The questions raised by O'Keefe et al. challenge us to think clearly about the intent of incarceration generally and the objective of administrative segregation in particular. Our comments address several points: the study's methodology, the context of administrative segregation, several attendant pragmatic concerns linked to its practice, and the challenges of understanding the needs and motivations of individual offenders.
O'Keefe et al.1 followed 262 inmates for one year in Colorado State Penitentiary and assessed them repeatedly with a battery of validated assessments (e.g. the Beck Hopelessness Scale and the Brief Psychiatric Rating Scale). The hypotheses of their study were that inmates in administrative segregation would develop symptoms such as psychosis, agitation, and self injurious behavior that are consistent with what has been labeled security housing unit (SHU) syndrome2; that their symptoms and function would worsen more so than comparison groups of offenders; and that not only would the symptoms and functioning of segregated offenders with or without mental illness deteriorate, but the observed rate would be more rapid in those with mental illness.1 There is apparent face validity to this assertion. The research advisory group for this study indeed included advocates for the mentally ill who participated in the design and oversight of the study to assure a balanced study design. Nevertheless, the results of this ground-breaking study were inconsistent with the expected results. The study found that, as a group, most offenders did not deteriorate psychiatrically, most offenders showed no change, and in fact, many individuals showed improvement, some of whom were those with a diagnosed mental illness.
The questions raised by O'Keefe et al.1 challenge us to think clearly about the intent of incarceration generally and of administrative segregation in particular. Our comments address the study's methodology, the context of incarceration, the pragmatics of administrative segregation, and the challenges of understanding the individual offender's needs and motivations.
The study by O'Keefe et al.1 reflects a very ambitious project. The authors faced a panoply of challenges that included experimental design, control group selection, data collection, and outcome measure selection. Designing a prospective, longitudinal study of seriously mentally ill adult men in administrative segregation presents any researcher with daunting methodological hurdles. O'Keefe et al.1 utilized a quasi-experimental design with five groups. Given the intrinsic limitations of the study environment, with group assignment determined, not by the researchers but by the correctional system (administrative segregation or not) and the mental health clinicians (mentally ill or not), the study design nonetheless created a reasonable real-world test of the hypotheses. Significant strengths of the study include its duration and the repeated-measures design. The full year of assessments more realistically reflects the timeframe of greatest concern regarding potential psychological impact. The use of five repeated measurements provides improved power and the ability to determine trends more accurately. Replication in other settings is important in determining generalizability of the findings. That said, finding other systems to test the year-long effects of administrative segregation under more scientifically controlled conditions is itself challenging.
Each of the groups had an adequate sample size, after a reasonable and documented process of recruitment attrition. The demographic heterogeneity both within and across groups reflects the real world of correctional systems. The use of a single rater across all sites is a potential limitation of the study. Any drift in practice cannot be corrected through inter-rater reliability assessments. However, the use of the Brief Symptom Inventory (BSI), a standardized, well-validated, objective questionnaire reduces that problem. It is also important to note that the data, before and after transformation, are not at the extremes, thus avoiding any potential ceiling or floor effect. Further, the similarity in statistical results between the BSI and other instruments used (as stated by the authors, but not reported in their article1) supports the stability of the assessments.
In sum, the methodology of the study is by no means perfect, but it does appear to reflect a solid attempt to improve the scientific database in an area of contentious policy and human rights debate. The way toward consensus certainly involves multiple future studies in a variety of settings and jurisdictions.
Beyond the methodology, it is of central importance to clarify context: what exactly are we studying? O'Keefe et al.1 examined the effects of a specific condition of confinement (administrative segregation) on people over time, not the effects of solitary confinement. What is the difference? Solitary confinement typically refers to conditions that incorporate isolation and sensory deprivation: one person relegated to a small, windowless cell with minimal or no distractions (for example, very limited or no books, magazines, radio, or television), food delivered through a trap door without spoken communication, and no access to other inmates, family, or friends.
Today's prisons are not the dungeons of the 1800s.3 Inmates are not kept in total darkness where they are fed bread and water. In fact, there is little to no isolation at all. Most of the cells in administrative segregation units have two inmates in them, and those who are in a single cell are housed next to inmates on either side, are able to talk to them, and may talk to one another at recreation. The inmates communicate with staff members (correctional officers, custody supervisors, school teachers, nurses, social workers, and others) as they make their rounds. The cells are about the same size as those of the general population. The inmates still receive mail, can make legal and personal phone calls, get an hour a day of out-of-cell recreation, receive visitors, can be involved in educational services and a variety of religious services, are allowed books and other reading materials in their cells, and usually have radios. They eat the same meals with the same portions as are afforded inmates in the general population. They have access to the same commissary, with some limitation of items and the amount they are allowed to spend. The cells have windows in the front door and in the rear of the cell through which the inmates receive natural sunlight, and the interior lighting is similar to that in cells in the general population. The inmates in administrative segregation have access to medical, dental, and mental health care. This environment is consistent across most, if not all, state correctional systems, as reflected in their published policies or administrative directives (see, for example, Refs. 4,–,7).
