XII. MENTALLY ILL PRISONERS AND SEGREGATION
Prisoner Brown [who is confined in a supermax facility in Indiana] has had seizures and psychiatric symptoms since childhood. He has bipolar disorder and a severe anxiety disorder, a phobia about being alone in a cell, and many features of chronic post-traumatic stress disorder. After he has been in his cell for a while, his anxiety level rises to an unbearable degree, turning into a severe panic attack replete with palpitations, sweating, difficulty breathing, and accompanying perceptual distortions and cognitive confusion. He mutilates himself – for example, by inserting paper clips completely into his abdomen – to relieve his anxiety and to be removed from his cell his cell for medical treatment.
- Inmate evaluation by Dr. Terry Kupers, Indiana, July 1997.
When [the mentally ill are] in segregation, if they're not appropriately engaged they continue exhibiting the behaviors that got them there in the first place. If anything, they heighten that activity, which then puts them back before a disciplinary committee, and they get more [segregation] time. So instead of getting out, they wind up staying longer and longer and longer, and they deteriorate.
- Michael J. Sullivan, former director, Wisconsin Department of Corrections, 2001.
If prisons are the end-of-the-line for those who fail to abide by society's rules, the various lockdown, isolation, and segregation units within correctional settings are the end-of-the-line for those prisoners who fail to abide by the internal rules and regulations that govern the prison system. Mentally ill prisoners are disproportionately confined in such settings. Isolated day-in, day-out in tiny, barren cells with scant contact with any other human beings, including mental health staff, prisoners with mental illness are left to suffer cruelly. Mental health care in such units is woefully inadequate. Many prisoners decompensate, becoming so psychotic they are eventually removed for brief hospital stints. Once stabilized, they are returned to the segregation units, where they are likely, over time, to decompensate again.
Overview of Segregation
All prison systems in the United States have "prisons within prisons," harsh solitary punishment cells where prisoners are sent temporarily for breaking prison rules. In the last two decades, however, corrections departments have increasingly chosen to segregate or isolate disruptive, rule-breaking, or otherwise dangerous prisoners for prolonged periods. Many of them are placed in special super-maximum security facilities; others are confined in segregation units within regular prisons. The prisoners may be confined in segregation units administratively - meaning the segregation is an administrative housing or classification decision. Administrative segregation can, and often does, continue indefinitely until the correctional authorities unilaterally decide to release the prisoner back to the general prison population. Prisoners may also be isolated as punishment for a disciplinary offense. Disciplinary segregation is usually for a fixed term, set by the internal prison hearing process that led to conviction for the offense.
The nomenclature of the new, specialized segregation facilities varies - secure housing units, supermaximum security (supermax) prisons, intensive management units. Human Rights Watch typically refers to them as "supermax" prisons or as segregated confinement. Whatever the name, and despite some variation among prison systems with regard to supermax and segregated confinement, the basic model is a modern day version of solitary confinement. Prisoners typically spend their waking and sleeping hours locked alone in small, sometimes windowless cells, some of which are sealed with solid steel doors. They are fed in their cells, their food passed to them on trays through a slot in the door. Between two and five times a week, they are let out of their cells for showers and solitary exercise in a small enclosed space. Most have little or no access to education, recreational, or vocational activities or other sources of mental stimulation. Radios and televisions are usually prohibited; the number of books or magazines reduced to a bare minimum - if any. They are allowed scant personal possessions. In some prison systems, there are increased "privileges" or programs for administrative segregation prisoners who maintain good behavior for designated periods of time. These privileges, such as in-cell video educational programming, are limited, and typically do not include opportunity for out-of-cell interaction with other people - prisoners, staff, or others. The prisoners are usually handcuffed, shackled, and escorted by two or three correctional officers every time they leave their cells.
In recent years, states have begun incarcerating ever-larger proportions of their prison population in these highly controlled environments. Between 1994 and 2001, according to the Corrections Yearbook 2001, the average percentage of prisoners in segregation and protective custody increased from 4.5 percent to 6.5 percent. The exact number of prisoners held in administrative or disciplinary segregation on any given day is unknown. As of January 1, 2001, thirty-six states reported a total of 49,348 segregated prisoners, excluding prisoners held in protective custody. Individual states vary considerably in the proportion of their prison population that is segregated: Arkansas reported that 15 percent of its prison population was in either administrative or disciplinary segregation; Texas reported 6.8 percent in administrative segregation (and provided no data on disciplinary segregation); New York reported 7.8 percent in disciplinary segregation and none in administrative segregation. As of February 2000, Human Rights Watch's research indicated that more than twenty thousand prisoners were housed in special supermaximum security facilities.
Mentally Ill in Segregation
[I]n all of the systems that I've studied in one fashion or another, if a prison system has gone bad or is bad…in its provision of mental health care, what you have to do is go to the segregation units and you will find the sickest people locked down, unattended to, and it's the way that a malfunctioning prison system operates to hide their mentally ill [I have found this in]… every system that I've ever looked at and the poorer the system, the more serious the conditions, the close deterioration, terrible nightmare for the inmate."
- Testimony of Fred Cohen, LL.M., LL.B., Austin v. Wilkinson, September, 2001.
The mentally ill are disproportionately represented among prisoners in segregation. As discussed earlier in this report, persons with mental illness often have difficulty complying with strict prison rules, particularly when there is scant assistance to help them manage their disorders. Their rule-breaking can lead to increasing punishment, particularly if they engage in aggressive or disruptive behavior. Eventually accumulating substantial histories of disciplinary infractions, they land for prolonged periods in disciplinary or administrative segregation. For example:
·In Oregon, 28 percent of the prisoners in the state's intensive management units (the state's most secure facilities) are on the mental health caseload.
·The New York Correctional Association reports that 23 percent of all prisoners in special housing units (SHUs) are on the mental health caseload. According to its survey of a sample of prisoners in New York's SHUs, nearly one-third of the SHU prisoners on the mental health caseload have had prior psychiatric hospitalizations. Over one-half suffer from depression; 28 percent are diagnosed with either schizophrenia or bipolar disorder. It also found that the average SHU sentence for mentally ill prisoners is six times longer than that reported for SHU prisoners generally.
·As of July 2002, 31.85 percent of the administrative segregation population in California prisons, or 1,753 prisoners, were on the mental health caseload. In Corcoran State Prison, 423 of the 1400 SHU beds (30.21 percent) and in Valley State Prison for Women, twenty-nine of the forty-four SHU beds (65.91 percent) were inhabited by mentally ill prisoners.
· Dr. Dennis Koson reported in 1998 that in New Jersey:
[a]s a result of [the] disciplinary process that all but criminalizes the most common symptoms of mental illness as well as the lack of alternative housing facilities, mentally ill inmates are almost three times more likely to be found in administrative segregation than they are in general population.
His descriptions of some of the prisoners' conditions were searing. One prisoner in administrative segregation at Eastern Jersey State Penitentiary:
stood at the window rocking and staring. His room was incredibly foul, reeking of feces and garbage. There was blood everywhere on the window. He had cut his hand on the edge of the window the day before and was rubbing his hand on the window again. He generally was not responsive to questions, instead just stared at his hand.
·At Indiana's Secure Housing Unit (SHU), in the Wabash Valley Correctional Facility, staff in 1997 acknowledged to Human Rights Watch that somewhere between one-half and two-thirds of the prisoners were mentally ill.
·29 percent of prisoners in Washington State's intensive management units manifested some mental illness symptoms, with 15 percent qualifying as seriously mentally ill.
·In 1997, a federal court in Iowa found that half of the mentally ill prisoners at Iowa State Penitentiary (ISP) were in disciplinary detention or administrative segregation. The high security Cellblock 220, at ISP, housed so many seriously mentally ill prisoners that it was commonly known as the "bug range." The judge wrote that:
[I]nmates in the bug range urinate and defecate anywhere other than their stools. Some inmates cover the walls of their cells with feces. Other inmates gather their urine and throw it at anyone who passes by their cell. Some of these inmates also defecate and urinate in the communal shower and cover the walls and fixtures with their excrement.
·In the Special Needs Unit (SNU) for the seriously mentally ill in Pennsylvania prisons, those with discipline problems are channeled into the SNU Disciplinary Custody cells. When Human Rights Watch visited Graterford, eleven of the twenty-three prisoners in SNU 1 were in Disciplinary Custody, where they were kept in their cells twenty-three hours per day.
Impact of Segregation on the Mentally Ill
Mental health records for prisoners in Ohio State Penitentiary, a supermaximum security facility. Psychiatrists' Clinic Progress Note: "At OSP [O.'s] behavior deteriorated precipitously…. The isolation at OSP provoked quite serious decompensation with both self-destructive and aggressive behaviors;" Treatment Team Mental Health Evaluation: "[O.] is not to return to OSP...Apparently at OSP, the confinement at that institution intensified his propensity to become violent, aggressive, and self-destructive…. His mental health problems contraindicate the transfer back to OSP in the future." Treatment Team Progress Note, "Regarding transfer back to OSP, although stable at the present time, it is perhaps to be anticipated that further deterioration and decompensation would occur if [P.] were to be transferred back to that super maximum security prison."
