How to Create Madness in Prison

by | September 23, 2010

Guest Post by Terry A. Kupers, M.D., M.S.P.

Editors’ note: Dr. Terry Kupers is one of the world’s leading experts on the psychological effects of solitary confinement. A psychiatrist with a background in psychoanalytic psychotherapy, forensics, and social and community psychiatry, he teaches at the Wright Institute, a graduate school of psychology in Berkeley, California, while also maintaining a private practice and serving as a consultant to mental health centers and social rehabilitation programs in the community.

Dr. Kupers has studied and worked with prisoners in solitary confinement, and describes mentally ill inmates confined in segregated housing units as “the most severely psychotic people I have seen in more than 25 years of practice.” He has testified in several large class action litigations concerning jail and prison conditions, sexual abuse, and the quality of mental health services inside correctional facilities, and served as a consultant to Human Rights Watch, Amnesty International, and Stop Prisoner Rape. His books include Prison Madness: The Mental Health Crisis Behind Bars and What We Must Do About It.

The piece below is an  excerpt from a longer article that appeared in the book Humane Prisons, edited by David Jones (Oxford: Radcliffe Publishing, 2006). In the full article, available online here, Dr. Kupers describes in detail each of the ingredients in his “recipe for creating madness in our prisons”–which is in fact also a recipe for creating an explosion in long-term solitary confinement.


It’s worth pausing for a moment to consider how we created as much madness as exists today in our prisons. Perhaps, after exploring how we arrived at this dreadful state of affairs, we can strive to reverse the process and foster sanity, at the same time developing humane and effective prisons.

In the era of mental asylums, when individuals suffering from serious mental illness were confined in large public psychiatric hospitals, institutional dynamics came under the spotlight….[Critics] were very concerned about the self-fulfilling-prophecy aspect of the staff’s diagnostic process, and they warned poignantly that incremental denial of freedom to individuals within “total institutions,” whether they actually suffer from a bona fide mental illness or not, leads them inexorably to increasingly irrational and desperate attempts to maintain their dignity and express themselves.

Today, because of recent interconnected historical developments – including deinstitutionalization, reduced resources for public mental health services and relatively less sympathy in criminal courts for defendants with psychiatric disabilities – serious mental illness is more likely acted out in prisons than in asylums. In fact, in the U.S.A., there are more people suffering from serious mental illness in the jails and prisons than there are in psychiatric hospitals. And the bizarre scenarios enacted in correctional settings today can make the “back wards” of 1940’s asylums look tame in comparison.

Consider as an example the scenario where the disturbed/disruptive prisoner winds up in some form of punitive segregation, typically in a supermaximum security unit where he remains isolated and idle in his cell nearly 24 hours per day. In the context of near-total isolation and idleness, psychiatric symptoms emerge, even in previously healthy prisoners. For example, a prisoner may feel overwhelmed by a strange sense of anxiety. The walls may seem to be moving in on him (it is stunning how many prisoners in isolated confinement independently report this experience). He may begin to suffer from panic attacks wherein he cannot breathe and he thinks his heart is beating so fast he is going to die. Almost all prisoners in supermaximum security units tell me that they have trouble focusing on any task, their memory is poor, they have trouble sleeping, they get very anxious, and they fear they will not be able to control their rage. The prisoner may find himself disobeying an order or inexplicably screaming at an officer, when really all he wants is for the officer to stop and interact with him a little longer than it takes for a food tray to be slid through the slot in his cell door. Many prisoners in isolated confinement report it is extremely difficult for them to contain their mounting rage, and they fear losing their temper with an officer and being given a ticket that will result in a longer term in punitive segregation.

Eventually, and often rather quickly, a prisoner’s psychiatric condition deteriorates to the point where he inexplicably refuses to return his food tray, cuts himself or pastes paper over the small window in his solid metal cell door, causing security staff to trigger an emergency “takedown” or “cell extraction.” In many cases where I have interviewed the prisoner after the extraction, he confides that voices he was hearing at the time commanded him to retain his tray, paper his window or harm himself.

The more vehemently correctional staff insist the disturbed prisoner return a food tray, come out of his cell or remove the paper from the cell door so they can see inside, the more passionately the disturbed prisoner shouts: “You’re going to have to come in here and get it (or me)!” The officers go off and assemble an emergency team – several large officers in total body protective gear who, with a plastic shield, are responsible for doing cell extractions of rowdy or recalcitrant prisoners. The emergency team appears at the prisoner’s cell door and the coordinator asks gruffly if the prisoner wants to return the food tray, or do they have to come in and get it? While a more rational prisoner would realize he had no chance of withstanding this kind of overwhelming force, the disturbed prisoner puts up his fists in mock boxing battle position and yells “Come on in, if you’re tough enough!” The officers barge in all at once, each being responsible for pushing the prisoner against the wall with the shield or grabbing one of his extremities. The prisoner is bruised and hurt, but when a nurse examines the shackled prisoner and asks about injuries he responds that they hardly scratched him.

This kind of “cell extraction,” which occurs in some supermaximum security prisons as often as ten times per week and reminds one of the scenario sociologists of deviance described in 50’s asylums, is not the only outbreak of madness within correctional institutions. Officers in facilities of all levels of security tend to yell at prisoners and tend to threaten prisoners with harsh reprisals if they do not obey orders quickly or thoroughly enough. Prisoners in whom anger has mounted because of the extremity of their situation typically respond in an angry tone, perhaps meeting swearing with swearing. Or they mutilate themselves repeatedly, or they smear faeces or throw excrement at staff. With each angry, bizarre act on the part of prisoners, correctional staff become more harsh and punitive, less interested in listening to the prisoners’ expressed grievances, less concerned about prisoners’ pain and suffering, and more quick to respond to the slightest provocation with overwhelming force.

The recipe for creating madness in our prisons is easy enough to explicate, one merely needs to identify the steps that were taken to reach the current state of affairs. Here is the recipe:

Begin by over-crowding the prisons with unprecedented numbers of drug-users and petty offenders, and make sentences longer across the board.

Dismantle many of the rehabilitation and education programs so prisoners are relatively idle.

Add to the mix a large number of prisoners suffering from serious mental illness.

Obstruct and restrict visiting, thus cutting prisoners off even more from the outside world.

Respond to the enlarging violence and psychosis by segregating a growing proportion of prisoners in isolative settings such as supermaximum security units.

Ignore the many traumas in the pre-incarceration histories of prisoners as well as traumas such as prison rape that take place inside the prisons.

Discount many cases of mental disorder as “malingering.”

Label out-of-control prisoners “psychopaths.”

Deny the “malingerers” and “psychopaths” mental health treatment and leave them warehoused in cells within supermaximum security units.

Watch the recidivism rate rise and proclaim the rise a reflection of a new breed of incorrigible criminals and “superpredators.”



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