterious conditions, despite a policy change that made the most severe category of SMI (LOC 1) an exclusion criteria to segregation. This policy excluded people with Level of Care 1 (defined as significant disability primarily due to a mental health diagnosis of major depressive disorder, schizophrenia, schizoaffective disorder, bipolar disorder, psychotic disorder, severe anxiety disorder, or severe personality disorder) from housing without mental health services deemed as being sufficient. Per this policy, people with the designation Level of Care 1 were to be housed in only three out of the state’s several correctional facilities.

Findings

For the statewide prison population, 2.6% (n = 544) were not given an initial mental health assessment, and 15.7% (n = 3,272) were in maximum custody on June 30th, 2016. Viewing the same population, 9.5% (n = 1,970) were identified as having SMI. Out of the group placed in maximum custody, 16.8% (n = 549) were identified as having a SMI.

There are five Levels of Care (LOC), and LOC 1–3 are considered SMI according to DOC policy. There were 58 people with a LOC 1 designation, the most severe, who were currently incarcerated in the entire system. Although the LOC 1 group was small, it is worth pointing out that most of this group (n = 49) was in maximum custody, as visible in Figure 1. This is the only LOC group for which this is the case. Agency policy dictates that people with LOC 1 be housed in special mental health housing units with staff present 24 h, andrestricted from all but three facilities. However, this policy was not implemented, as 15.5% (n = 9) of people with LOC 1 were housed in general population on June 30th, and none were in the TU, a designated psychiatric unit.

Figure 1.

Percentage in segregation by Level of Care (LOC).

People identified as having a SMI (n = 549) had spent an average of 56.7 days longer in segregation when compared to the non-SMI population (n = 2,723). Because the data include outliers and different sample sizes, it is also worth examining the median number of days, which also differ between the SMI (79 days, n = 549) and non-SMI groups (61 days, n = 2,723). Both estimates show that individals with SMI spend more time in segregation. These numbers are also underestimates of time spent in segregation because available data were left-bound. Since the earliest available data were from January 1st, 2014, 911 days is the longest stay visible in this dataset. It is unlikely that people entered segregation on December 31st, 2013; therefore, we can infer that these stays were longer to some unknown degree.

Of the 31 people who were identified as being held in segregation-like conditions in the mental health TU, 22 (71.0%) had previous clinical records of self-harm (such as cutting themselves or injesting material). Out of those currently in segregation with a record of self-harm, more people began self-harming while in segregation (n = 66) than before entering segregation (n = 19). We cannot infer that segregation caused self-harm. Regardless, more people began to self-harm for the first time while in segregation than in a less restrictive setting. Out of those in segregation with a clinical record of self-harm, 23.8% (n = 20) were flagged as having SMI.

The TU beds were occupied at the time data was collected. However, none were occupied by the group (Level of Care 1) for which they were allocated, according to DOC policy. Out of the 26 beds in the TU, 14 were occupied by people with LOC 2, 11 were occupied by people with LOC 3, and one was occupied by someone with LOC 4.

Additionally, disciplinary records show incarcerated people were being placed in segregation as punishment for self-harming, as self-harm is considered a disciplinary offense in the same category as tattooing or self-mutilation. Self-harm is often a learned behavior in prisons, and its propensity to be viewed as manipulative or malingering by correctional staff endangers human life (Cummings & Thompson, 2009). Even if a mandated disciplinary response to other behaviors (tattooing, destruction of property) is neccesary, segregation is not the only possible response. Correctional staff have the ability to choose from different disciplinary punishments, including loss of yard time or phone calls, as opposed to increasing time in segregation.

This state DOC currently follows best practice recommendations of tracking other measures of mental illness besides diagnosis for its correctional population (Grisso, 2005). There is a separate “flag” for people who have no mental illness but have frequent episodes like hunger strikes or suicide attempts, and a flag for people who have had past psychiatric treatment. They also use an initial screening, follow-up assessment, and code for mental illness based on severity of diagnosis, as previously explained. However, there is no evidence suggesting that these practices influence the department’s housing placements. Additionally, the DOC policy also references the Diagnostic and Statistical Manual-4, which is no longer used in the field. Use of outdated terminology (e.g., referring to “Axis I diagnoses”) should be terminated. We recommend that the DOC consult the American Psychiatric Association’s standards for mental health care in corrections, and base its new definition of SMI on functioning and degree of impairment rather than specific disorders.

