Hell Is A Very Small Place: Voices From Solitary Confinement

It is well recognized that over the past several decades US prisons and jails have become the nation’s largest inpatient psychiatric hospitals.  This is not surprising when you realize the majority of the US correctional population, the largest in the world at well over two million, suffers from mental illness. 1  Leaving aside the question whether it is appropriate to incarcerate the mentally ill, at least those with serious mental illness, how we choose to treat a significant percentage of mentally ill inmates is to place them in solitary confinement. 2  This means how we treat a significant percent of the mentally ill in this country is to torture them.

In the editors’ introduction to Hell is A Very Small Place, Voices From Solitary Confinement, a chapter that should be required reading for all health care students, Jean Casella, James Ridgeway and Sarah Sourd note that on any given day between 80,000 and 120,000 men, women and children are held in solitary confinement in US prisons and jails. 3  One-third to one-half of those placed in solitary confinement already suffer mental illness that is frequently accompanied by developmental disabilities, physical disabilities and substance addictions.  

A similar percent of all others placed in isolation will develop psychiatric symptoms, if not complete decompensation, particularly if they are confined for an extended period of time.

Beyond severe depression, the panoply of psychiatric symptoms experienced by those in solitary, experienced at rates far beyond those seen in the general prison population, include self-harm and mutilation including self-blinding, self-amputation of fingers and testicles and suicide by, for example, biting through the veins in the wrist or by jumping headlong off a bunk.  While inmates held in isolation constitute approximately five percent of the prison population they account for approximately 50 percent of prison suicides.  The mentally ill are more likely to be placed in solitary because, predictably, they are more prone to commit rule violations or irrational acts and/or are disproportionately preyed upon by other prisoners.  Inmates suffer in isolation despite the fact no court every sentences them to solitary confinement.  They are placed in solitary by prison officials and guards frequently for arbitrary reasons as trivial as using profane language.  Those in isolation can be held for days or multiple decades without any due process rights.  The practice does not reduce prison violence but does substantially increase taxpayer burden.

How decompensation happens or is exacerbated while in solitary is simply explained by forensic psychiatrist Terry Kupers.  “The recipe for creating madness in our prisons is,” Kupers states in his essay, “easy enough to explicate, one merely needs to identify the steps taken to reach the current state of affairs.”  That is, simply add to already overcrowded facilities with dismantled rehabilitation programs a large numbers of prisoners suffering from serious mental illness, restrict visiting and ignore or deny treatment for mental health issues and there your are. 

To more fully appreciate Dr. Kupers’ assessment, one should also read his June 2014 expert report, readily available, on solitary confinement conditions at Eastern Mississippi Correctional Facility (EMCF). 4  Briefly summarized, his evaluation found at EMCF “extreme” and “inexcusable suffering” made apparent, in part, by the “shocking level of filth and lack of sanitation.”  EMCF staff were, he found, “shockingly inattentive to the prisoners basic human needs” and when not exhibiting “dreadful callousness” guards used “systematic excessive force,” in part, to inject powerful psychotropic medications oftentimes “over the objections” of inmates.  Kupers concluded his study by stating, “prisoners are isolated, abandoned, forced to live in abject filth and darkness, subjected to violence and danger, denied care for the most basic human needs.”  The consequential “toll that isolated confinement takes on these prisoners is enormously exacerbated by appallingly cruel features.”  In sum, he said EMCF solitary confinement “conditions can be accurately described as torture.”

That solitary confinement, even absent the “inexcusably horrible” conditions identified at EMCF,  constitutes torture is the same conclusion the United Nations Special Rapporteur on Torture, Juan E. Mendez, drew in 2011 when he recommended the practice be limited to no more than 15 days and be absolutely prohibited for those with mental disabilities and juveniles. 5  In his statement to the UN, Mendez, a victim of solitary confinement himself, stated, “considering the severe mental pain or suffering solitary confinement may cause, it can amount to torture or cruel, inhuman or degrading treatment or punishment when used as a punishment, during pre-trial detention, indefinitely or for a prolonged period for persons with mental disabilities or juveniles.”            

That solitary confinement, an American invention, is widely used today is particularly disturbing because we have known about the harmful effects of isolating prisoners for nearly two centuries.  As the editors point out, while isolating criminal individuals in the late 18th century was thought to allow them to be more penitent, thus the term penitentiary, by the early 19th century the practice became viewed as cruel.  Alexis de Tocqueville in 1833 wrote the practice was, “beyond the strength of man; it destroys the criminal without intermission and without pity; it does not reform, it kills.”  After visiting Eastern State Penitentiary in 1842 Charles Dickens wrote, “very few men are capable of estimating the immense amount of torture and agony which this dreadful punishment . . . inflicts upon the sufferers.”  Dickens referred to those in solitary as “buried alive.”  In 1890, the US Supreme Court In re: Medley also recognized the practice caused enduring psychiatric harm.  Writing for the court Justice Samuel Miller, also a physician, found many prisoners “became violently insane,” others “committed suicide” and those “who stood the ordeal better were not generally reformed, and in most cases did not recover sufficient mental activity to be of any subsequent service to the community.”  Despite creating conditions that Atul Gawande noted in 2009, “horrified our highest court a century ago,” we have nevertheless regressed with little, if any, forethought. 6  In 1983, after two prison guards were killed at an Illinois penitentiary, the entire prison went into lock down.  Lock down remained in place and the modern practice of solitary confinement, and what we know today as supermax prisons that hold approximately 25,000 prisoners in isolation, was born.   

