Los Angeles County Jail: America's largest mental health facility. (Riker's Island is second.)

Anyone interested in solitary confinement should be aware of this article in the most recent issue of the Journal of the American Academy of Psychiatry and the Law: Solitary Confinement and Mental Illness in U.S. Prisons: A Challenge for Medical Ethics,” by Jeffrey L. Metzner, MD and Jamie Fellner, Esq. Metzner is a respected forensic psychiatrist and professor at the University of Colorado School of Medicine; Fellner is senior counsel in the U.S. Program of Human Rights Watch. 

Several professional organizations and activist groups made up of medical and mental health practitioners have condemned the treatment of detainees at Guantanamo and elsewhere in the so-called war on terror. In particular, they have denounced the idea that members of their professions should play any role in that treatment. But as Metzner and Fellner point out, there has been “scant professional or academic attention to the unique ethics-related quandary of physicians and other health-care professionals when prisons isolate inmates with mental illness.” This despite the fact that for some prisoners, “isolation can be as clinically distressing as physical torture.”

The authors provide an overview of the use of extended solitary confinement, both on prisoners in general and on those who suffer from mental illness. As we’ve written before, prisons and jails are now the nation’s largest institutions for the mentally ill, and solitary confinement cells in particular serve as our new asylums. Yet “very few physicians in the APA [American Psychiatric Association] and AMA [American Medical Association] have experience or knowledge regarding correctional mental health care, let alone correctional environments in general,” write Metzner and Fellner.  “Administrative segregation, supermax, rules infractions, mental health rounds, and ‘kites’ are terms most noncorrectional physicians do not understand.” A “serious educational effort” is needed, they argue, so that mental health practitioners understand such practices as “the isolation of seriously ill patients for months, even years, that would never be condoned in a noncorrectional mental health setting.”

Metzner and Fellner end by urging these professionals to take an ethical stand, and to “use their institutional authority” to challenge the torturous practices.

The professional organizations should acknowledge that it is not ethically defensible for health care professionals to acquiesce silently to conditions of confinement that inflict mental harm and violate human rights. They should affirm that practitioners are ethically obligated, not only to treat segregated inmates with mental illness, but also to strive to change harmful segregation policies and practices. Finally, the organizations should not be content with clarifying the ethics-related responsibilities of individual practitioners in these circumstances. They should actively support practitioners who work for changed segregation policies, and they should use their institutional authority to press for a nationwide rethinking of the use of isolation. The medical professions’ commitment to ethics and human rights would be well served by such steps.

What follows is the abstract of the article. The full piece, which is accessible to readers with no background in medicine or the law, is available online. 

In recent years, prison officials have increasingly turned to solitary confinement as a way to manage difficult or dangerous prisoners. Many of the prisoners subjected to isolation, which can extend for years, have serious mental illness, and the conditions of solitary confinement can exacerbate their symptoms or provoke recurrence. Prison rules for isolated prisoners, however, greatly restrict the nature and quantity of mental health services that they can receive. In this article, we describe the use of isolation (called segregation by prison officials) to confine prisoners with serious mental illness, the psychological consequences of such confinement, and the response of U.S. courts and human rights experts. We then address the challenges and human rights responsibilities of physicians confronting this prison practice. We conclude by urging professional organizations to adopt formal positions against the prolonged isolation of prisoners with serious mental illness.

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