- Plaintiff's exhibits in Austin v. Wilkinson.
"It's a standard psychiatric concept, if you put people in isolation, they will go insane…. It's a big problem in the California system, putting large numbers in the [secured housing units, California's supermax confinement facilities]… Most people in isolation will fall apart."
- Sandra Schank, staff psychiatrist, Mule Creek State Prison, California.
Perhaps nowhere in corrections is the contradiction between the paradigm of security and that of mental health more apparent than in supermax settings. Whatever the correctional justification for such facilities, it is clear they were not designed with their mental health impact in mind. Indeed, mental health experts did not participate in the development of such regimes. Nor, until very recently, have mental health staff had much of a say in who gets placed in segregation or how long they should stay under such damaging conditions. Moreover, only security staff can mandate changes in privileges or amenities for individual prisoners in segregation.
Yet most independent psychiatric experts, and even correctional mental health staff, believe that prolonged confinement in conditions of social isolation, idleness, and reduced mental stimulation is psychologically destructive. How destructive depends on each prisoner's prior psychological strengths and weaknesses, the extent of the social isolation imposed, the absence of activities and stimulation, and the duration of confinement.
The Human Rights Committee, in General Comment 20, said that "prolonged solitary confinement" of prisoners may amount to torture or other cruel, inhuman or degrading treatment or punishment. The European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT), which has reviewed a number of prison settings akin to U.S. segregation and supermax facilities, has noted that isolation can militate against reform and rehabilitation and can impair physical and mental health. According to the CPT, "It is generally acknowledged that all forms of solitary confinement without appropriate mental and physical stimulation are likely, in the long-term, to have damaging effects resulting in deterioration of mental faculties and social abilities." It has reminded European governments that:
The principle of proportionality calls for a balance to be struck between the requirement of the situation and the imposition of a solitary confinement-type regime, which can have very harmful consequences for the person concerned. Solitary confinement can in certain circumstances amount to inhuman and degrading treatment; in any event, all forms of solitary confinement should last for as short a time as possible.
Prisoners have described life in a supermax as akin to living in a tomb. At best, prisoners' days are marked by idleness, tedium, and tension. For many, the absence of normal social interaction, of reasonable mental stimulus, of exposure to the natural world, of almost everything that makes life human and bearable, is emotionally, physically, and psychologically damaging. As Professor Hans Toch has noted, "unmitigated isolation is indisputably stressful, and it reliably overtaxes the resilience of many incarcerated offenders." Psychologist Craig Haney notes:
Empirical research on solitary and supermax-like confinement has consistently and unequivocally documented the harmful consequences of living in this kind of environment…. Evidence of these negative psychological effects come from person accounts, descriptive studies, and systematic research…conducted over a period of four decades, by researchers from several different continents….
According to a federal judge, prolonged supermax confinement "may press the outer bounds of what most humans can psychologically tolerate." Even if they have no prior history of mental illness, prisoners subjected to prolonged isolation may experience depression, despair, anxiety, rage, claustrophobia, hallucinations, problems with impulse control, and/or an impaired ability to think, concentrate, or remember.
Prisoners with preexisting psychiatric disorders are at even greater risk of suffering psychological deterioration if kept in segregation for prolonged periods. The stresses, social isolation, and restrictions of life in a supermax can exacerbate their illness or provoke a reoccurrence, immeasurably increasing their pain and suffering. A federal district judge trenchantly observed that placing mentally ill or psychologically vulnerable people in supermax conditions "is the mental equivalent of putting an asthmatic in a place with little air to breathe."
A variety of individuals are especially prone to psychopathologic reactions to the reduced environmental stimulation and social isolation of supermax confinement. Professor Hans Toch's study of prison prisoners led him to conclude, for example, that suicidal prisoners can be pushed over the edge and pathologically fearful prisoners can regress into a psychologically crippling panic reaction. According to Dr. Stuart Grassian, "individuals whose internal emotional life is chaotic and impulse-ridden, and individuals with central nervous system dysfunction," are particularly unable to handle supermax conditions. Yet among the prison population, these are the very individuals prone to committing infractions that result in segregation. Even the expert in prison mental health care retained by the California Department of Corrections for the Madrid v. Gomez litigation acknowledged that some people cannot tolerate supermax conditions:
Typically, those are people who have a pre-existing disorder that is called borderline personality disorder, and there's a fair amount of consistent observation that those folks, when they'[re locked up in segregation] may have a tendency to experience some transient psychoses, which means just a brief psychosis that quickly resolves itself when they're removed from the lockdown [segregation] situation.
Indeed, individuals with psychopathic personality disorders are, by virtue of their condition, particularly unable to tolerate restricted environmental stimulation.
Dr. Stuart Grassian has testified that many mentally ill prisoners suffer from:
a combination of psychiatric disorders predisposing them to both psychotic breakdown and to extreme impulsivity…. [S]uch individuals [tend] to be highly impulsive, lacking in internal controls, and [tend] to engage in self-abusive and self-destructive behavior in the prison setting, and especially so when housed in solitary. [T]hey are among the most likely to suffer behavioral deterioration in supermax confinement.
According to psychiatrist Dr. Terry Kupers, the conditions in segregation can cause someone with a vulnerability to psychosis:
to go off the deep end. People who are vulnerable to psychosis have a relatively fragile or brittle ego. When they are made to feel very anxious, or very angry, or very distrustful, their ego tends to disintegrate - in other words, as anger or anxiety mounts, their ego falls apart. They regress, lose control, can't test reality. And this is the beginning of a psychotic decompensation…. If there's nobody to talk to then one is left alone to sort out one's projections, the reality-testing is more difficult - and paranoid notions build up. Activities also bind anxieties and play a role in our testing of reality, so being without activities leaves anxieties to mount - again, there's ego disintegration, and with a disintegrated ego there's even less opportunity or capacity to test the reality of paranoid or unrealistic ideas."
Dr. Kupers also explained the impact of isolated confinement on the mentally ill in his testimony as plaintiff's expert in a lawsuit that challenged, among other issues, the confinement of mentally ill prisoners in Wisconsin's supermax:
[The impact] depends on what the mental illness is. Prisoners who are prone to depression and have had past depressive episodes will become very depressed in isolated confinement. People who are prone to suicide ideation and attempts will become more suicidal in that setting. People who are prone to disorders of mood, either bipolar…or depressive will become that and will have a breakdown in that direction. And people who are psychotic in any way…those people will tend to start losing touch with reality because of the lack of feedback and the lack of social interaction and will have another breakdown, whichever breakdown they're prone to. There are a lot of reasons why these people break down in isolated confinement. First of all, it's almost total isolation and total inactivity. So what happens is that all of us know who we are and maintain our sanity basically by acting, by doing things, by being productive, by mastering things and by relating to other people…. Someone with a mental illness, especially a psychosis, has lots of fantasies. When those fantasies get out of proportion, we call them delusions. The way we check those delusions is to have them in constant social interaction with others so they can say what they're thinking and find out whether they're being crazy or whether that's a realistic perception. When you deprive a person of that kind of feedback on a constant basis and they have a tendency towards psychosis, they will tend to break down.
In some states, such as California, New York, Arkansas, and Georgia, the stresses of living in a lockdown environment are made worse by the practice of double-bunking prisoners. While companionship is usually a good thing, forced companionship for more than twenty-three hours a day in a cell not much bigger than a closet can lead to violent outbursts, especially amongst mentally ill prisoners.
· In one notorious instance, a seriously mentally inmate at Phillips Correctional Institution, Georgia, warned staff that he was going to snap and attack his cell-mate. Instead of placing him in a single cell, the guards simply gave him a new cell-mate. When he began showing signs of aggression toward this second cell-mate, they removed him and brought in a third. The third was found the next morning stomped to death and with a pencil through his eye.
Lost in Segregation
The longer a seriously mentally disordered individual remains acutely disturbed, the worse the long-term prognosis. Rapid and intensive treatment of acute psychiatric disorders offers the best chance for rapid recovery and serves to minimize long-term symptomatology and disability. The problem of mental breakdown and disability in super-maximum security units is thus two-fold: First, the conditions of confinement tend to exacerbate pre-existing psychiatric disorders to cause decompensation in individuals who are psychologically vulnerable under duress. Second, with continued confinement in these same conditions - particularly in the absence of meaningful psychiatric services - the afflicted prisoner's condition tends to deteriorate even further, and the long-term prognosis worsens.
