All alone

This week we are discussing solitary confinement…

Isn’t it freaky how online platforms seem able to predict our interests? Last week, I turned to Disney+ for a crime & punishment film I needed for work purposes. And then this week on a mini-break I logged on to find a nice relaxing movie, only to be confronted by the platform’s 'because you watched' suggestion of yet another crime saga! And the thing is, both on duty and off duty, I am interested in all things crime & punishment. So in for a penny, in for a pound...

Bronson

A biographical film armed with a hefty degree of artistic license, Bronson tells the story of Charles Bronson, the well-known muscled and mustachioed fixture of the solitary cells within Britain's high secure prison estate (HSE). First imprisoned in 1974 aged 22 under his birth name of Michael Peterson, excepting a handful of days he’s been under various kinds of lock and key ever since. How can this be though? After all, his original sentence - for armed robbery - was just seven years!

Mainly it’s due to his behaviour whilst inside prison. Attempted murder. Grievous bodily harm to fellow prisoners and staff. Taking hostage an art teacher, a doctor, and governors. And massive wanton destruction of prison and special hospital property and buildings. Acts like this do not go hand-in-glove with timely release.

Rehab

Proponents of the benefits of imprisonment talk about its potential for rehabilitation. Yes, some prisoners can and do learn useful things behind bars - reading & writing, the wrongness of their offending behaviour, and practical skills for gainful employment after release. Creative avenues of self-expression are also taught within some secure environments. Mr Bronson, for example, attended art classes behind bars and has become a notable prison artist: despite being in solitary, he turns out some impressive pieces.

Still, a key question posed by Bronson is this: are such rehabilitative benefits mere silver linings within a de facto harmful black thunder cloud? Were it possible to write Mr Bronson into a sequel to Sliding Doors, we could rewind his life back to just before the events that led to his first imprisonment. A longitudinal criminal justice case study could then follow, potentially with incredible answers to deep questions. Was he always destined to go down the same disturbing life trajectory - regardless of whether he was imprisoned? Or could he have turned out far more benign and productive, like so many other young men born and bred in post-war Luton? And did his earliest years in solitary confinement and other forms of detention do him significant and lasting psychological harm, mould his longer-term behaviours, and beget his whole life story?

Warning

I'm a HSE healthcare professional (HCP). Mr Bronson has been detained within the HSE for ever so long. And in Britain, Prison Service Order PSO 1700 mandates a nurse visiting all solitary prisoners daily and a doctor every three days. As a result, like many other HSE HCPs I have met and cared for Mr Bronson. So I voice no personal opinion about his case other than noting that the safe housing of such an unusually violent prisoner must pose a fiendishly difficult dilemma for any prison governor.

Leaving him aside though, I have formed definite conclusions about solitary confinement per se - views honed during countless 72-hourly 'Doctor's Seg Rounds' in the UK as well as many visits to various other countries’ solitary confinement units. [1]

So what do I think? Whilst a degree of separation from the rest of the prison population is sometimes necessary, never have I seen solitary confinement produce lasting improvement in a prisoner’s mental and physical health. On the contrary, I often see mental and physical health deteriorate. And for certain, I think that its longer-term use should come armed with a health & safety warning every bit as serious as those emblazoned across modern-day cigarette packets: ‘Solitary confinement is bad for your health'. And I’m far from the first to say this…

COVID

The world has just been groaning under the weight of COVID lockdowns. Though undeniably bitter, our own ‘pandemic sufferings’ have been just a small taste of the horrific suffering endured week in, month out, even year in, decade out by prisoners held in long-term solitary confinement. And solitary confinement wasn’t exactly rare before the pandemic:-

… it [solitary confinement] continues to be used across the globe – including for vulnerable groups such as prisoners with disabilities and children – in contravention of international standards. This is despite increasing recognition of its detrimental psychological and physiological effects, and of the economic costs… New Zealand, for instance, saw a 151 per cent rise in the use of solitary confinement over the five-year period up until 2016, compared to a 16 percent rise in the prison population… In the US, a report detailed how blind and deaf prisoners in solitary confinement experience a heightened form of sensory deprivation as a result of their disability...
(Global Prison Trends 2018, Penal Reform International)

Sensory distortion is a key feature of solitary confinement syndrome. This syndrome is a very real thing. I have seen it in some of my patients around the world and it’s most upsetting to witness. How much worse must it be to experience it?

