Solitary Confinement of Prisoners
with Mental Illness:
Litigation and Lessons Learned
Academic and Health Policy Conference on
Correctional Health
Chicago, Illinois
March 22, 2013
James F. DeGroot, Ph.D.
Director of Mental Health
GA Dept. of Corrections
Katherine L. O’Neill, LICSW
Director of Behavioral Health
MA Dept. of Corrections
Greg Markway, Ph.D.
Director of Mental Health
MO Dept. of Corrections
Solitary Confinement of Prisoners
with Mental Illness
• Background Litigation (15 minutes)
– James F. DeGroot, Ph.D.
• Lessons Learned
– Katherine L. O’Neill, LICSW, MA Dept. of Corrections
(25 minutes)
– Greg Markway, Ph.D., MO Dept. of Corrections
(25 minutes)
– James F. DeGroot, Ph.D., GA Dept. of Corrections
(15 minutes)
• Questions and Answers
Solitary Confinement of Prisoners
with Mental Illness
Background Litigation
• Basis of Litigation
• Human Rights Framework
• Scientific Research
• Position Statements
Solitary Confinement of Prisoners
with Mental Illness
Basis of Litigation
• Eighth Amendment
– Conditions of confinement (Deliberate Indifference)
– Evolving Standards of Decency
– Madrid v. Gomez (1995)
• Class Action Litigation in 14 states (AL, AZ, CA,
Solitary Confinement of Prisoners
with Mental Illness
Human Rights Framework
• Principles
– Respect the humanity and inherent dignity of all
– Prohibit torture or other cruel, inhumane or
degrading punishment or treatment
• International Covenant on Civil and Political
• Inter-American Commission on Human Rights
Solitary Confinement of Prisoners
with Mental Illness
Scientific Research (What happens to people
deprived of social contact for months or years?)
• Challenges
Cress-sectional studies
• Colorado State Penitentiary SuperMax Study
Solitary Confinement of Prisoners
with Mental Illness
American Psychiatric Association (Approved by the Board of
Trustees, 12/2012) (Approved by the Assembly, 11/2012):
“Prolonged segregation of adult inmates with serious mental
illness, with rare exceptions, should be avoided due to the
potential for harm to such inmates. If an inmate with serious
mental illness is placed in segregation, out-of-cell structured
therapeutic activities (i.e., mental health/psychiatric
treatment) in appropriate programming space and adequate
unstructured out-of-cell time should be permitted.
Correctional mental health authorities should work closely
with administrative custody staff to maximize access to
clinically indicated programming and recreation for these
Solitary Confinement of Prisoners
with Mental Illness
National Alliance on Mental Illness (11/2012):
“Solitary confinement is the placement of individuals in locked, highly
restrictive and isolated cells or similar areas of confinement for
substantial periods of time with limited or no human contact and
few, if any, rehabilitative services. Placement in solitary
confinement frequently lasts for weeks, months, or even years at a
time. It is extensively documented that solitary confinement is
used disproportionately in correctional settings for juveniles and
adults with severe psychiatric symptoms. In some states, it is
reported that more than half of all inmates in facilities utilizing the
most extreme forms of solitary confinement and social isolation are
diagnosed with serious mental illnesses… NAMI opposes the use of
solitary confinement and equivalent forms of administrative
segregation for persons with mental illnesses.
Solitary Confinement of Prisoners
with Mental Illness
National Alliance on Mental Illness (11/2012) cont.:
“NAMI calls upon states to establish mental health alternatives
to solitary confinement that include enhanced mental health
treatment, services and programs; crisis intervention training
for correctional officers, and mental health step-down units.
States that have adopted such proactive efforts to eliminate
solitary confinement have documented highly positive results
that include reduced psychiatric symptoms, less violence, and
significant cost savings.”