Unfortunately, the length of time in segregation can be substantial. No longer a matter of spending fifteen days in the "hole," prisoners can end up spending years, even decades, in solitary confinement, sometimes only leaving when they are released from prison at the end of their sentence. Administrative segregation can be indefinite, contingent on "good behavior." Disciplinary segregation can turn endless because of subsequent infractions. Achieving sufficient periods of good behavior to secure release from segregation is particularly difficult for mentally ill prisoners. The same inability to comply with the rules that got them placed in segregation originally then extends the time in isolated confinement. For example, in Texas over nine thousand prisoners are currently incarcerated in administrative segregation cells. Prisoners have to "earn" their way back to general population through abiding by the rules over extended lengths of time. A March 2002 report by forensic psychologist Keith Curry, based on research in eight prisons visited over a fifteen-day period, found that "of the 68 inmates reviewed for whom the length of stay could be roughly estimated from the medical record, the average length of stay in segregation appeared to be 5.2 years with a range of one month to seventeen years." Curry pointed out that:
Seriously mentally ill inmates…react more negatively to the relative inactivity and sensory deprivation of 23 hour a day lockdown. As external reality clues recede, their mental functioning often deteriorates with concomitant restriction of their already inadequate coping skills. In the absence of active mental health treatment, seriously mentally ill inmates may become the "bottom dwellers" of the prison system, trapped in segregation units by their illness and unable to adapt to the hard conditions found at the deep end of the correctional system….
As Michael Sullivan, former head of Wisconsin's Department of Corrections, recently testified in court:
When [the mentally ill] are in segregation, if they're not appropriately engaged they continue exhibiting the behaviors that got them there in the first place. If anything, they heighten that activity, which then puts them back before a disciplinary committee, and they get more time. So instead of getting out, they wind up staying longer and longer and longer, and they deteriorate.
Many prison segregation units have systems of "levels" in which prisoners, through good behavior, can obtain increased privileges. The level system is supposed to offer the segregated prisoner incentives for good behavior, or disincentives for misconduct. Prisoners with mental illness, however, find it hard to leave the most restrictive levels.
[I]t is plain that seriously mentally ill inmates differentially lack the ability to understand, internalize, and react appropriately to the disincentives of this level system. Seriously ill inmates are overrepresented in the lower levels of administrative segregation and the long periods spent mired there can be attributed to the serious symptoms of their mental illness. In a circular fashion, the extreme social and sensory deprivation of segregation in turn exacerbates those same symptoms that have kept these inmates stuck at the bottom due to repeated disciplinary infractions.
The Lack of Quality Mental Health Services for Segregated Prisoners.
Across the country, the treatment of mentally ill prisoners in segregated facilities is egregiously deficient. However limited the mental health services for general population prisoners, it is significantly worse for those who are segregated. There are typically too few staff to attend to the high proportion of mentally ill prisoners in segregation. Many are untreated or undertreated because staff dismiss their symptoms as manipulation to get out of segregation. The physical design and rules of social isolation and forced idleness preclude treatment measures. Indeed, the very conditions that can exacerbate mental illness also impede treatment and rehabilitation. Few states have sought to develop ways of providing appropriate mental health treatment options within the context of reasonable security precautions for segregated prisoners.
As discussed above in chapter IX, the mentally ill require a range of treatment options besides psychopharmacology - group therapy, private individual therapy or counseling, milieu meetings, training in the skills of daily living, psychoeducation aimed at teaching patients about their illness and the need to comply with medication regimes, educational programs, vocational training, other forms of psychiatric rehabilitation, supervised recreation, and so forth. In effective mental health programs, some or all of these components can play a crucial part in restoring or improving mental health, or, at the very least, in preventing further deterioration in the patient's psychiatric condition. Many states do not provide such services to prisoners in the general population. But even states that have sought to expand the range of mental health services to prisoners, confront the obstacle of segregation. While medications generally are prescribed to seriously mentally ill prisoners in segregation facilities, therapeutic interventions are conspicuous by their absence.
The cornerstone of segregation is isolation of the prisoner. Out-of-cell time is limited to showers and recreation, and typically requires an escort of correctional officers. Most facilities do not have the security staff - even if they have the office space - to permit prisoners to be escorted for regular private meetings with mental health staff. Mental health staff who want to talk with a prisoner typically must do so standing at the cell front - in full earshot of other prisoners and non-mental health staff. As a result, little cell-front therapy occurs. The rules mandating prisoner in-cell isolation also preclude group therapy, supervised recreational activities, or other forms of group programming. The requirement of isolation flies in the face of the medically accepted fact that most mentally disordered people need to interact with others, even if in incremental steps. They benefit from group therapy and psychiatric rehabilitation activities. They need structured days. If a prisoner is too disturbed or angry to be with others, he needs a treatment plan that will slowly move him in the direction of socialization.
"The mental health team struggles with this," Mule Creek Prison (California) warden Mike Knowles told Human Rights Watch. "There are restrictions within administrative segregation that restrict their ability to do what they need to do - like group therapy. They struggle trying to communicate with inmates from cell doors." Former acting mental health director for Washington State's Department of Corrections, Mike Robbins, is also concerned about limited programming in segregation facilities:
Not all Intensive Management Units in the state are as attuned to mental health needs as I feel they should be. The offender in an IMU setting has less contact with mental health while they're there. I'd like to see that improved. It's not a good setting for someone with a serious mental illness.
Robbins told Human Rights Watch that mental health staff are supposed to do regular rounds of the IMUs, but that the policy is not formally mandated by Central Office, and accurate data on the numbers, and needs of, seriously mentally ill prisoners within IMUs are not tracked department-wide.
Correctional authorities cite punishment and safety considerations as militating against group activities for prisoners in segregation. But denying mentally ill prisoners therapy, as a form of punishment, is not only counterproductive, it is needlessly cruel. Moreover, to the extent punishment is supposed to function as a deterrence - that objective is misplaced when it is the prisoner's mental illness and disorders which prompt acting out or dangerous behavior. Unfortunately, most prison systems function solely on a disciplinary model of punishment for misbehavior; they do not institute, even for the mentally ill, systems of behavioral incentives that might have a greater beneficial impact. As to safety considerations, there is no question that some prisoners are so dangerous and volatile that their interaction with others must be carefully controlled. But even these prisoners, when they decompensate and are transferred to hospital settings, are often able to interact with others without serious incident. Their ability to function in hospital settings raises questions about whether their dangerousness is connected to prison conditions and the treatment they receive there.
If prisoners were on the mental health caseload prior to being transferred to segregation, they are likely to be visited periodically by mental health staff. But because regular segregation units are frequently deeply unpleasant places that are not conducive to therapeutic interactions - noisy, dirty, too hot, or too cold, as well as being crammed full of prisoners who are often intimidating and hostile - mental health staff often spend as little time in them as they can. In prison after prison, our research indicates that visits to prisoners by mental health staff tend to be quick, "how are you doing" cell-front exchanges, what some observers dismissively term "drive-by" visits. Psychiatrists visit even less frequently, and then only to check on medication. Treatment plans other than medication are typically nonexistent; and medication compliance efforts are almost as rare. There is also rarely any monitoring of the mental health of prisoners who were not on the mental health caseload when they begin doing time in the segregation unit - despite the mental health risks of prolonged segregation even for prisoners with no prior mental health histories.
Prisoners who want to talk with mental health staff can wait a long time before anyone shows up at their cellfront. For example, in Nevada a number of prisoners from different prisons, most of them in isolation units, wrote to Human Rights Watch to complain that their requests for medical and mental health appointments routinely were followed by lengthy delays in accessing treatment. One Nevada prisoner in the protective custody unit at the High Desert State Prison in Indian Springs, sent Human Rights Watch copies of multiple request forms he had submitted to see medical doctors and psychiatrists. One request form dated April 20, 2002, responded to ten days later, stated: "you are scheduled for next month or as soon as possible. The medical dept is backed up for months." This sort of delay can prompt acting out and self-mutilation by prisoners desperate to obtain mental health services.
Our research also suggests that mental health staff are unduly quick in concluding that prisoners who request psychiatric assistance are malingering. For example, absent a careful evaluation through diagnostic work-ups, it is impossible to determine whether a self-mutilating individual has genuine psychiatric problems. Staff suspicion of malingering - and the decision to withhold services - is particularly prevalent for segregated prisoners who may have an understandably strong desire to gain even a temporary reprieve from their conditions. Staff also discount the possibility that some prisoners may be exaggerating their psychiatric symptoms because that is frequently the only way to get the help they need. In addition to assuming malingering, mental health staff may be also unduly quick to assign diagnoses of personality disorders rather than Axis I diagnoses.