United

So what does the United Nations (UN) have to say about solitary confinement? Actually, quite a lot. The Nelson Mandela Rules read as follows:-

Rule 43

1. In no circumstances may restrictions or disciplinary sanctions amount to torture or other cruel, inhuman or degrading treatment or punishment. The following practices, in particular, shall be prohibited: (a) Indefinite solitary confinement; (b) Prolonged solitary confinement...

Rule 44

For the purpose of these rules, solitary confinement shall refer to the confinement of prisoners for 22 hours or more a day without meaningful human contact. Prolonged solitary confinement shall refer to solitary confinement for a time period in excess of 15 consecutive days.

Rule 45

1. Solitary confinement shall be used only in exceptional cases as a last resort, for as short a time as possible and subject to independent review…

2. The imposition of solitary confinement should be prohibited in the case of prisoners with mental or physical disabilities when their conditions would be exacerbated by such measures. The prohibition of the use of solitary confinement and similar measures in cases involving women and children, as referred to in other United Nations standards and norms in crime prevention and criminal justice, continues to apply.

At this point we could ask, ‘The UN is so down on it, so why is solitary confinement still such a strong feature across the globe?’

Europe

Leaving the effectiveness of the UN aside though, let’s return to Europe, which of course is the continent within which the star of Bronson is confined.

European detainees benefit from extra protection over and above UN guidelines. That’s thanks to the Council of Europe (CoE) and its European Convention for the Prevention of Torture and Inhuman or Degrading Ill-treatment or Punishment, which itself builds on Article 3 of the CoE’s founding legal instrument, the European Convention of Human Rights:-

No one shall be subjected to torture or to inhuman or degrading treatment or punishment.

The CoE’s European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) monitors compliance with the convention bearing its name, and its position statement on solitary confinement makes persuasive and sombre reading:-

Solitary confinement… can have an extremely damaging effect on the mental, somatic and social health of those concerned. This damaging effect can be immediate and increases the longer the measure lasts and the more indeterminate it is. The most significant indicator of the damage which solitary confinement can inflict is the considerably higher rate of suicide among prisoners subjected to it than that among the general prison population… In addition, it can create an opportunity for deliberate ill-treatment of prisoners, away from the attention of other prisoners and staff.

… ensuring that there is a positive doctor-patient relationship between them is a major factor in safeguarding… medical personnel should never participate in any part of the decision-making process resulting in any type of solitary confinement, except where the measure is applied for medical reasons. On the other hand, health-care staff should be very attentive to the situation of all prisoners placed under solitary confinement...

The CPT’s assertion that solitary confinement is associated with long-term damage to ‘somatic’ or physical health received a boost recently with the publication of the results of a European public health study. A review of over 800,000 person-months spent in Danish solitary confinement showed such incarceration to be associated with a significantly higher chance of death within five years of release. [2]

So the European Prison Rules do right to include a focus on solitary confinement:-

The medical practitioner shall report to the director whenever it is considered that a prisoner’s physical or mental health is being put seriously at risk by… conditions of solitary confinement… Such visits [by healthcare professionals to prisoners in solitary confinement] can in no way be considered as condoning or legitimising a decision to put or to keep a prisoner in solitary confinement.

Statements

In addition to these legal instruments and codes of practice though, groups of international experts have gathered to ponder the best available evidence about the pros and cons of solitary confinement.

In 2007 at the International Psychological Trauma Symposium, the Istanbul statement on the use and effects of solitary confinement was issued. [3] And it's particularly interesting to note that three groups of detainees were picked out as being especially high risk for solitary conditions:-

The use of solitary confinement should be absolutely prohibited in the following circumstances:

- For death row and life-sentenced prisoners by virtue of their sentence.

- For mentally ill prisoners.

- For children under the age of 18.

Then around a decade later, a summit in Santa Cruz was convened to review the interplay between solitary confinement and health. The resulting Consensus Statement from the Santa Cruz Summit on Solitary Confinement and Health includes eight guiding principles:-

1 The Santa Cruz Summit on Solitary Confinement and Health reaffirms the Istanbul Statement as an appropriate framework for reforming solitary confinement… solitary confinement subjects prisoners to significant risk of serious harm and it therefore should be used only when absolutely necessary, and only for the shortest amount of time possible.

