6

Sanctioned Torture

“THEY’RE NOT THERE YET,” the man called out as I tried the door to the courtroom. It was early, and the door was still locked. He was sitting on the wooden bench across from the door; his T-shirt and baseball cap looked out of place in the imposing marble-lined hall. I walked over, and he introduced himself as Ray Echevarria. He had been there every day since the trial began, he told me.

It was December 2014, and I was at the federal courthouse in Manhattan to cover the trial of Terrence Pendergrass, a Rikers Island corrections officer who had been charged with violating the human rights of the man’s son, Jason Echevarria, a prisoner on the special unit for people with mental illness that Pendergrass was supervising. Echevarria was twenty-five and had spent nearly at year at Rikers when he died from untreated medical complications after he poisoned himself. “I’m here for my son,” the senior Echevarria told me later. “I’m here to support his spirits.… I’m pretty sure he knows I’m here.”

With a long history of behavioral problems and a diagnosis of bipolar disorder, Jason Echevarria had been prescribed medication for much of his life. When he was growing up, his father had arranged his own schedule as a city bus driver so he could take his son to doctor and therapist appointments. But nothing seemed to help very much. “To hold a conversation with him?” his father said to me during the Pendergrass trial. “No. Fantasies all the time, that he was a gang member, that he was a Latin King. All fantasy.”

At Rikers, where he’d been sent on a robbery charge, Echevarria gained a reputation for being something of a troublemaker and was moved around repeatedly from jail to jail. (The complex is made up of ten different jails.) Some of his behavior seemed more annoying than violent or even actively disruptive: a corrections officer testified that once, after bringing Echevarria to his cell and removing his handcuffs, Echevarria refused to take his arm out of the tray slot; this meant the officer couldn’t shut the slot. Another time, Echevarria stuffed his mattress into the slot, with the same result. Often, it seemed to stem directly from his mental illness. He tried to kill himself several times, including once by swallowing a battery. According to the criminal complaint against Pendergrass, it was the suicide attempts that had landed Echevarria on the special mental health unit—the unit where he ultimately succeeded in killing himself.

Astonishingly, this special unit was not designed to provide treatment for prisoners with mental illness. It was designed to punish them. Established in 1998, the “mental health assessment unit for infracted inmates”—known by the acronym MHAUII, pronounced like the Hawaiian island—consisted entirely of solitary confinement cells designed specifically for sick patients who broke rules (“infracted” in the jail euphemism). People were locked in their cells for at least twenty-three hours a day; when they did come out, they had to be handcuffed. The cells were bare: a fiberglass platform bed, a metal toilet, and a metal sink. Food and medication were handed to them through a slot in the door. Human contact was kept to a minimum.

“MHAUII was designed as a more treatment-oriented form of segregation”—i.e., solitary confinement—wrote Elizabeth Ford, the psychiatrist responsible for mental health care at Rikers, “with the opportunity to earn extra hours out of one’s cell for good behavior. The idea was solid—positive reinforcement—but the practice was not. Within several years of opening, MHAUII was indistinguishable from regular solitary confinement.”¹ With conditions like this, it didn’t take much for individual officers to take the abuse even further. As one civil rights attorney put it, once you start to dehumanize people this way, there are no limits, and there is no sense of obligation toward them. Conditions on MHAUII got so bad, and led to so much abuse and neglect, that it was shut down shortly before the Pendergrass trial started.

The day before Echevarria died in 2012, there was a sewage backup on the unit. This happened often. Raw sewage flooded several cells, including number four, where Echevarria was being held. A corrections officer gave Echevarria a packet of concentrated detergent—known as a soap ball—to clean his cell. The detergent is caustic and extremely toxic, and even prisoners without a history of suicide attempts are supposed to get it only after it’s been diluted in quantities of water. At around 4:30 that afternoon, Echevarria began banging on the door of his cell. When a corrections officer went to see what was wrong, he said, Echevarria told him he had eaten the soap ball and that he needed medical care. “He was yelling off the top of his voice,” the officer testified, “panting as if he couldn’t breathe,… saying he needs a doctor. Get me a doctor. I can’t breathe.” The officer went to Terrence Pendergrass, the supervising captain on duty. “Don’t call me if you have live, breathing bodies,” the officer testified Pendergrass told him. “Only call me if you need a cell extraction [a forcible removal from a cell] or if you have a dead body.”²

Shortly after that, the officer reported, he walked past Echevarria’s cell again and this time saw vomit on his window and on the floor of the cell. Again he reported it to Pendergrass, who said Echevarria should “hold it.”³ About an hour after Echevarria first reported swallowing the detergent, a pharmacy technician came around to deliver medications, escorted by another corrections officer. Noting the vomit and Echevarria’s coloring, the technician told the officers that he could die without medical treatment and asked the officer escorting her to inform Pendergrass. The officer informed Pendergrass, who asked him to document what had happened. But before the officer could finish his report, Pendergrass led him away. Echevarria never got any medical care. At 8:30 the next morning, a physician’s assistant found him dead on the floor of his cell, blood and white foam coming out of his mouth.