For example, Dr. Roberta Stellman reported the following about care at Gatesville prison in Texas:
treatable conditions are not diagnosed and treatment, therefore is not initiated…. [S]urprisingly, many inmates are not given an Axis I diagnosis. Yet the more difficult diagnosis of a personality disorder is readily made, usually antisocial personality disorder, without [adequate] documentation…self injury is too often labeled "attention-seeking" and again the dynamics of the behavior are disregarded.
Examples of seriously ill prisoners not receiving adequate mental health treatments in supermax units are legion. We note some examples below:
In some of Alabama's prisons, a high proportion of inmates with serious mental illness are confined in segregation, including some inmates who appeared to expert observers to be experiencing even more acute episodes of illness than their counterparts in the prison mental health treatment units. "Despite the fact that the mental condition of inmates segregation [sic] were often worse than those on the mental health units, they had even fewer contacts with mental health treatment staff, were assessed even less frequently by the psychiatrist, and received only psychotropic medication and intensive correctional supervision. When the psychiatrist is available to segregation inmates, interviews are conducted at the open cell front where there is no confidentiality from other inmates or in an open correctional office where there is no privacy from correctional staff." 
When Human Rights Watch visited Indiana's Maximum Control Facility in 1997, Dr. Terry Kupers, who joined our research team for the visit, interviewed a prisoner who had been intermittently under psychiatric care since the age of four. He was unable to tolerate solitary confinement and was one of the worst self-mutilators in the history of the facility. Yet he was repeatedly deemed free of psychiatric disorders and received no treatment. He was eventually sent to Indiana's other supermax facility, the Secured Housing Unit, where, despite a regime of psychotropic medication, he was still actively hallucinating, displayed other symptoms diagnostic of schizophrenia, and was very depressed. The psychiatrist at the SHU told us that many of the prisoners receiving psychotropic medications were faking psychotic symptoms "to make an excuse of mental illness." In some cases, the psychiatrist labeled as "manipulative" symptoms that, in the judgment of Human Rights Watch's team of psychiatrists, were clearly signs of serious psychiatric disorders.
In many segregation units, mental health services are so poor that even floridly psychotic prisoners receive scant attention, abandoned in their cells accompanied only by their hallucinations. After reviewing the harrowing testimony of plaintiffs' experts regarding conditions in administrative segregation in Texas, a federal judge concluded:
inmates in administrative segregation…are deprived of even the most basic psychological needs. The scene revealed by the plaintiffs' experts, one largely unrefuted by defendants' emphasis on policies and procedures, is one of a frenzied and frantic state of human despair and desperation. Furthermore, plaintiffs submitted credible evidence of a pattern in TDCJ [Texas Department of Criminal Justice] of housing mentally ill inmates in administrative segregation - inmates who, to be treated, would have to be removed to inpatient care. These inmates, obviously in need of medical help, are instead inappropriately managed merely as miscreants…. Whether because of a lack of resources, a misconception of the reality of psychological pain, the inherent callousness of the bureaucracy or officials' blind faith in their own policies, TDCJ has knowingly turned its back on this most needy segment of its population….
Plaintiffs' experts in Ruiz had presented compelling testimony that administrative segregation was "used to warehouse mentally ill patients who need medical and psychiatric attention." Dr. Dennis Jurczak, for example, stated "there was something desperately wrong with a system that would have people this ill sitting in segregation and not being recognized by the mental health staff as needing assistance," including floridly psychotic prisoners. According to the court decision, "Dr. Jurczak found that many of these individuals were not being followed by the mental health staff and many were not identified as mentally ill." Court orders led the department to identify and remove many seriously decompensated prisoners from administrative segregation. However, in 2002,forensic psychologist Keith Curry, retained by the Ruiz attorneys, found that prisoners needing sub-acute care remained housed in administrative segregation (indeed congregated in the most restrictive levels) even though the level of care necessary to treat their illness did not exist in administrative segregation. The prisoners instead were only able to receive outpatient care and, according to Curry:
The quality of outpatient mental health care delivered to inmates surveyed in segregation ranged from adequate to virtually nonexistent…. [The outpatient care suffered from] low and variable caseloads, inadequate and uneven staffing, absent or irrelevant individualized treatment planning, serious and persistent problems with medication administration, and most importantly, the substitution of monitoring for treatment…. Training, supervision, and enforcement of policies and procedures were uniformly weak.
In Louisiana, at Angola Prison's Camp J, a disciplinary housing unit holding 457 prisoners in lock-down conditions, observers who have been allowed into the prison assert that they have encountered a number of overtly psychotic prisoners, several of whom were receiving neither medication nor counseling. According to attorney Keith Nordyke, who has been involved in class action litigation against conditions at Angola, "I was seeing what I considered to be very disturbed, psychotic inmates, who couldn't control their behavior at all. I saw nine or ten. Many were not receiving medication, mental health treatment."
In Florida, until recently, even the pretense of counseling prisoners in segregation was absent. Prisoners in the closed management units (CMUs) lived in cells with external coverings blocking any view out of the windows; they were not permitted radios or allowed to borrow books from the prison library. A 1995 procedural manual on CMUs prepared by the Florida Department of Corrections' Adult Services Programs Office, detailed the prisoner living conditions: "Inmates confined on a 24 hour basis, excluding showers and clinic trips, may exercise in their cells. However, if confinement extends beyond a 30 day period, there shall be an exercise schedule providing a minimum of two hours per week of exercise outside the cell." The1995 manual's one reference to the mental health of prisoners merely stated that a psychologist "shall prepare an assessment if the inmate is assigned to close management for more than 30 continuous days and not assigned to work outside the housing unit. If the confinement extends beyond 90 continuous days a new psychological assessment shall be complete after each subsequent 90 day period." The manual stated that prisoners in Florida's ten close management units must maintain a clean record for six months before being eligible for any form of in-cell programming.
Six years after the manual was written, at the tail end of the Osterback v. Moore class action lawsuit filed by mentally ill prisoners against these conditions, in a tacit admission that these units were excessively restrictive, the Florida Department of Corrections sent an internal memo to all its prison wardens. The wardens were ordered to remove external visual shielding on the cell windows; to immediately build exercise stations to be placed in close management yards; to allow closed management prisoners the use of radios; and to allow prisoners to borrow up to three books a week from the prison library (while the 1995 manual had not explicitly documented the denial of library privileges, the 2001 document implicitly acknowledged that this had, in fact, been the case.) In-cell educational opportunities, according to the memo, would now kick in after sixty days, instead of the previously mandated six months. Significantly lacking, however, was any reference to improved mental health counseling on the units.
Three months after the memo went out, without admitting liability, the Florida Department of Corrections offered to settle the Osterback case. They proposed consolidating the ten close management units into four sites by October 2003; increasing staff training on mental health issues; performing mental health screening both before and after a prisoner's placement in the units; assessing the behavioral risk of each prisoner so as to better lay the groundwork for mental health planning; and "provid[ing] a full range of outpatient mental health services (e.g., group/individual counseling; case management; psychiatric consultation; psychotropic medications; and timely referral to inpatient care), commensurate with clinical need, as determined by the Defendant's mental health staff." The new plan stated that "all [CMU] inmates shall be allowed out of their cells to receive mental health services specified in the [individualized service plan], unless, within the past 48 hours, the inmate has displayed hostile, threatening, or other behavior that could portend harm or danger to others." Plaintiffs accepted the terms of the proposal settlement and it was approved by the court on December 27, 2000.
It remains to be seen whether comprehensive mental health services will indeed be implemented within the time frame laid out in this settlement agreement. Lawyers for the plaintiffs told Human Rights Watch that, as of April 2003, the Florida Department of Corrections was continuing to discipline seriously mentally ill prisoners in the CMUs for such offenses as talking through their doors to neighboring prisoners; and that guards used pepper spray on seriously ill prisoners for creating disturbances, talking, and masturbating. The attorneys also alleged that, while Florida had created a good set of protocols regarding issues of concern such as the monitoring of side-effects of medication and the availability of regular meetings with psych specialists and psychiatrists, the realities do not always match the promise. "In theory they're supposed to monitor side effects," attorney Peter Siegel stated. "The problem is on paper they do everything and on the ground they do very little. People on medications are supposed to be monitored regularly by these psych specialists. And some do it and some don't."