2 The Summit reaffirms that the use of solitary confinement should be absolutely prohibited for certain groups of especially vulnerable persons, including the mentally ill, children, older adults, people with chronic health conditions… and pregnant women…

3 Reduction in the use of solitary confinement should be further informed by the growing evidence-based knowledge that prolonged isolation accomplishes few if any legitimate penological purposes…

4 Solitary confinement reform is consistent with ongoing efforts to address and enhance correctional officer health and wellness…

5 The unique ethical challenges faced by correctional medical and mental health care providers who work inside solitary confinement units are not easily resolved…

6 Meaningful forms of independent external and internal monitoring and oversight are essential…

7 As more prison systems significantly limit or eliminate solitary confinement, it is important that stakeholders document and disseminate evidence about the impact of these reforms…

8 Because the overuse of solitary confinement reflects and is related to dysfunction in the larger correctional systems in which it is deployed, its reform should be recognized as part of the broader movement to reform prisons…

Ill

I am struck that both these statements use the term ‘mentally ill’ in their descriptors of those who should not be held in solitary confinement, rather than more detailed phrases such as ‘permanently psychotic’ or ‘severely or enduringly mentally ill’.

This wider bracket of ‘mentally ill’ may be argued to include those with:-

• psychiatric effects from withdrawal from alcohol or drugs,

• psychiatric effects from drug taking,

• personality disorders,

• significant difficulty adjusting to prison life,

• even mild degrees of anxiety or depressive disorders.

Applying this wider definition would bar the vast majority of Club Solo’s regular patrons - certainly in the prisons I visit or work in, and I suspect in the vast majority of prisons worldwide.

N G

It’s taken the best part of two decades to formulate my own opinions about solitary confinement. That’s quite long enough! So I’ll close now with the best, oldest and thankfully shortest conclusion I’ve ever read on this subject:-

“It is not good [N G] for man to be alone...”

God (Genesis 2:18)

And our Creator should know what’s best for us, His creations, shouldn’t He?

Dr Rachael Pickering is our voluntary Chief Medical Officer. Her personal opinions are not necessarily the same as those of Integritas Healthcare. We are always grateful for support.

Notes

[1] ‘Seg’ is short for ‘segregation’, which is the name that solitary confinement goes under within the UK prison system.

[2] Wildeman, C et al. Solitary confinement placement and post-release mortality risk among formerly incarcerated individuals: a population-based study. Lancet Public Health 2020: Feb;5(2):e107-e113

[3] This statement should not to be confused with the Istanbul Protocol, which deals with the documentation and evidencing of torture in general.

Near Miss

The trial and conviction of ex-police officer Derek Chauvin for the killing of George Floyd is to be welcomed as evidence that no-one - not even a law enforcement officer - need be exempt from the rule of law.

This tragedy has highlighted the dangers of law enforcement officers deploying unsafe restraint mechanisms on detainees. What hasn’t been so much talked about, though was mentioned in the trial, is the fact that even the most professional person is only as good as his or her training. A rogue person at the centre of a major incident is rarely the perpetrator of a one-off error. Usually, they will have been committing ‘near misses’ for years…

A near miss is an event that had the potential to cause injury or ill health but did not actually do so.

A risky-behaving professional could behave in an unsafe manner - such as deploying an unsafe restraint technique - 100 consecutive times with the first 99 episodes being near misses. Finally though, the 100th episode results in harm. Sometimes that harm is serious or even fatal.

So often, long before the fateful event, the risk-taker is well-known within his or her workplace - for taking a cavalier approach to health & safety, for not following policies & procedures, or for being difficult to line manage.

And this is true for all kinds of professionals, not just law enforcement officers. Take healthcare professionals…

We’ve just had a near miss in the prison I work in. A drug-addicted prisoner nearly received a duplicate dose of methadone [a prescribed alternative to street heroin]. I prescribed a dose for her, ignorant of the fact that she had already received a dose earlier that day. I didn’t know about that first dose because it had been marked erroneously as declined - that is, not swallowed - in her medical record. It was only by sheer luck that the true situation came to light before she was given my prescribed dose. I insisted on submitting a ‘near miss’ report because, just like unsafe restraint positions, methadone in excess can cause fatal respiratory depression.