Even as jail and prison administrators become more aware of the needs of people with mental illness, there have been an alarming number of reports of abuse or neglect of sick prisoners. Jason Echevarria is far from the only one to die at Rikers in recent years. In 2014, Jerome Murdough, a homeless former Marine diagnosed with schizoaffective disorder, was arrested in the stairwell of a housing project in Harlem where, he told police, he had gone to escape the cold. Barely a week after he got to Rikers, he died in a mental health observation unit when a malfunction in the heating system drove temperatures above 100 degrees and corrections officers failed to check on him at appropriate intervals.⁴ Psychotropic drugs, which Murdough was taking at the time of his death, make patients particularly susceptible to heat because it makes it harder for the person to recognize that he’s hot, and they also make the body less able to cope with the heat.

These cases go well beyond the largest and most troubled institutions such as Rikers. In April 2015, for example, Jamycheal Mitchell, a twenty-five-year-old man with schizophrenia and bipolar disorder, was arrested for stealing five dollars’ worth of junk food from a 7-11 in Portsmouth, Virginia. After his arrest, a psychiatric examiner found that “Mr. Mitchell’s thought processes were so confused that only snippets of his sentences could be understood; the rest were mumbled statements that made no sense” and recommended that he be sent to the state hospital for competency restoration.⁵ The state mental health employee who was supposed to have arranged Mitchell’s transfer to the hospital instead stuffed the paperwork into a drawer along with the paperwork of others awaiting transfer. Mitchell spent more than four months in the Hampton Roads Regional Jail awaiting a transfer that never came. He eventually died of starvation.

Mitchell’s family filed a lawsuit alleging that Mitchell had rarely been allowed out of his cell. Officers had turned off his water, the lawsuit says, a common response to prisoners who misbehave. His cell was covered in urine and feces. Mitchell had no clothes, mattress, sheet, or blankets. He was allegedly rarely fed; he lost between forty and fifty pounds. The lawsuit said he was rarely given his psychotropic medication; in the last month before he died, he did not get any at all. Perhaps worse than the neglect, though, fellow prisoners reported to attorneys for Mitchell’s family that corrections officers taunted Mitchell, treating him “like a circus animal.” Officers kicked and punched him, they said, even while he was handcuffed. Another officer allegedly twisted Mitchell’s arm when he stuck it outside the tray slot.⁶ An internal investigation at the jail cleared its employees of all wrongdoing. I visited the jail shortly before the family’s lawsuit was filed; the warden told me that his employees took excellent care of the prisoners, including the ones with mental illness.

Other cases are even more grotesque. In 2012 Darren Rainey was serving a sentence for cocaine possession in a Florida prison. Because he had been diagnosed with schizophrenia, he was being housed on a unit for prisoners with mental illness. When officers found that he had smeared his cell with feces, they dragged him to a “special” shower to clean up. The water in the shower, which could be turned on and off only from the outside, was 160 degrees—the legal limit is 120 degrees.⁷ According to other prisoners who witnessed the event, Rainey screamed repeatedly to be let out. Officers left him in the scalding water for two hours; by the time they took him out, he was dead, his skin so red it looked as if he’d been “boiled” and peeling “like fruit roll-ups.”⁸

It’s hard to imagine how anybody could justify this kind of cruelty, let alone perpetrate it; corrections officials are quick to suggest that such cases are rare. Talk to prisoners, though, or people who were formerly incarcerated, and abuse is the norm, though events that reach the level of what happened to Jamycheal Mitchell or Darren Rainey are rare. That they happen at all, however—that they are even possible in multiple prison and jail settings across the country—is a horrific indication of the flaws of the current system. Worse, this kind of abuse is often merely an extension of the discipline that facilities regularly use—including solitary confinement and restraints—to punish people who act out. For prisoners with mental illness, such tactics, even when not lethal, can have terrible effects on their illness; in some cases, they may result in permanent trauma.

All of this raises far-reaching questions about the provision of mental health care in the criminal justice system. How can institutions that are built around discipline and punishment, that rely on officially sanctioned forms of psychological pressure and duress, provide, under any circumstances, the kind of setting necessary for effective treatment? And even if they can, what does it mean for doctors and other medical staff who work within them and must adhere to the strictures of life inside them?