Even within units specifically developed for mentally ill prisoners, such as California's Enhanced Outpatient Units (EOP), disciplinary rules that lead to segregation can frustrate mental health treatment efforts. Mental health clinicians have input into disciplinary hearings for EOP prisoners and can provide information for the disciplinary officers (who are security staff) to consider, but it is the disciplinary officers who have the ultimate say about punishments - including segregated confinement - to be meted out for infractions. When Human Rights Watch visited Mule Creek, fifty-five of the 187 prisoners in administrative segregation were on the mental health roster. Although the duration of such segregation is not prolonged, no more than perhaps two or three months, the prisoners in segregationlack guaranteed, regular access to the mental health programs and services available to them in the EOP. While their EOP status means that the prisoners are supposed to receive ten hours per week of out-of-cell group sessions, in practice, because of staffing shortages and security concerns, most of their interaction with psychologists and mental health staff occurs in cell-front interaction when the staff make their daily rounds in the EOP segregation units. What limited out-of-cell therapy is provided occurs with the prisoners in tiny single holding cells, known to staff and prisoners alike as "cages," in which those perceived as security threats are held while undergoing therapy. It is far from uncommon for EOP administrative segregation prisoners to have to be sent to mental health crisis units for stabilization. According to administrative staff at Mule Creek prison, fully half of all crisis bed admissions at the facility come from the EOP administrative segregation population.
From Segregation Units to Psychiatric Centers and Back
Eleven years ago, the Journal of Prison & Jail Health reported that, across the country, prisoners with mental illness move back and forth between segregation and psychiatric centers.
In segregation, the psychological stressors typically found in corrections are exacerbated and the atmosphere will frequently be counter-therapeutic…. For some [prisoners], this environment causes mental deterioration to the point of necessitating psychiatric hospitalization.
Little has changed in subsequent years. The movement of mentally ill prisoners from segregation units to hospitals and back to segregation remains a prominent feature of their life in prison. When mentally ill prisoners in segregation become unmistakably psychotic, they are transferred in-patient psychiatric facilities. Once the prisoners are stabilized, they are returned to segregation.
·Correctional officers at Valley State Prison for Women, in California, told Human Rights Watch of one prisoner confined in the facility's secured housing unit (SHU) who, "rubs feces all over her body, her hair, her cell. She's been here almost a year. She screams at herself, anybody that walks by there. She floods her cell. She destroys everything that's in it." Periodically, she is removed to a mental unit for crisis intervention. But, the officers reported, after about three days, she is always returned to the SHU.
·In a study of Washington State's Intensive Management Units, four University of Washington researchers found a pattern of:
movement between acute care and mental health housing for a time before being admitted to IMU, with IMU admission becoming an increasingly frequent event. In these cases, inmates are described as escalating in violence, unpredictability, or extremely bizarre behavior, and as difficult to manage in other prison settings. They are often recognized as psychotic or seriously mentally ill.
· In New York, numerous seriously mentally ill prisoners are incarcerated in the state's Special Housing Units (SHU), in a type of isolated cell that prisoners in New York call "the box." Attorneys from the Prisoners' Rights Project who have litigated several mental illness-related cases and are currently engaged in a system-wide mental health lawsuit, allege that a substantial number of seriously mentally ill prisoners spend years, even decades, bouncing back and forth between the SHU and Central New York Psychiatric Center. Prisoners' Rights Project attorney Sarah Kerr stated in a December 2000 presentation to the New York State Democratic Task Force on Criminal Justice Reform:
One schizophrenic prisoner whose medical chart we reviewed has been admitted to CNYPC [Central New York Psychiatric Center] on more than 20 occasions since his incarceration in the late 1970s; we know that he has been housed continuously in 23 hour confinement for at least the period from early 1991 through May 2000, and that at least six of those ten years in segregation were in SHU.
When the decision has been made that a prisoner should be transferred to a psychiatric unit or facility, the actual move may be delayed by space limitations in those facilities. In Mississippi, for example, it can take several weeks for a prisoner to be removed to an inpatient unit. Such delays are primarily due to lack of staff and lack of space, and sometimes a lethargic bureaucracy plays a part. Also, the hospitals are simply reluctant to accept disruptive prisoners, even if they are acutely ill.
Once removed from segregation and provided a better level of mental health care in specialized psychiatric unit or hospital, many prisoners are stabilized and able to function more normally. But when they are then returned to segregation, they begin again the process of psychiatric deterioration. "Many times, the inmate, upon discharge from a psychiatric hospitalization, is returned to segregation, where the pattern repeats," the authors of the Journal of Prison & Jail Health article wrote. In recent years, mental health experts have documented this phenomenon in numerous states whose mental health services were being challenged in litigation. For example, when Dr. Keith Curry toured Texas's prison system in 2002 and reviewed the records of mentally ill prisoners in connection with the Ruiz litigation, he discovered that in the six months from September 2001 to March 2002, McConnell prison had sent ninety-one prisoners out of the facility on mental health crisis transfers. Of these, thirty had been removed from administration segregation, forty-four of the ninety-one were repeat referrals, and fourteen of them were for psychotic decompensation while in segregation.
In Oregon, many of the mentally ill prisoners housed in the prisons' Intensive Management Units decompensate and are then sent to the psychiatric intensive care unit. But this is only a short-term solution: two-thirds of those sent to the Mental Health Unit spend only ten to fourteen days there, and the rest at most three or four months. They are then back to the IMU, where many proceed to decompensate again.
Most prison systems recognize that the cycle between segregation units and psychiatric crisis units or hospitals, referred to by some administrators as a "ping pong effect," is a problem that benefits nobody. The problem is particularly acute for those mentally ill prisoners who are violent and disruptive. They frequently have both serious mental illness (Axis 1) and serious personality disorders (Axis 2) that make their treatment and rehabilitation notoriously difficult yet their mental condition also makes them the greatest management challenge correctional authorities face. These prisoners invariably end up in prolonged segregation or supermaximum security confinement. It may be their Axis 2 disorder that accounts for the behavior that places them in segregation, but because of their Axis I illness, they cannot handle the stressful isolation and they decompensate.
But even in Washington State, Mike Robbins, the acting mental health director for Washington State's Department of Corrections, told Human Rights Watch that many of the most difficult-to-control prisoners in the state end up in Intensive Management Units, the state's supermax facilities. The combination of Axis 2 personality disorders and Axis 1 illnesses renders them too hard to control in the prison system's Special Offender Units (SOU) in which the more intensive mental health programs are concentrated.
If someone cycles between the Special Offender Unit and the Intensive Management Unit [IMU], if they're troublesome enough the SOU staff will refuse to take them back, because they're not amenable to treatment and they're using up scarce resources. If it's not appropriate to put them in an IMU, where do we put them? We don't want to put them in a mental health program because they're so disruptive they blow up the program. It's a huge problem for corrections in general nationwide. We're struggling with it. The agency has not turned a blind eye to it.
At McNeil Island prison in Washington, the Department of Corrections has developed a different system. The staff emphasize continuity of care, attempting to keep mentally ill prisoners within the same facility and dealing with the same staff for prolonged periods of time, rather than bouncing them between different institutions. They stress the importance of linking mental health treatment to chemical dependency and substance abuse treatment, and they have instituted weekly meetings in which mental health patients have a chance to discuss their illnesses and treatment schedules with case managers. The mental health staff have also worked hard to increase their input into disciplinary processes, and have, in some instances, successfully convinced the prison authorities to reclassify someone out of Maximum Security custody if they believe that prisoner could be better served in a mental health program.
There are no easy answers for how to handle and help dangerous and disruptive prisoners who suffer from Axis 1 or Axis 2 disorders. Mental health experts told us progress is possible, but requires paradigm shifts in which correction officials must relinquish some of the usual rules by which prisons operate. Facilities would have to be run according to treatment protocols as determined by mental health staff. Public officials would have to support a form of incarceration that differed markedly from the traditional prison and be willing to stand up to critics who would argue that such treatment-oriented facilities "coddled" the worst prisoners. Another obstacle, of course, would be funding. No one doubts that a treatment-oriented milieu for mentally ill prisoners who are disruptive must be labor-intensive - and hence expensive. Yet until the expense is undertaken, the vicious cycle of segregation and decompensation and short-term hospitalization will continue until the prisoners are ultimately released, at least as sick as they were upon entry into the criminal justice system, from prison back into the community.
Keeping the Mentally Ill Out of Segregation
Courts have also recognized that conditions that inflict serious pain or injury are constitutionally suspect. "While prison administration may punish, it may not do so in a manner that threatens the physical and mental health of prisoners." As one federal judge cogently noted, if the U.S. Constitution precludes forcibly incarcerating prisoners under conditions that will, or very likely make them seriously physically ill, "these same standards will not tolerate conditions that are likely to make inmates seriously mentally ill."
Several recent court cases indicate the Eighth Amendment prohibition against cruel and unusual punishment may be violated when prisoners with serious mental illness or at increased risk for mental illness are confined in harsh, isolated high security facilities:
·In the landmark Madrid v. Gomez case in California, a federal district court in 1995 ruled that it was unconstitutionally cruel and unusual punishment to confine the mentally ill in the security housing unit (SHU) of Pelican Bay prison. The court ruled:
For these inmates, placing them in [a SHU]] is the mental equivalent of putting an asthmatic in a place with little air to breathe. The risk is high enough, and the consequences serious enough, that we have no hesitancy in finding that the risk was plainly unreasonable. Such inmates are not required to endure the horrific suffering of a serious mental disorder or major exacerbation of an existing mental illness before obtaining relief.
