Restricted Housing of Mentally Ill Inmates
The Society of Correctional Physicians acknowledges that prolonged segregation of inmates with serious mental illness, with rare exceptions, violates basic tenets of mental health treatment. Inmates who are seriously mentally ill should be either excluded from prolonged segregation status (i.e. beyond 4 weeks) or the conditions of their confinement should be modified in a manner that allows for adequate out-of-cell structured therapeutic activities and adequate time in an appropriately designed outdoor exercise area. SCP further recommends that correctional systems provide mental health input into the disciplinary process in order to appropriately shunt some of these inmates into active mental health housing and programming rather than disciplinary segregation when the mental condition is a mitigating factor in the commission of the infraction. Adopted by the SCP Board of Directors, July 9, 2013. [SCP became the American College of Correctional Physicians in 2015.]
The number of persons incarcerated in prisons and jails in the United States has risen dramatically during the past three decades, with a significant increase in prisoners with serious mental illness. Studies and clinical experience have consistently indicated that 8 to 19 percent of prison inmates have psychiatric disorders that result in significant functional disabilities and another 15 to 20 percent will require some form of psychiatric intervention during their incarceration (1, 2). Physicians working in U.S. prison facilities may face difficult ethical challenges arising from unique and difficult working conditions, conflicting obligations to patients, employers, and the public, and tensions between reasonable medical practices and the prison rules and culture. In recent years, physicians have increasingly confronted a new challenge: the prolonged confinement of prisoners with serious mental illness in restricted housing, a corrections practice that has become prevalent despite the psychological harm it may cause in these patients. There has been scant professional or academic attention to the unique ethics-related quandary of physicians and other healthcare professionals when prisons isolate inmates with mental illness (3).
Segregated housing isolates inmates from the general correctional (i.e., jail or prison) population to provide services and activities apart from other inmates, whether for protective or disciplinary reasons. Facilities may refer to such conditions as administrative segregation, protective custody, disciplinary segregation, or supermax (4).
Restricted housing, or solitary confinement, for the purposes of this position statement, refers to confinement in the cell with markedly reduced out-of-cell (programming or yard) time, and marked reduction in privileges and activities. Inmates in restricted housing are generally locked in their cells for 23 hours per day or more. Correctional systems vary regarding the use of single or double cells in these units.
Serious mental illness: Incarcerated persons with one of the conditions listed below shall not be admitted to the to a segregation unit for a prolonged period of time (i.e. for more than 4 weeks).
- Documented diagnosis or evidence of any of the following Diagnostic and Statistical Manual IV Axis 1 conditions in existence currently or within the preceding three months: Schizophrenia (all sub-types); Delusional Disorder; Schizophreniform Disorder; Schizoaffective Disorder; Brief Psychotic Disorder Substance-Induced Psychotic Disorder (excluding intoxication and withdrawal); Psychotic Disorder Not Otherwise Specified; Major Depressive Disorders; Bipolar Disorder I and II
- A diagnosed mental disorder that includes being actively suicidal.
- A diagnosis of a mental disorder that is frequently characterized by breaks with reality, or perceptions of reality that leads to significant functional impairment.
- A diagnosis of a cognitive disorder (e.g. delirium, dementia) that results in a significant functional impairment.
- A diagnosis of a severe personality disorder that is manifested by or associated with frequent episodes of psychosis or depression and results in significant functional impairment.
- A diagnosis of mental retardation.
Problematic aspects of restricted housing on mental illness
Two principal factors contraindicate the placement of mentally ill inmates in restricted housing, the adverse effects on the mental illness and the injustice of disciplinary placement without consideration of the mental illness.
Many patients with mental illness, such as depression, can be expected to worsen as a result of isolation imposed by restricted housing. There is consensus among clinicians that placement of many or most inmates with serious mental illness in these settings is contraindicated because their psychiatric conditions will clinically deteriorate or not improve (5, 9). In other words, many inmates with serious mental illnesses are harmed by disciplinary placement in restricted housing (10). Moreover, programming targeted to the behaviors that led to confinement is commonly unavailable in restricted housing. Consequently, these behaviors may be expected to resume upon release, increasing the likelihood of re-confinement in restricted housing.
Mental illness is commonly ignored during the assignment of disciplinary confinement in restricted housing. Elderly inmates with dementia may be easily identified and provided with frequent re-direction and, often, special housing to prevent harm to themselves or others; however, the equivalent needs of inmates with serious mental illness are less often recognized, and deviant behaviors are more often met with discipline rather than treatment. Inmates with serious mental illness have more difficulty adapting to prison life than do inmates without a serious mental illness. They are less able to negotiate the complexity of the prison environment, resulting in more prison rule infractions and more time both in “lock-up” and in prison (5). Inmates with serious mental illnesses committed infractions at three times the rate of non-seriously mentally ill counterparts (6, 7). The failure to consider the contribution of mental illness to a given behavior in assigning disciplinary segregation is unjust and arguably indifferent to the significant potential of harm for a mentally ill offender.
- Metzner JL: Guidelines for psychiatric services in prisons. Crim Behav Ment Health 3:252–67, 1993
- Morrissey JP, Swanson JW, Goldstrom I, Rudolph L, Manderscheid RW: Overview of Mental Health Services by State Adult Correctional Facilities: United States, 1988. Washington, DC: U.S. Department of Health and Human Services, publication (SMA)93-1993, 1993, pp. 1–13)
- Metzner JL, Fellner J: Solitary Confinement and Mental Illness in U.S. Prisons: A Challenge for Medical Ethics. J Am Acad Psychiatry Law 38:104–8, 2010
- National Commission on Correctional Health: Standards for Mental Health Services in Correctional Facilities. Pages 60 – 61, 2008
- Work Group on Schizophrenia: American Psychiatric Association practice guidelines: practice guideline for the treatment of patients with schizophrenia. Am J Psychiatry 154(suppl):1–63, 1997
- Morgan DW, Edwards AC, Faulkner LR: The adaptation to prison by individuals with schizophrenia. Bulletin of the American Academy of Psychiatry and the Law, 21, 427-433, 1993
- Lovell D, Jemelka R: When inmates misbehave: The costs of discipline. The Prison Journal, 76, 165-179, 1996
- Lovell D, Jemelka R: Coping with mental illness in prison. Family & Community Health, 21, 54-66, 1998
- Metzner JL, Dvoskin JA: An Overview of Correctional Psychiatry. Psychiatric Clinics N Am , 29: 761-772, 2006
- Metzner JL: Class Action Litigation in Correctional Psychiatry. J. Amer. Acad. Psychiatry and the Law, 30: 19-29, 2002