Lessons Learned:
The Massachusetts Department of Correction’s
approach to treating and managing mentally ill
offenders with long-term segregation sanctions
Academic and Health Policy Conference on Correctional Health
Chicago, Illinois
March 22, 2013
O’Neill, LICSW
Director of BehavioralHealth
Massachusetts Department ofCorrection
Time-line of litigation
• 1/2006 -Records requested in conjunction with inmate suicide in
• 10/2006 –Investigation launched by Disability Law Center (DLC) into our
Segregation Units
• 1/2007 –Pre-litigation meetings with both sides took place to try and
address concerns
• 3/2007 – DLC filed suit against MA-DOC alleging that “confining prisoners
with “serious mental illness” in segregation violates the 8th Amendment,
ADA and Rehabilitation Act of 1973
• 4/2012 DLC and DOC achieve Settlement Agreement
The Requests
• DLC asked Court to prohibit DOC from confining
inmates with mental illness from segregation for
more than 1 week
• DLC proposed a broad definition of SMI which would
have required special treatment units for a large
percentage of inmates
• DLC toured facilities with their counsel and experts
interviewing several inmates
• DLC issued requests for extensive documentation
from mental health records and administrative
MA-DOC Response
• Retained psychiatric expert (Jeffrey Metzner, M.D.,)
for input
• Developed and implemented initiatives stemming
from expertise and experience of MHM (MH
provider) & Dr. Metzner
• DOC created “buy in” and executive leadership
showed strong support for mental health input and
• Worked with MHM to identify needs and to develop
programs and protocols that made sense for our
MA-DOC initiatives
• DOC implemented legal definition of “Serious
Mental Illness” (SMI)
– Trained all staff (custody, administration & clinical
in applying definition)
– Developed a system for identification and tracking
inmates with SMI
– Committed to excluding inmates with SMI
designation from long-term segregation to include
Massachusetts's SMI Definition
MA-DOC Initiatives
• DOC implemented MH Classification System
– Individually based needs assessment tool
– Identifies appropriate level of services
– Service levels range from case management to inpatient
– Clearly identifies inmates with history of suicidal behavior,
SMI designation, and inmates with high level of need for
mental health services
MA-DOC Initiatives
• Developed specialized mental health units as
placement alternatives to long-term
– Secure Treatment Program (February 2008)
• 19 Beds, Maximum Security Prison
– Behavior Management Unit (July 2010)
• 10 Beds, Maximum Security Prison
MA-DOC Initiatives
• Complete revision of the 103 DOC 650 MH Policy and
Procedures to memorialize all initiatives
• DOC opened the Intensive Treatment Unit (ITU) in
May 2012
– 32 Beds, Female Offenders
– Designed to provide behavioral interventions and crisis
• Inmates with shorter term segregation sanctions are
provided enhanced services
– Weekly out of cell clinical contact
MA-DOC Initiatives
• Complete enhancement of Residential
Treatment Unit Program (RTU)
– 4 RTUs across system, total of 208 beds
– Designated mental health staff
– Evidence based curriculums
– Meaningful activities & socialization opportunities
– Support for therapeutic communities
MA-DOC Initiatives
• DOC formalized process for MH input into
disciplinary process
• Developed specialized training for all staff working in
specialized units
• DOC enhanced Inmate Management System (IMS)
– Improve communication across disciplines
– Easily track performance data
– Monitor trends and revise practices accordingly
Applying the MH Classification System
Massachusett’s Numbers
*January 2013
Massachusett’s Numbers
Massachusetts's Needs
Developing our Alternative Units
Why CQI should NOT be an afterthought
Monitoring Performance
Collecting Meaningful Data
In the Headlines
The Outcomes
* As of January 2013
Use of Force Incidents
Staff Assaults
Inpatient Hospitalization Days
Inpatient Days (Averages)
Disciplinary Infractions
DDU Outcomes
ITU Outcomes
*May-December 2013
• 15% reduction in all self-injurious behaviors
• 20% reduction in transfers to inpatient
psychiatric hospitalization
• 33% reduction in days on constant mental
health watch
• 46% decrease in total crisis contacts
Truly a Team Effort!
Special Thanks to the following:
-The Commissioner’s Office
-DOC Legal Division
-DOC Health Services Division
-Joel Andrade, Ph.D., LICSW & Dana Neitlich, LICSW
-MHM Services, Inc.
-Site Superintendents and DOC Administrations
-University of Massachusetts Correctional Health
-The clinical teams and unit coordinators for the STP, BMU, RTUs
and ITU.
An Innovative Approach to
Solitary Confinement
The Potosi Reintegration Unit (PRU)
Potosi Correctional Center
Missouri Department of Corrections
Presented by Greg Markway, Ph.D.
• Potosi Correctional Center is the most secure
facility in Missouri
• Very limited movement in the camp
• PCC houses offenders sentenced to death
• Historically, has housed most difficult
offenders—the “Hannibal Lecters” of MO
Background (2)
 PCC had a small Ad Seg unit that housed
offenders with serious Protective Custody
needs, as well as offenders who had seriously
assaulted or killed other offenders or staff
 How do you decide when an offender is
ready/able to return to general population?
 What makes this offender safer today than
last week?
Background (3)
• HU-1 was a small Ad Seg Unit, housing
approximately 21 offenders
• The unit was no longer economically feasible
unless it took on a new mission
• Through the creativity of our custody division,
and the cooperation mental health, a new
mission was developed.
Mission of PRU
 Take some of the most difficult to manage
offenders, those in long-term single cell ad
seg, and provide programming with the goal
of returning them to general population if
 Be able to answer why they can be returned
to GP, or why they need to stay in Ad Seg
 Develop collaborative programming with
mental health, custody, and classification
Initial Obstacles
• Resistance of custody staff— “How far down
has corrections gone?”
• Perception of coddling offenders who have
been “the worst of the worst”
Seeds of Change
• Warden approached staff with new mission
(Staff Buy-In)
• Developed Oversight Committee—Unit
Manager, Deputy Warden, Classification,
Mental Health, and Medical Staff (Broad
• Any committee member allowed to veto a
recommendation (all staff on committee equal
in input and responsibility)
Program Development
 Cleared an office to be used as small
classroom/group room (camera, panic
 Special desks designed (allowed offenders to
be in room together while still restrained—but
also allow movement)
 Offenders assessed fresh (WAIS, MMPI, etc.)