The court also ordered the exclusion from the SHU of:
those who the record demonstrates are at a particularly high risk for suffering very serious or severe injury to their mental health, including overt paranoia, psychotic breaks with reality, or massive exacerbations of existing mental illness as a result of the conditions in the SHU. Such inmates consist of the already mentally ill, as well as persons with borderline personality disorders, brain damage or mental retardation, impulse-ridden personalities or a history of prior psychiatric problems of chronic depression…. Such inmates are not required to endure the horrific suffering of a serious mental illness or major exacerbation of an existing mental illness before obtaining relief…. [S]ubjecting individuals to conditions that are `very likely' to render them psychotic or otherwise inflict a serious mental illness or seriously exacerbate an existing mental illness cannot be squared with evolving standards of humanity or decency…. A risk this grave-this shocking and indecent-simply has no place in civilized society.
After the Madrid ruling, new administrators were brought in to Pelican Bay, many of the staff were re-trained, and a new mental health infrastructure was developed for the prison. In January 1998, the prison published plans for the creation of a high security unit specifically catering to its seriously mentally ill prisoners. Over one hundred seriously mentally ill prisoners were removed from Pelican's Bay's security housing unit and placed into the new specially designed Psychiatric Services Unit (PSU). In the PSU, prisoners must receive group therapy, regular access to psychiatrists and to counselors, and routine mental health monitoring.
Court monitors appointed under the Madrid ruling have generally written favorably on the PSU and on the mental health services the new unit provides. But they have also critiqued the program for failing to live up to certain requirements. In particular, the reports have found that PSU prisoners do not receive enough out-of-cell programming. "During the past three years, defendants have worked to establish various corrective action plans to address shortfalls in their compliance efforts," the Special Master wrote in October 2000.
Some of these programs, like the development of a data-processing system to measure EOP [Enhanced Outpatient Program] and PSU inmate activity, expansion of the number of rooms that are available for group therapy, implementation of a program for outdoor recreation for PSU inmates, and utilization of a PSU level system have proven successful. Other corrective action plans, including those related to the hiring and retention of staff, and those related to providing EOP and PSU inmates with minimum out of cell structured therapy, have not proved effective.
The report went on to fault the PSU for "chronic staffing shortages, including psychiatrist shortages and a long-term problem with inadequate numbers of psychiatric technicians…. For two and one half years the PSU has failed to meet its structured therapy requirements."
·In October 2001, a federal district judge in Wisconsin issued a preliminary injunction against the confinement of seriously mentally ill prisoners at the state's super-maximum security prison, ruling that plaintiffs had demonstrated a substantial likelihood that such confinement was unconstitutional. The subsequent settlement agreement between the parties approved by the judge establishes a permanent prohibition on the confinement of seriously mentally ill prisoners in the supermax. The state has moved thirty-nine seriously mentally ill prisoners out of the facility (which housed 260 prisoners at the time of the ruling). The settlement permits an exception to the exclusion of seriously mentally ill from the supermax only if the department of corrections establishes the dangerousness of an prisoner and the absence of feasible alternative placements in Wisconsin or outside the state. In such cases, the department must also "identify the additional services that will be provided to the inmate to help him with his serious mental illness and to ameliorate the effect the conditions at Supermax have on that illness."
·A 1998 Ohio Department of Rehabilitation and Correction (DRC) policy specifically stated that:
Inmates who are seriously mentally ill…will not be placed at Ohio State Penitentiary [the state's supermaximum security prison]…. Any inmate who is seriously mentally ill and has been inadvertently transferred to Ohio State Penitentiary shall be transferred to another institution in an expeditious manner.
Nevertheless, in class action litigation against Ohio State Penitentiary (OSP), the presence of seriously mentally ill prisoners at the facility was documented and, under the spotlight, the DRC had to remove them from the prison. A federal district court granted plaintiffs a preliminary injunction preventing the DRC from returning those prisoners to the OSP. It noted there was "little dispute," even from the DRC, that placing seriously ill prisoners in that prison could cause decompensation and deterioration of a prisoner's mental health. The DRC's own psychiatrist acknowledged in his testimony that he had consistently recommended against the return of seriously mentally ill prisoners to OSP because of the likelihood of psychiatric harm. In the settlement concluding part of the class action, the DRC agreed that mentally ill prisoners should not be housed at OSP and that those removed from the prison on grounds of mental illness could never be returned there. Prisoners excluded from supermax confinement in Ohio are those suffering from a serious mental illness or mental retardation, those deemed actively suicidal or suffering from a severe cognitive disorder that results in significant functional impairment, and those with a severe personality disorder that is manifested by frequent episodes of psychosis, depression, or self-injurious behavior.
The Ohio DRC now places seriously mentally ill prisoners who it deems to require high security confinement in the residential treatment unit (RTU) at the Southern Ohio Correctional Facility, a maximum-security prison in Lucasville. However, according DRC policy, when high maximum security classified prisoners are released from the RTU because mental health staff consider them stable and able to cope outside of such a specialized unit, they are placed in the "J-4" administrative control unit. This unit operates with essentially the same rules and restrictions as the supermaximum security prison. There are, nonetheless, substantial differences between the supermax and the J-4 unit. The J-4 cells have open fronts with bars instead of a solid door thus reducing the isolation and enabling prisoners to communicate with each other more easily. There is structural programming, outdoor and indoor recreation, and opportunities for prisoners to interact. The unit also provides more access to mental health treatment than in the OSP. Pointing to these factors, the federal district court hearing the class action against OSP denied a motion to grant a preliminary injunction preventing the DRC from placing prisoners with serious mental illness in the J-4 unit, concluding they were unlikely to prevail on their claim that such confinement violated the Eighth Amendment.
·In the Ruiz lawsuit in Texas, after extensive testimony by plaintiffs' psychiatric experts about the presence of severely ill, including floridly psychotic, prisoners in administrative segregation who were receiving little or no medical care, the federal district court ruled that confining the mentally ill in segregation was unconstitutional. In the Ruiz case, a federal court in 1999 noted that in Texas:
Separately from and independent of, the determination that the conditions of deprivation in administrative segregation violate the constitution, it is found that administrative segregation is being utilized unconstitutionally to house mentally ill inmates - inmates whose illness can only be exacerbated by the depravity of their confinement. As to mentally ill inmates…the severe and psychologically harmful deprivations of [the] administrative segregation units are, by our evolving and maturing society's standards of humanity and decency, found to be cruel and unusual punishment.
The court subsequently ordered the Texas Department of Criminal Justice (TDCJ) to develop plans to make sure:
seriously mentally ill prisoners for whom the conditions of administrative segregation are injurious or pose a significant risk of serious deterioration in their mental status are not housed in regular administrative segregation, but are rather housed in inpatient mental health hospitals or other facilities appropriate for the level of mental health care that they require.
In conjunction with the University of Texas Medical Branch at Galveston and the Texas Tech University Health Sciences Center in Lubbock, the TDCJ conducted thorough reviews of its prisoner population in high security institutions such as the Estelle Unit, and relocated several dozen of its sickest prisoners into hospital settings. The TDCJ also developed new mental health treatment programs for prisoners who would otherwise be in regular administrative segregation, including one in the Specialized Administrative Segregation Maintenance Program for prisoners who have been stabilized on medication in a hospital setting but have a pattern of discontinuing treatment and decompensating. Another program is the Enhanced In Cell Treatment Program for prisoners with chronic mental illness who do not require ahigher level of care but do requiretreatment and contact to mitigate the effects of the segregation environment. In addition to special reviews of administrative segregation prisoners by mental health staff to identify acutely mentally ill patients, the TDCJ also contracted with a consultant to provide an independent review mechanism to ensure seriously ill offenders are removed from segregation.
·Although Connecticut did not have a lawsuit hanging over its head, it nonetheless changed its rules regarding the incarceration of seriously mentally ill prisoners in its supermax prison. Persistently mentally ill prisoners, registering a four or a five on the five-tiered mental health categorization system used by the Connecticut Department of Correction, are not sent to the supermax Northern Correctional Institution (NCI). "It had to do with the nature of the environment at Northern," Brett Rayford, director of health and mental health services for the department, stated. "Interaction with other people was limited. The facility was designed to contain people even more than other facilities." Nevertheless, mental illness continues to disproportionately plague the supermax prison: of the 450 prisoners at NCI as of mid-2002, 111 were categorized as mental health level three.
 Inmate evaluation by Dr. Terry Kupers, member of a Human Rights Watch research team in July 1997. See Human Rights Watch, Cold Storage: Super-Maximum Security Confinement in Indiana (New York: Human Rights Watch, 1997), p. 37.