“Hell” includes four additional chapters by another psychiatrist and by a law, political science and philosophy professor.  Law Professor Laura Rovner’s discussion of the courts’ interpretation of whether prolonged isolation violates the Constitution’s 8th amendment’s prohibition against cruel and unusual punishment is in some ways as disturbing as Kupers’ work.  Federal courts, in Madrid v. Gomez (1995),  have reasoned that though solitary confinement conditions posed a “shocking and disturbing” risk of exacerbating mental illness, somehow isolating someone for 31 years was allowable because, in Silverstein v. the Bureau of Prisons (2014), “the opinion of the prison administrator on how to maintain internal security carries great[er] weight” and because the mental health issues that Mr. Silverstein developed while in isolation, were only “minor mental health symptoms.”  This intellectual jujitsu would likely make John Yoo envious.      

The editors’ most substantive accomplishment is in offering sixteen first person accounts, some via interviews, by current or former long-term solitary confinement inmates under the headings “enduring,” “resisting” and “surviving.” 

Among the 16, Syed Fahad Hashmi, a former graduate student in international relations, plead guilty for allowing a friend, who later became a cooperating witness in terrorism cases, to use his cell phone and to stay for two weeks in his London apartment with luggage containing raincoats, ponchos and waterproof socks.  Hashmi plead guilty only after spending three years in pre-trial solitary confinement that Juan Mendez found had “no justification.”  He is serving 15 years in solitary at ADX (the US Penitentiary Administration Maximum) in Colorado. 

Judith Vazquez, who spent several years in solitary in New Jersey, became so obsessed with having to feel the wind, she spends six months using her nails to scrape until they bled a small opening in the rubber seal around a four inch wide window in her cell.  “Upon seeing this little opening,” she writes, “I acted savagely.”  I only had room to put one nostril at a time against the hole, and I would breathe in so hard.  It gave me a sense of being human again.  It was my secret air supply, which was what kept me alive.” 

Joseph Dole, who spent more than 10 years in solitary and is still incarcerated, Shaka Senghor, now a free man but spent over seven years in solitary and Todd Lewis Ashker, who spent 30 years in solitary are accomplished authors and successful plaintiffs.  Beyond their accounts of “SHU (Secure Housing Unit) Syndrome,” life in the “Graves” spent, in part, hurling “feces-filled bottles” at one’s enemies and successful efforts by prison staff to play racial groups against one another, all three men wonder whether the purpose of solitary is to drive corporate profits.  Senghor writes, “the officers have no interest in seeing me turn my life around, to most of them I represent job security.”  The guards at Folsom Penitentiary in California, Ashker writes, arranged for “Roman gladiator pit-style fights,” that the guards then wrote up as incidents proving the need for more solitary confinement and more guards. 7

William Blake, who has been held in isolation for over 29 years to date, perhaps best sums up what the editors try to accomplish with this work.  Blake writes,“If to imagine what kind of death, even a slow one, would be worse than twenty-five years in the box – and I have tried to imagine it – I can come up with nothing.  Set me afire, pummel and bludgeon me, cut me to bits, stab me, shoot me, do what you will in the worst of ways, but none of it could come close to making me feel things as cumulatively horrifying as what I’ve experienced through my years in solitary.”   


1. KiDeuk Kim, et al., “The Processing and Treatment of Mentally Ill Persons in the Criminal Justice System,” The Urban Institute (March 2015).  At: http://www.urban.org/research/publication/processing-and-treatment-mentally-ill-persons-criminal-justice-system.

2. To have a sense of what it is like to be held in solitary confinement view the six minute video, “This Is What It Feels Like to Spend Years In Solitary Confinement,” at Slate.  At: http://www.slate.com/.

3. A December 20, 2016 podcast interview with Jean Casella is at: www.thehealthcarepolicypodcast.com.

4. Expert Report of Terry A. Kupers, M.D., M.S.P., Eastern Mississippit Correctional Facility (June 16, 2014).  At: https://www.aclu.org/sites/default/files/assets/expert_report_of_terrry_kupers_with_table_of_contents.pdf.

5. Juan E. Mendez, “Report of the Special Rapporteur on Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment,” (February 1, 2013) United Nations, Human Rights Council.  At: http://www.ohchr.org/Documents/HRBodies/HRCouncil/RegularSession/Session22/A.HRC.22.53_English.pdf.  See also, “Solitary Confinement Should Be Banned in Most Cases, UN Expert Says,” UN News Centre (October 18, 2011).  At: http://www.un.org/apps/news/story.asp?NewsID=40097#.WHY_8FMrLIU.

6. Atul Gawande, “Hellhole,”The United States Holds Tens of Thousands of Inmates in Long-Term Solitary Confinement. Is this Torture?”  The New Yorker (March 30,2009).  At: http://www.newyorker.com/magazine/2009/03/30/hellhole.

7. It’s worth noting the day after the election of Donald Trump the two largest private prison corporations in the US, Corrections Corporation of America and GEO Group, saw their stock prices increase by 58 and 28 percent respectively.              

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