(Anonymous UK prison doctor)

Restraint is used in both law enforcement and health & social care settings, either by physically holding the person, mechanically using equipment such as handcuffs or velcro straps, or chemically using pepper spray or a sedative. It should never be used as punishment, but only if there is a risk of harm to the person being restrained or to others around them. However, if someone is restrained, there must be safeguards in place to ensure that the benefit outweighs the potential harm of the restraint itself.

The United Nations Standard Minimum Rules for the Treatment of Prisoners (the Nelson Mandela Rules) provides guidelines on the use of restraint on prisoners, including the training of prison staff in its use:-

Rule 76

Training referred to in paragraph 2 of rule 75 [All prison staff shall possess an adequate standard of education and shall be given the ability and means to carry out their duties in a professional manner] shall include, at a minimum, training on:

(c) Security and safety, including the concept of dynamic security, the use of force and instruments of restraint, and the management of violent offenders, with due consideration of preventive and defusing techniques, such as negotiation and mediation;

Turning then to the issue of detainees like George Floyd being restrained, we could extrapolate this guideline as applying to any professional who may have to use restraint in their work environment. All would-be restrainers should be optimally trained to ensure that they may carry out their duties safely, and employers should be accountable for the provision of high quality training.

Whether you are a healthcare professional, a law enforcement official or a member of the public, you should have confidence in the safe and appropriate use of restraint. And we all have an obligation to support these individuals in pushing for optimal training and corporate responsibility.

Have you seen someone repeatedly ‘get lucky’ with unsafe working practices - be it unsafe restraint, inadequate record keeping, or anything else? Then raise a concern. And every time you come across or are involved in a near miss, report it as such. Doing so helps managers and their organisations - to improve training for all their staff, to close down unsafe practices, and to discipline the small minority of personnel who refuse to abide by safe practices. The end result is a safer environment for everyone.

Dr Esme MacKrill with Dr Rachael Pickering

The Ms Maxwell Series: How small is too small?

Last week: what is torture?

Last week we started to revisit the topic of torture as it had made the British news once again when Ghislaine Maxwell’s brother, Ian, spoke out against the apparently torturous conditions in her New York jail. Mr Maxwell reported his sister is being held unnecessarily under constant surveillance, in a 6x9ft (1.8x2.7m) cell with no natural light, and with terrible food & water rations.

However, as we discussed, deciding whether Ghislaine is being tortured is complex. The United Nations (UN) Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (CAT) contains a complex definition of torture, which can be difficult to interpret. And, although the United States of America (USA) has signed the CAT, it has not signed the Optional Protocol to the Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment (OPCAT). So the UN’s Subcommittee for the Prevention of Torture and Cruel, Inhuman or Degrading Treatment or Punishment (SPT) cannot inspect her cell within one of the USA’s many prisons and other places of detention.

Even if the USA was signed up to OPCAT, the SPT does not have published standards by which to judge whether - as Ian Maxwell claims - Ghislaine’s living space is indeed too cramped, too short on natural light & too lacking in privacy or if her food is really all that bad.

However, if Ghislaine was incarcerated in Europe, she would be held by a member state of the Council of Europe (CoE). All such states are automatically signed up to both its European Convention on Human Rights (ECHR) and its more detailed Convention on the Prevention of Torture and Inhuman or Degrading Treatment or Punishment, which, through inspections by the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT), tries to ensure that the ECHR’s prohibition of torture is respected.

How small is too small?

So then, if for some reason Ghislaine was extradited to Europe, she and her cell may just be lucky enough to be inspected by a delegation from the CPT, which does have well-known standards. Let’s consider purely its standard on living space, which is the most objectively assessable of the complaints raised by Ian Maxwell on her behalf…

According to the CPT, each detainee should have ‘6m² for a single-occupancy cell + sanitary facility’ or ‘4m² of living space per prisoner in a multiple-occupancy cell + fully-partitioned sanitary facility’. By this definition then, Ghislaine’s single-occupancy 6x9ft (1.8x2.7m) cell - at ~4.9m² - is too small. Whether or not it could be considered ill-treatment amounting to torture - as per either the UN’s definition or the deliberation of judges sitting at the European Court of Human Rights (ECtHR) - is a far more complex, thorny question.

How does nelson mandela come into this issue?

Within International Humanitarian Law, prisoners’ basic needs must be met and their human dignity maintained. And so, in 2015, the United Nations revised its 1955 Standard Minimum Rules for the Treatment of Prisoners, now known as the Nelson Mandela Rules - as the late President of South Africa was, in his earlier years, very famously ill-treated whilst behind bars.