Some mental health assessment dates were also missing, although this was rare (2.2% had no entry for their most recent mental health assessment, n = 456). As an example, one person who was in segregation had been in extended lockdown for 146 days, had a history of self-harm prior to entering segregation, and had no record of receiving a mental health assessment in four years. Another individual with SMI (LOC 3) had been in extended lockdown for 136 days with no mental health assessment during that time and a history of self-harm. Perhaps most notably, there were 7 people who had spent at least 911 days in segregation (the longest period visible in the dataset) without an assessment. The ACA recommends that individuals in segregation be assessed by a mental health provider every 30 days if they have a mental health diagnosis, and every 90 days with no diagnosis (Resnik et al., 2016). The lack of recent mental health assessments for those in segregation violates ACA standards.

Discussion and Policy Implications

This study aims to advance prior research by using this state’s DOC as a case study for improvements to policy regarding housing placement for people with SMI and its use as punishment for mental health symptoms or episodes. We find that not only were mental health assessment data incomplete, but housing options for people categorized as having SMI were non-therapeutic and primarily constituted isolation. No individuals who were assigned the most critical mental health indicator (LOC 1) were placed in the TU, which is a deviation from DOC policy. Although some people with SMI may benefit from protection from other incarcerated people, there are also mental health risks posed by isolation, and, in our sample, protective custody was less often used for people with SMI than extended lockdown or administrative segregation. Mental health symptoms including self-injury and suicide attempts were treated by placing individuals in segregation. We recommend the following policy reforms: 1) update policy to reflect psychological best practices on the diagnosis and treatment of SMI and trauma-informed care; 2) do not classify suicide attempts or self-harm as a disciplinary offense; 3) provide monthly mental health assessments for people in segregation, regardless of the duration of their stay; and 4) eliminate segregation as i) a form of mental health or suicide watch, ii) a response to suicide attempts or self-harm, and iii) housing for people with SMI. We discuss each of these in turn.

Broaden and Update the Definition of Serious Mental Illness

Given that the Bureau of Justice has found that 49.2% of people in jail or prisons reported symptoms of mania disorder, psychotic disorder, or major depressive disorder (which all fall under the DOC’s current definition of SMI), it is highly unlikely that only 9.5% of the DOC population have a SMI (James & Glaze, 2006). Regular evaluations need to be implemented to ensure that mental health symptoms are captured by treatment staff. Answering positively to question(s) about psychiatric history at intake should also disqualify someone from segregation. One study of California prisons found that completed suicide correlated more strongly with a history of psychiatric treatment than a diagnosis of mental illnesses such as major depression or generalized anxiety disorder (Patterson & Hughes, 2008).

The Department’s policy needs to be revised to reflect changes to the Diagnostic and Statistical Manual of Mental Disorders, 5^th Edition. Guidelines that use the “axes” system are no longer up-to-date, and diagnostic criteria for mental illness have undergone major changes from the fourth to fifth editions. Mental health professionals working in the prisons should also undergo mandatory training on the relationship between trauma, mental disorders, substance use disorders, and screening and assessment for trauma-related disorders (Pelletier, 2016).

Following the example of other jurisdictions and in accordance with the growing body of literature on trauma-informed care, the DOC should also add post-traumatic stress disorder (PTSD) as a qualifying diagnosis for SMI. Inclusion of PTSD as a SMI would be a potential first step in acknowledging the higher rates of lifetime trauma and PTSD present in incarcerated populations, and the traumatic impact of the prison environment and segregation itself (Hagan et al., 2018; Wolff et al., 2014). Mississippi prisons, for example, include PTSD and severe generalized anxiety disorder in their criteria for admission to a step-down unit that phases people out of segregation, given that these diagnoses can significantly impair functioning (Kupers et al., 2009). In the long term, clinically addressing symptoms of PTSD could potentially reduce the need to utilize segregation as a de-escalation tactic, as PTSD has been linked to suicidality, aggressive behavior, and self-harm (Facer-Irwin et al., 2019).

Since it is likely that this DOC is grossly underreporting prevalence of SMI (based on their lack of data and in comparison to state and nationwide data), another ideal outcome would be increased mental health staffing, proportionate to the increase in identifiable incarcerated people with SMI. Additional staffing is dependent on funding, yet we argue that the long-term mental, fiscal, and physical costs of ignoring mental health needs outweigh this cost.