As noted by O'Keefe et al.,1 the conditions of confinement in administrative segregation in the Colorado State Penitentiary that reflect the study conditions are quite different from those expected in solitary confinement. Inmates there are provided medications, a library, and programs. An intercom system for on-demand communication between the inmate and the control center staff is present in each cell. Officers make rounds every 30 minutes, performing visual checks. Inmates receive at least one hour of recreation five times per week plus a 15-minute shower three times per week. Incentive-based programming incorporates three progressive levels, bringing more privileges with each level earned. The most restrictive level usually lasts 7 days; thereafter, televisions are permitted in the cells. Three televised cognitive classes are part of the incentive programming. Mental health services include individual counseling sessions, psychiatric medication management, and crisis management.
Conceptually, the results of the Colorado study are consistent with the observations of those of us who have worked in administrative segregation during the past decade: inmates tend not to decompensate in administrative segregation, and some indeed improve psychologically. While we might expect psychiatric decompensation if someone in the community were suddenly placed in an environment similar to administrative segregation, it is because prison settings differ dramatically from community settings. Context and contrast matter, as they do in all human experience. The transition from a prison general population setting to administrative segregation is not as dramatic as that from the community to prison. The results of the study underscore not only the fact that people are resilient and are able to thrive under even difficult environmental conditions, but even more so highlight the degree to which the differences among the general population prison setting, administrative segregation, and the extreme of solitary confinement have been misunderstood.
With respect to psychological factors that could account for the Colorado study's findings, it is important to understand the experiential factors associated with administrative segregation. Some inmates perceive it as a preferred environment. Some inmates with severe behavioral problems seek out administrative segregation to decrease interpersonal stimulation from inmates and staff. Similarly, some inmates with psychotic disorders seek out less stimulating environments, preferring to be alone and limit human interaction, just as individuals in the community with severe mental illness self-impose isolation, limit social contact, and avoid stimulation. Inmates may also seek out administrative segregation to obtain a self-imposed protective-custody status, living out of the general population, avoiding selected adversaries, and being in an environment that they perceive as having fewer safety risks.
Correctional settings clearly present a raft of challenges. Of relevance are the concerns surrounding administrative segregation: purpose, mission creep, prevention, and informed decision making. The purpose of administrative segregation is clearly stated in most administrative directives. Those placed in administrative segregation are individuals who, following a due process hearing, are classified as a threat to staff, other inmates, or facility security. The intent is to provide a safe environment to allow time for the individual to change his behavior appropriately. More research studies on the outcomes of administrative segregation are clearly needed to determine to what degree those conditions of confinement and associated programs actually work to change behavior.
The adage, build it and they will come, applies to many situations, including administrative segregation. In a coordinated effort and review of people in Colorado's administrative segregation program, the Colorado Department of Corrections recently reclassified and removed 36.9 percent of those in the population.4 The overinclusion of individuals in administrative segregation can easily happen as, over time, the criteria for classification into the program inadvertently expand. Careful and conscientious oversight can help to reduce, if not eliminate, such risks.
Separate from remediation, prevention of problematic behavior is a key concern. By identifying inmates, with or without mental illness, with whom we can intervene proactively, we may diminish the likelihood of an administrative segregation placement. By developing appropriate corrections-modified, evidence-based practices, we may then implement differential therapeutic options (psychotherapeutic and pharmacologic) to enhance interpersonal problem-solving skills, reduce impulsive aggression, and enhance emotional self-regulation (see, for example, Refs. 8,–,10).
O'Keefe et al. note, “This study was not designed to address the question of whether segregation is an appropriate confinement option for offenders, including those with serious and persistent mental illness” (Ref. 1, p). We will not confront this question either, but believe that stressing the importance of proactive, evidence-based therapeutic interventions has the potential to decrease dramatically the number of inmates who would otherwise enter an administrative segregation placement.
Disclosures of financial or other potential conflicts of interest: None.
- © 2013 American Academy of Psychiatry and the Law