These 122 rules provide guidance on all aspects of a prisoner’s journey from admission right through to release. Regarding solitary confinement, rules 44 and 45 state:-

44. For the purpose of these rules, solitary confinement shall refer to the confinement of prisoners for 22 hours or more a day without meaningful human contact. Prolonged solitary confinement shall refer to solitary confinement for a time period in excess of 15 consecutive days.

45. 1. Solitary confinement shall be used only in exceptional cases as a last resort, for as short a time as possible and subject to independent review, and only pursuant to the authorization by a competent authority. It shall not be imposed by virtue of a prisoner’s sentence.

What about her lack of privacy?

We do not know the exact amount of time per day that Ghislaine is confined to her cell. We also do not know whether she is allowed day-to-day interaction with other detainees. However, in his interview Ian Maxwell stated the following:-

Ghislaine has been in prison now for nearly 250 days and counting… she is under 24 hour round-the-clock surveillance with ten cameras, including one that moves and tracks her movements. And on top of that there are four guards that are looking at her, and presumably there is another guard looking at the camera feeds. She is not allowed to move into the corners of her cell and she’s not allowed to be within two and a half feet of the cell door. That is her existence every day.

As we mentioned last week, Ian Maxwell intimated that - subsequent to Mr Epstein’s high profile suicide last year whilst in prison - Ghislaine is under constant surveillance due to the authorities’ fear that she too may try to end her life whilst in custody. However, he does not believe that she is a suicide risk, making this level of monitoring a ‘grotesque over-reaction’.

What should be done to prevent suicide in custody?

The World Health Organisation (WHO) has written guidance on suicide prevention in jails and prisons. This document explains that a thorough risk assessment process should be completed for every prisoner when they are admitted to the prison and advises on appropriate management techniques as and when necessary.

Adequate monitoring of truly suicidal prisoners is necessary, given that hanging can cause serious brain damage within three minutes and death within five to seven minutes.

The use of camera technology has become increasingly popular as an alternative to prison guard watches. Even so it still requires surveillance of camera footage and prompt action. The guidance say:-

Moreover, most inmates dislike constant observation if it occurs without emotional support and respect. Therefore, camera surveillance should never be utilized as a substitute for the officer’s observation of the suicidal inmate and, if used, should only supplement the direct observation of staff.

If Ghislaine’s New York jailors have conducted risk assessments that clearly identify her being high risk of suicide, then constant surveillance may be a necessity for her own safety. However, if Ian Maxwell’s claims are true and her jailors are acting purely out of an excessive fear for their own reputation, then her level of monitoring is truly excessive and could even be counter productive.

But what’s in a name?

However, let’s for a moment leave aside the varying degrees of both lack of privacy and cramped cells endured by Ghislaine and very many others of the world’s ~11 million prisoners. Instead, let’s consider the undeniable psychological and physical health consequences to keeping prisoners in any sort of secure environment where perpetual confinement and frequent observation are the orders of the day…

The COVID-19 pandemic lockdown has imposed on a massive percentage of the world’s free citizens has given us a tiny taste of the psychological sequelae of imprisonment. It is therefore unsurprising that detainees, especially those who have been kept in confined conditions, suffer from anxiety, panic, insomnia, paranoia, aggression and depression. These psychological symptoms in turn can increase the risk of self-harm and suicide.

Detainees kept under such conditions are also at higher risk of a range of physical effects such as joint and back pain, deterioration of eyesight, lethargy and cachexia.

Are such conditions ill-treatment? And could they be said to amount to torture, as defined by the UN’s CAT or as interpreted by the ECtHR’s judges? You try to decide. But either way, it’s neither necessary nor proportionate punishment for offending human beings in general to be kept in such conditions.

So what about her diet and exposure to sunlight?

Although the above symptoms may be caused purely by psychological stress, they cannot often be separated from the physical consequences of poor diet and lack of sunlight. And so next week we will focus on Ian’s claims that Ghislaine receives practically inedible food and is not given enough exposure to natural light.

How may such allegations be assessed?

What are the potential health consequences of such ill-treatments?

And are they ill-treatments that could be said to amount to torture?

Until next time…

Dr Esme MacKrill with Dr Rachael Pickering