The DOC should additionally consider broadening the definition of SMI to include anxiety-related disorders, trauma-related disorders, and include behavioral management programing tailored to indivudals with psychopathy or severe personality disorders. Massachusetts prisons, for example, include dementia, neurodevelopmental disorders, other cognitive disoders, any disorder marked by dissociation, and all anxiety- and trauma-related disorders as sufficient for placement in its Secure Treatment Units, which function as an alternative to segregation (Massachusetts Department of Correction, 2019).

Eliminate Segregation as a Response to Suicide Attempts or Self-Harm

The DOC health care policy purports to include “stabilization of the mentally ill and the prevention of psychiatric deterioration in the correctional setting,” yet their practice of placing mentally ill people in segregation does the opposite. Given the extensive body of research demonstrating a link between segregation and suicide (Grassian, 2006; Hayes, 1995; Marzano et al., 2016; Patterson & Hughes, 2008; Reeves & Tamburello, 2014), placing individuals in segregation cannot be expected to be an appropriate or humane response to suicide attempts. In a national study of prison suicides, Mr. Hayes writes “A primary recommendation, based chiefly on overwhelmingly consistent research, is that isolation should be avoided whenever possible” (1995, p. 7).

Since diagnosis alone does not correspond to treatment need, (supported by the 64 people who were not diagnosed with SMI but have frequent “mental health interventions”) excluding people with SMI from segregation does not fully ensure that those at risk of deteriorating in segregation are diverted. This state is not alone—other jurisdictions have used segregation as a mental health observation status or as overflow for TUs (Bauer, 2016). Measures should be taken to ensure swift clinical intervention and non-restrictive environments after suicide attempts. Self-harm should be decoupled from tattooing and other discplinary infractions, and should initiate a clinical response.

To address an increasing rate of suicide in administrative segregation, California state prisons have incorporated preplacement mental health screenings, monitoring individuals new to segregation every half hour, and improved tracking of suicidal behavior (Patterson & Hughes, 2008). As an alternative to isolation, the Oregon Department of Correction has implemented “blue rooms” that play nature videos and are used alongside virtual reality goggles as a de-escalation tactic for both staff members and incarcerated people. The department has also added extensive wellness programing for staff members, including meditation and mindfulness training, without increased funding (Saunders et al., 2017).

Eliminate the Use of Segregation for People with Serious Mental Illness

Similar jurisdictions have successfully eliminated the use of segregation for those diagnosed with SMI. Mississippi, another “tough-on-crime” state that also has one of the highest rates of incarceration in the US, implemented a step-down program for its incarcerated persons diagnosed with SMI, transferring those requiring inpatient psychiatric care to a prison with an inpatient unit. The step-down program takes place in a separate unit, lasts three to six months, is inclusive of frequent self-harm, and is targeted towards people with SMI whose functioning is most impaired. Programing includes psychoeducation, group therapy while in ankle restraints, incentivizing behavior, peer-led programing, and increased access to library and media resources (Kupers et al., 2009).

Research suggests that even short stays in segregation have lasting impacts on mental health. During a six-year period in California state prisons, 53% of suicides in segregation happened within the first three weeks of placement (Patterson & Hughes, 2008). One study of 13,776 people incarcerated in Danish prisons found that mortality after release was significantly higher for those who spent time in segregation. The authors suggest that in countries like the US, where stays in segregation can last years, data would show an additional connection between segregation and natural mortality due to lack of exercise or other causes (Wildeman & Andersen, 2020).

This policy change needs to be accompanied by addressing staff members’ fear of malingering by incarcerated persons. Fear of malingering is common among corrections officers, and there are legitimate incentives for malingering, such as need for institutional attention, desire for medication, or an attempt to transfer facilities (Kolodziejczak & Sinclair, 2018). Malingering could be one topic covered in segregation-specific staff training, as staff members should also be equipped to manage other presenting issues such as social withdrawal or attention-seeking behaviors (Gendreau & Labrecque, 2018).

Do Not Classify Self-Harm or Suicide Attempts as a Disciplinary Offense

People with SMI often find it more difficult or impossible to comply with prison rules (Abramsky & Fellner, 2003). One study of New York prisons found that “periods of high disciplinary involvement overlap with symptomatic behavior for seriously disturbed inmates” (Toch & Adams, 2002). Accumulating disciplinary infractions can prolong stays, resulting in mentally ill incarcerated people spending longer periods of time in an environment that exacerbates or worsens their illnesses. For example, the Pennsylvania DOC reported that incarcerated people with SMI were three times more likely to serve their maximum sentence (Abramsky & Fellner, 2003). Incarcerated persons who attempt suicide risk being punished for damaging state property, being fined for restitution, and being placed in an environment that exacerbates suicidality as a result (Abramsky & Fellner, 2003).