 Programming brought into unit (MH,
volunteers, chaplain, classification staff)
Uneasy First Steps
• Offenders brought into class for programming
• Little progress initially—offenders struggling—
“Would just sit there in a fetal ball
• No interaction
Signs of Progress
• Psychologist noted one offender liked to draw,
so she took an art therapy approach
• Art supplies were allowed on the unit
• Offender drew a picture in group, and others
began commenting on it—the ice was broken
Next Steps
• 3 months into the program, staff began
discussing incentives for offenders—needed
to be personalized and realistic
• Began with things the offenders had shown
they liked to do
• Led to development of true individualized
behavior plans
• Offenders did not trust this– “Had to throw
them a bone”
Incentive Program
• Once program began, officers stated: “We’ve
never seen these guys act like this before.”
Incentive Examples
 Listen to books on CD with portable CD player
in cell for set time
 Keep book or magazine in cell
 Work on jigsaw puzzle
 Rec time outside cell with another offender
 Purchase a CD player with own funds
 Have access to art materials
 Eat lunch outdoors with another offender
Other activities
• TV time/movie discussion group—Groundhog
Day example
• GED classes
• Other programming with inmate facilitators
• Dogs
Behavior Change Examples
• Offender with poor reading skills requested
book to go along with CD—working on his
own reading skills
• Offender who frequently swallows objects
now is able to wear his eyeglasses and keep
Bible in cell
• Some offenders are helping others learn to
read, complete homework, etc
Staff Behavior Changes
• “We became like parents looking at our kids’
pictures. People developed an interest in the
offender as a person.”
• Oversight Committee truly became
• Interestingly, now mental health has to slow
custody down in granting privileges
• Custody officers advocate for offenders
• Dramatic reduction in uses of force in the unit
• Officers now raise questions about
medication/mental health/medical issues
• Officers see offenders as people
• Officers are proud of their accomplishments
with the offenders
• “Administration treated us like human beings”
Georgia Lessons Learned
The Georgia Department of Corrections’
Approach to Reducing Mentally Ill Offenders in
Solitary Confinement
James F. DeGroot, Ph.D.
Director of Mental Health
Georgia Department of Corrections
Georgia Lessons Learned
• Time-line of Litigation
– 1972 – 1998 Guthrie v. Evans
– 1984 – 1998 Cason v. Seckinger
– 2002 – 2004 Fluellen v. Wetherington
Georgia Lessons Learned
• Eighth Amendment Complaints
• External Audit Results (2008): Mentally ill
offenders were disproportionally represented
in lock-down units.
Georgia Lessons Learned
% of offenders receiving MH services
% of all DRs received by MH
% of MH and GP receiving sanctions
% of MH and GP placed in disciplinary
% of all offenders in disciplinary
segregation receiving MH services
% of MH and GP serving more than 2
weeks in disciplinary segregation
Georgia Lessons Learned
• Procedures already in place:
DR Evaluations (mitigating circumstances)
Alternative sanctions
Weekly lockdown treatment sessions
Weekly lockdown rounds
Activity Therapy
Individualized Behavior Therapeutic Unit
Isolation/Segregation Health Screening
Out-of-cell mental health services
Out-of-cell structured/unstructured activities
Mental Health input into disciplinary process
Georgia Lessons Learned
• New Procedures
– Publish monthly oversight results
– Upper level management support
Georgia Lessons Learned
• Six months after publishing oversight
6 Months Later
% on Mental Health
% of all DRs to Mental Health
% of MH and GP Sanctions
MH = 88%
GP = 74%
MH = 78%
GP = 84%
MH = 50%
GP = 59%
% MH and GP in Disciplinary Seg
MH = 56%
GP = 21%
MH = 18%
GP = 14%
MH = 19%
GP = 16%
% of all offenders in Disciplinary
MH = 63%
GP = 37%
MH = 33%
GP = 67%
MH = 67%
GP = 33%
% of MH and GP serving more than MH = 43%
2 weeks in disciplinary seg
GP = 30%
MH = 14%
GP = 27%
MH = 4%
GP = 14%
Georgia Lessons Learned
• Data
– % of males receiving MH services system-wide
– % of MH in High-Maximum Security
• Corrective Action
– High-Maximum Security Supportive Living Unit
– Therapeutic Modules
Georgia Lessons Learned
Therapeutic Mental Health Modules at Augusta State Medical Prison
Georgia Lessons Learned
• Data
– % of all self-injurious behavior in lockdown
– % of all suicides in lockdown
Georgia Lessons Learned
• What works in reducing mentally ill offenders
in solitary confinement?
– Upper Level Management Support
– Mental Health Standards of Care
– Monthly Data Reports
– Publish the results

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