 Testimony of Michael J. Sullivan, former director, Wisconsin Department of Corrections, Jones 'El v. Berge, Civil Case 00-C-0421-C (W.D. Wisconsin, September 20, 2001), p.39.
 Based on visits to a dozen such facilities and extensive other research, Human Rights Watch has criticized prolonged supermax confinement as being disproportionately severe to legitimate security and inmate management objectives and for imposing pointless suffering and humiliation on prisoners, in violation of international human rights standards.Human Rights Watch, "Out of Sight: Super-Maximum Security Confinement in the United States," A Human Rights Watch Report, vol. 12, no. 1(G), February 2000;Human Rights Watch, "Red Onion State Prison: Super-Maximum Security Confinement in Virginia," A Human Rights Watch Report, vol. 11, no. 1(G), May 1999; and Human Rights Watch, Cold Storage: Super-Maximum Security Confinement in Indiana (New York: Human Rights Watch, 1997).
 A few prison systems, e.g., New York and California, double-cell inmates in segregation.
 The punitive restrictions on inmates in segregation can reach the tragically absurd. In Texas, inmates at the lowest levels of segregation were denied regular hygiene products; they had to use an all-in-one soap, a restriction which experts on supermax confinement found astonishing. Ruiz v. Johnson, 37 F. Supp. 855 (S.D. Texas, 1999). In Massachussetts, inmates in the Departmental Disciplinary Unit at MCI-Cedar Junction were allowed to have junk novels, but regulations expressly forbade any educational reading material. See Torres v. DuBois, 1997 Mass. Super. Lexis 539 (Feb. 10, 1997).
 Camille G. Camp and Camp, George M., Corrections Yearbook 2001: Adult Systems (Connecticut: Criminal Justice Institute, 2002), p. 38. Protective custody refers to non-punitive segregation of inmates from the general population to protect them from other inmates.
 Human Rights Watch, "Out of Sight: Super-Maximum Security Confinement in the United States," A Human Rights Watch Report, vol. 12, no. 1(G), February 2000, p. 3. Explaining the trend toward supermax incarceration, the authors of the Human Rights Watch report wrote that:
Thinly staffed, overcrowded, and impoverished facilities breed tension and violence, particularly where prison management has not placed a high priority on promoting staff-inmate and inmate-inmate relations predicated on mutual respect. Many corrections authorities have turned to prolonged supermax confinement in an effort to increase their control over prisoners. They believe that if they can confine all the most dangerous or disruptive inmates in facilities designed specifically for that purpose, they will be able to increase safety and security in other prisons…. A significant impetus for supermax confinement also comes from politicians. Crime and punishment have been central issues in American politics for over two decades, and advocating harsh punitive policies for criminal offenders remains a politically popular position. Elected officials advancing tough-on-crime policies have promoted large supermax prisons for their symbolic message, regardless of actual need. Fearful of being accused of 'coddling inmates' or being 'soft on crime,' few politicians have been willing to publicly challenge supermaxes on human rights grounds.
 Testimony of Fred Cohen, Preliminary Injunction Hearing, Austin v. Wilkinson, No. 4:01 CV 0071 (N.D. Ohio, September 24, 2001), p. 14.
 Human Rights Watch telephone interview with Gary Fields, administrator, Counseling and Treatment Services, Oregon Department of Corrections, June 24, 2002.
 Correctional Association of New York, "Mental Health in the House of Corrections," forthcoming publication, p. 14; Eng v. Coughlin, 80-CV-385S, 1988 U.S. Dist. LEXIS 18327 (W. D. N.Y., January 29, 1988). In March 1998, the New York Department of Correctional Services agreed to resolve a lawsuit against Attica prison by no longer keeping seriously mentally ill inmates, "or those known to be at substantial risk of serious mental or emotional deterioration," in the special housing unit (SHU) at Attica. The New York Department of Correctional Services did not, however, extend the exclusion ofmentally ill inmates from special housing units throughout its system. Judge William M. Skretny of the United States District Court Western District of New York issued a voluntary Stipulation of Dismissal on March 16, 1998, after both parties agreed to the removal of seriously mentally ill inmates from Attica's SHU, speedier mental health screening for incoming inmates, and periodic mental health monitoring of SHU inmates.
 Correctional Association of New York, "Mental Health in the House of Corrections," forthcoming publication.
 California Department of Corrections, Health Care Placement Unit, "Mental Health Adseg/SHU/PSU," population chart created on July 25, 2002.
New Jersey Prison System Report of Dr. Dennis Koson, C.F. v. Terhune, Civil Action No. 96-1840 (D.N.J., September 8, 1998), p. 6.
 Ibid., pp. 81-82.
 Human Rights Watch, Cold Storage: Super-Maximum Security Confinement in Indiana (New York: Human Rights Watch, 1997), p. 34.
 David Lovell, Kristin Cloyes, David Allen, Lorna Rhodes, "Who Lives in Super-Maximum Custody? A Washington State Study," Federal Probation, vol. 64, no. 2, Dec. 2000.
Goff v. Harper, Findings of Fact and Conclusions of Law, No. 4-90-CV-50365 (S.D. Iowa, June 5, 1997), p. 39.
 Human Rights Watch visited Graterford, August 12, 2002.
 These notes were part of plaintiff's exhibits introduced at trial and cited by the federal court granting plaintiff's request for a preliminary injunction precluding the return of prisoners with serious mental illness to Ohio's supermaximum security Ohio State Penitentiary. See Austin v. Wilkinson, Case No. 4:01-CV-71, Order (N.D. Ohio, September 21, 2001) (unpublished opinion), p. 24.
 Human Rights Watch interview with Sandra Schank, staff psychiatrist, Mule Creek State Prison, California, July 19, 2002.
 Human Rights Committee, General Comment 20, article 7 (Forty-fourth session, 1992), Compilation of General Comments and General Recommendations Adopted by Human Rights Treaty Bodies, U.N. Doc. HRI\GEN\1\Rev.1 at 30 (1994), para. 6.
 European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment, Report to the Finnish Government on the Visit to Finland, conducted between 10 and 20 May 1992, Strasbourg, France, 1 April 1993, CPT/Inf (93) 8.
 European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT), Report to the Icelandic Government on the Visit to Iceland, conducted between 6 and 12 July 1993, Strasbourg, France, 28 June 1994, CPT/Inf (94) 8, p. 26. In reviewing the practice of solitary confinement in one of Iceland's prisons, the CPT notes that a report by the country's minister of justice states that "psychiatrists, psychologists and other specialists have stressed that solitary confinement as practiced [at the prison] has a harmful effect on prisoners' mental and physical health, particularly in the case of those detained for long periods."
 Human Rights Watch has visited over a dozen supermax facilities across the United States and interviewed inmates confined in them.
 Hans Toch, "Future of Supermax Confinement," The Prison Journal, vol. 81, no. 3, September 2001, p. 378.
 Craig Haney, "Mental Health Issues in Long-Term Solitary and 'Supermax' Confinement," Crime & Delinquency, vol. 49, no. 1, January 2003, p. 130.
Madrid v.Gomez, 889 F. Supp. 1146 (N.D. California, 1995).
 Stuart Grassian and N. Friedman, "Effects of Sensory Deprivation in Psychiatric Seclusion and Solitary Confinement," International Journal of Law and Psychiatry (1986), vol. 8, pp. 49-65; Grassian, "Psychopathological Effects of Solitary Confinement," American Journal of Psychiatry (1983), vol. 140, pp. 1450-1454; Craig Haney, untitled draft of article on SHUs (2002) (unpublished).
Madrid v. Gomez, 889 F. Supp. at 1265 (citations omitted).
 Hans Toch, Men in Crisis: Human Breakdown in Prison (1975).
 Declaration of Dr. Stuart Grassian, Eng v. Coughlin, 80-CV-385S (W.D. New York) (undated).
 Testimony of Joel Dvoskin, quoted in Madrid v. Gomez, 889 F. Supp. at 1216.
 Declaration of Dr. Stuart Grassian, Eng v. Coughlin, 80-CV-385S (W.D. New York) (undated), citing H. Quay, "Psychopathic personality as pathological stimulation seeking," American Journal of Psychiatry vol. 122 (1965), pp. 80-83.
 Declaration of Dr. Stuart Grassian, Eng v. Coughlin, 80-CV-385S (W.D. New York) (undated). citing G. Cota & S. Hodgins, "Co-occurring mental disorders among criminal offenders," Bulletin of the American Academy of Psychiatry and Law, vol. 18, no. 3, pp. 271-81.
 Email communication from Dr. Kupers to Human Rights Watch, April 9, 2003.
 Testimony of Dr. Terry Kupers, Jones 'El v. Berge, Civil Case 00-C-0421-C (W.D. Wisconsin, 2001).