Mental health symptoms should not be punished, even if that punishment is not segregation. Although it may be impossible to determine the relationship between a psychiatric illness and behavior, disciplinary actions risk inhibiting therapeutic and behavioral progress (Abramsky & Fellner, 2003). Other punishments cited for the diverse set of behaviors that fall under “Self-Mutilation” include loss of recreation and yard time, loss of phone privileges, and loss of canteen. Loss of privileges was suggested by one treatment staff member as a better alternative to disciplinary segregation. The department can continue to count tattooing as an infraction, however cutting or otherwise harming oneself should not be a disciplinary offense.

Aside from the concerns already mentioned, incarcerated persons complained that a lack of air conditioning impacted their quality of life. High summer temperatures pose an increased threat for people on psychotropic medication, which can limit the body’s ability to sweat and regulate internal temperature, thus raising the risk of injury or death (Human Rights Clinic, 2015).

Provide Monthly Mental Health Assessments for Everyone in Segregation

Attention to mental health should not be limited to those who meet a specific set of diagnostic criteria (U.S. Department of Justice, 2016). Overall, regular and standardized mental health assessments were gravely insufficient in our dataset. For example, one man who had spent 338 days in segregation appeared to have no mental health assessment during the past four months. Since research suggests that segregation can incite mental illness (Grassian, 2006), preventative and frequent check-ins with mental health staff are necessary. It is also important that these check-ins take place in a confidential and separate room, not at the cell door where there is little privacy. Monthly assessments are within ACA recommendations for people in segregation and help provide a more accurate representation of SMI in segregation.

Increasing continuity of care before, during, and after incarceration is also imperative for addressing factors of interest to prison administrators like institutional violence and suicide. One study found that more than 50% of incarcerated persons who were taking medication for mental illness at prison admission did not receive pharmacotherapy while incarcerated. The authors attributed this to an increase in the prison population, without a corresponding increase in prison staff (Reingle Gonzalez & Connell, 2014). Other case studies have found as many as 844 incarcerated people, or more, on the medication caseload alone for one psychiatrist who is not a full-time staff member (Kupers, 2014). Of course, these problems cannot be unlinked from the increasing privitization of correctional industries, particularly mental healthcare, which in turn leads to unfilled positions and a profit-motivated approach to selecting medications and treatment options (Daniel, 2007).

Conclusion

The goal of these recommendations is that people with SMI do not spend time in segregation. However, diversion from segregation does not ensure better treatment or broader access to mental health inpatient services or other treatment. It does not even ensure that more individuals with treatment needs are treated. As otherwise stated: “The diagnostic approach to screening equates the need for clinical intervention with diagnosis” (Swartz & Lurigio, 2006, p. 51). The current emphasis on DSM-based diagnoses and the benchmark of SMI exclude many people from treatment. Previously mentioned remedies, such as attention to psychiatric history and self-mutilation attempts, can help address this issue.

The DOC prisons fail to provide a minimum standard of care, physically and psychically. What is most needed is an institutional, philosophical change that allows opportunities for those in psychological pain to stabilize and improve. Finally, prison administrators are motivated to cut costs related to healthcare and pharmacotherapy at the expense of the well-being and lives of people with SMI. A cost-benefit analysis of the use of segregation for people with SMI is lacking, and may suggest that the the high costs of increased supervision, lower ratios between staff and incarcerated people, and legal fees call for reductions in segregation. Regardless, we argue that the cost of human life and dignity must be considered above all else.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Serena Maszak-Prato*, MA, completed her Master’s degree in forensic psychology at John Jay College of Criminal Justice. She is currently a case investigator with the NYC Department of Health and Hospitals. Her research interests include correctional mental health care, violence prevention, and LGBTQ population concerns.

Leigh Graham, PhD, MBA, is research scientist in health policy and management, Harvard T.H. Chan School of Public Health, and senior advisor, Ariadne Labs. She is also a design critic at the Harvard School of Design. Her research bridges urban planning and public health for more equitiable communities, systems, and policies.

*The author’s time was supported in part through the Tow Policy Advocacy Policy Fellowship, with Dr. Graham as the faculty partner to the Fellowship program.

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