 Attorneys from the Southern Center for Human Rights told Human Rights Watch of this occurrence. It happened in 2001, while the prisoners were being held in an isolation unit pending disciplinary hearings.
 Texas Department of Criminal Justice data indicate that the administrative segregation population peaked in December 2000 at 9,074. Since then it has hovered just over nine thousand.
 Keith Curry, Ph.D., letter to the law offices of Donna Brorby, March 19, 2002, p. 4.
 Testimony of Michael Sullivan, Jones 'El v. Berge, Civil Case 00-C-0421-C (W.D. Wisconsin, September 20, 2001), p. 39
 Keith Curry, Ph.D., letter to attorney Donna Brorby, March 19, 2002, p. 7. Curry was describing his findings in Texas, but our research suggests his observations apply equally to supermax prisons generally.
 Human Rights Watch interview with Mike Knowles, warden, Mule Creek State Prison, California, July 19, 2002.
 Human Rights Watch interview with Mike Robbins, former acting mental health director, Washington State Department of Corrections, Olympia, Washington, August 19, 2002.
 Hans Toch and Kenneth Adams, Acting Out, 2002.
 The Nevada inmate, J.S., wrote to Human Rights Watch on August 23, 2002, and included copies of his medical treatment request forms.
 Dr. Stellman's December 10, 1998 report on mental health services in certain Texas prisons is quoted in Dr. Jeffrey Metzner's letter to attorney Donna Brorby, December 31, 1998, p. 12; on file at Human Rights Watch.
 Kathryn Burns, M.D. and Jane Haddad, Psy.D., "Mental Health Care in the Alabama Department of Corrections," Bradley v. Hightower, Civ. No. 92-A-70-N (N.D. Ala., June 30, 2000), pp. 85-86.
See Human Rights Watch, Cold Storage: Super-Maximum Security Confinement in Indiana (New York: Human Rights Watch, 1997). We were also disturbed by the SHU psychiatrist's stated willingness to give psychoactive medications to prisoners who are not psychotic. He attempted to justify this practice by saying the prisoners had affective disorders, even though it is not standard medical practice to prescribe antipsychotic medications for such disorders.
Ruiz v. Johnson, 37 F. Supp. 2d 855, 911 (S.D. Texas, 1999).
 Ibid., at 912.
 Keith Curry, Ph.D., letter to attorney Donna Brorby, March 19, 2002, p. 10.
 Human Rights Watch telephone interview with Nick Nordyke, May 7, 2002. Nordyke has been involved in prison litigation in Louisiana for over a decade.
Close Management Procedural Manual, p. 25 (State of Florida, Department of Corrections' Adult Services Program Office, August 1995).
 Ibid., p. 22.
 Ibid., p. 25.
Osterback v. Moore, Case No. 97-2806-CIV-HUCK (S.D. Florida). The lawsuit alleged that close management conditions were so harsh that they violated the Eighth Amendment to the U.S. Constitution. The case was settled on December 27, 2000, when the court entered a final judgement of injunctive relief in an unpublished order.
 Memorandum from Richard Dugger, deputy secretary, Department of Corrections, State of Florida, July 20, 2001.
Osterback v. Moore, Case No. 97-2806-CIV-HUCK (S.D. Florida, October 2, 2001), Defendants' Revised Offer of Judgement, Phased Consolidation Plan, Part A.5, p. 4.
 Ibid., p. 11.
 Human Rights Watch telephone interview with Peter Siegel, attorney, April 21, 2003.
 According to the prison, that day twenty-six prisoners were EOP status and twenty-nine were CCCMS status.
 Human Rights Watch telephone interview with an attorney who wished to remain anonymous, July, 2003.
 When Human Rights Watch visited these units, we saw group therapy rooms set up with a row of three to six cages lined up next to each other. The prisoners are escorted, in shackles, to this room from their cell; they are then locked into the holding cells and are unshackled. The cells are about the size of a priest's confessional; large enough to either sit down in or stand up in, but with no room to take even a single step. This qualifies as group therapy, because the prisoners can all hear the counselor and can all hear each other's comments. They cannot, however, necessarily see each other.
 Human Rights Watch telephone interview with an administrative officer, Mule Creek State Prison, August 18, 2003. Mental health staff double-checked the data.
 Article by William J. Rold, "Correctional Health Care," Journal of Prison and Jail Health, vol. 11, no. 1, 1992.
 Human Rights Watch interviews with correctional officers, Valley State Prison for Women, California, July 17, 2002.
 David Lovell, Kristin Cloyes, David Allen, Lorna Rhodes, "Who Lives in Super-Maximum Custody? A Washington State Study," Federal Probation, vol. 64, no. 2, Dec. 2000.
 Testimony by Sarah Kerr of the Legal Aid Society, Prisoners' Rights Project on Mental Health Care in Special Housing Units in New York State Correctional Facilities, p. 7. Presented before the New York State Democratic Task Force on Criminal Justice Reform, December 4, 2000.
 Human Rights Watch telephone interview with John Norton, July 24, 2002.
 William J. Rold, "Correctional Health Care," Journal of Prison and Jail Health, vol. 11, no. 1, 1992.
 Letter from Dr. Keith Curry to the law offices of Donna Brorby, March 19, 2002, p. 16.
 Human Rights Watch telephone interview with Gary Fields, administrator, Counseling and Treatment Services, Oregon Department of Corrections, June 24, 2002.
 The term "ping pong effect" was first mentioned to Human Rights Watch in an interview with correctional staff, Northern Correctional Institution, Connecticut, June 10, 2002.
 Human Rights Watch interview with Mike Robbins, former acting mental health director, Washington Department of Corrections, Olympia, Washington, August 19, 2002.
 This information was obtained during a Human Rights Watch meeting with security and mental health staff at McNeil Island, August 22, 2002.
Young v. Quinlan, 960 F.2d 351, 364 (3d Cir., 1992).
Madrid v. Gomez, 889 F. Supp. 1146, 1261 (N.D. Cal., 1995).
Madrid v. Gomez, 889 F. Supp. at 1265-66. (citations omitted).
Psychiatric Services Unit (PSU) Plan, January 26, 1998.
 The settlement to the Madrid case resulted in a Special Monitor being appointed to oversee Pelican Bay and the improvements made to its mental health care infrastructure. Human Rights Watch was not able to tour the PSU or interview prisoners held there to ascertain the treatment they are receiving.
Special Master's Report Re Status Of PSU And EOP Compliance With Health Services Remedial Plan, Madrid v. Terhune, No. C90-3094-T.E.H. (N.D. California, October 17, 2000).
Jones 'El v. Berge, Judgment in a Civil Case, Case No. 00-C-0421-C (W.D. Wisconsin, June 24, 2002) (unpublished).
 Ohio Department of Corrections Policy 111-07, quoted in Order of Judge James S. Gwin, Austin v. Wilkinson, Case No. 4:01-CV-71 (N.D. Ohio, November 21, 2001) (granting plaintiffs preliminary injunction).
 Testimony of Gary Beven, M.D., September 24, 2001 hearing, at 216, cited in Order of Judge James S. Gwin, Austin v. Wilkinson, Case No. 4:01-CV-71 (N.D. Ohio, November 21, 2001), p. 24.
 The settlement was signed on January 8, 2002.
 E-mail correspondence from Fred Cohen, to Human Rights Watch, July 9, 2003.
 According to Fred Cohen, the Psychiatric Director for the Ohio Department of Rehabilitation and Correction has final say before an inmate is sent to the supermax of Ohio State Penitentiary. At intake, a second full psychiatric evaluation is also conducted. Cohen served as a court-appointed monitor in the Ohio case for five years, and believes the state was very receptive to the proposed changes. Human Rights Watch telephone interview, August 8, 2002.
Austin v. Wilkinson, Case No. 4:01-CV-71 (N.D. Ohio, September 21, 2001) (unpublished opinion).
Ruiz v. Johnson, 37 F. Supp. 855 (S.D. Texas, 1999).
 Cited in Intervention Plan for Seriously Mentally Ill Offenders in Administrative Segregation, December 15, 2001.
 Plaintiffs' Response to Defendants' Report and Plan Concerning Seriously Mentally Ill Prisoners in Segregation, Ruiz v. Johnson, January 14, 2002; on file at Human Rights Watch.
 Human Rights Watch interview with Brett Rayford, director of health and mental health services, Connecticut Department of Correction, June 10, 2002. Human Rights Watch visited Northern Correctional Institution in 2001.
 Data provided by Clyde McDonald, field operations director, Correctional Managed Health Care in a Human Rights Watch interview, Connecticut, June 10, 2002; Human Rights Watch interview with Brett Rayford, director of health and mental health services, Connecticut Department of Correction, Connecticut, June 10, 2002.