ADMINISTRATIVE SEGREGATION. DISCIPLINARY SEGREGATION. Punitive segregation. Protective custody. Room confinement. Special Management. Special Housing Units. Lockdown. Isolation. The Bing. The Hole. The Box. There are many names for it, some official, some not, but they all refer to the same thing: solitary confinement—the brutal and perfectly legal practice of keeping people alone, with no human contact, in cells the size of a small bathroom for twenty-three or more hours a day for weeks, months, years, even decades at a time. At last count, there were at least eighty thousand people in solitary in the United States, a number that does not include juvenile facilities, immigration detention facilities, and local jails.⁹ Somewhere between a third and a half of those people are believed to have some form of mental illness.

The practice of solitary confinement rests on shaky foundations. It doesn’t have any place in formal criminal sentencing; it is unrelated to the crimes for which a person has been incarcerated. Instead, it is mostly used at the discretion of corrections officials themselves either because somebody decided, more or less arbitrarily, that the prisoner was a danger to the prison or, as is most often the case, as a form of additional punishment for prisoners who have violated certain rules or are otherwise deemed to have misbehaved. As a result, solitary confinement disproportionately draws in people with mental illness, even as it makes many ordinary prisoners sick. Solitary is also expensive, costing states as much as two to three times more per prisoner than ordinary incarceration. Each year, Texas spends $46 million above its regular correctional budget to pay for solitary confinement.¹⁰

Yet placing prisoners in isolation cells has been a feature of the modern US penal system since its inception in the early nineteenth century. The original idea, developed at Philadelphia’s Eastern State Penitentiary, was to cut the prisoner off from all human relationships so that he might focus his attention inward and rehabilitate himself. In recent years the practice has been justified as an important tool for managing jails and prisons. Even opponents of the practice acknowledge that it can be useful when used for short, determinate periods. Specific prisoners may need to be separated from one another, either for their own protection or the protection of others. Sometimes, an entire unit may need to be brought under control. Putting people into isolation cells can be a relatively safe and easy way to do that. More often, though, it’s easier to put an “unruly” prisoner—whether it is someone who has refused to return a food tray properly or who has threatened a corrections officer—away, out of sight, than it is to try to deal with the underlying problems that might be causing the behavior. One important question is what constitutes a reasonable period to hold somebody in solitary. In England, for example, a prison has to jump through numerous hoops, including getting dispensation from the Ministry of Justice and ordering special psychiatric examinations for the prisoner, to hold a person in solitary confinement for more then seventy-two hours. By contrast, jails and prisons in the United States have no such limitations. There is a sad irony to the fact that a doctor wishing to keep a patient hospitalized against his will for longer than seventy-two hours must seek permission from a judge.

Whatever the motivation, observers of the practice have from the outset found it morally dubious. “He never hears of wife or children; home or friends; the life or death of any single creature,” wrote Charles Dickens of one such prisoner, after visiting Eastern State in 1842, then considered the most modern prison in America. “He sees the prison-officers, but with that exception he never looks upon a human countenance, or hears a human voice. He is a man buried alive; to be dug out in the slow round of years; and in the meantime dead to everything but torturing anxieties and horrible despair.”¹¹

Solitary confinement today involves complete isolation in cells not much bigger than a closet: an average-sized man who stands in the middle and extends his arms will be able to touch both walls. Many don’t have windows. The bed is stainless steel or concrete, with a thin mattress. The “bathroom,” also stainless steel, is a combination toilet and sink stuck in a corner of the same tiny room. Officers hand meals through the tray slot. Prison food is hardly known for being delicious or plentiful, but prisoners and their families regularly report that portions in solitary units are even smaller. In a number of institutions, prisoners in solitary are fed the “loaf,” a barely edible and hard-to-digest mix of various foods ground together, instead of an ordinary meal.

The only physical contact they have with other human beings is with the corrections officers who search and handcuff them before letting them into or out of their cells. The process is cumbersome. According to legal scholar Keramet Reiter, “[The prisoner] backs up to the cell door and reaches his hands out through the cuff port. An officer handcuffs him before opening the cell door completely. Once the cell door opens, the officer will cuff the prisoner’s ankles together and tether his cuffed hands to a chain around his waist. The officer will grab the waist chain… and the two will shuffle slowly down the windowless corridors of the [solitary unit]. Usually, one or two additional guards will follow to ensure the prisoner remains under control.”¹² In testimony before Congress in 2012, Craig Haney, a psychology professor at UC Santa Cruz and an expert on solitary confinement, explained that the recreation yard in solitary units “often consists of a metal cage, sitting atop a slab of concrete or asphalt or, in the case of California’s Pelican Bay, a concrete-enclosed pen, one surrounded by high solid walls that prevent any view of the outside world.”¹³

Observing the effects of solitary confinement at Eastern State Penitentiary nearly two hundred years ago, Dickens concluded that “this slow and daily tampering with the mysteries of the brain [is] immeasurably worse than any torture of the body and because its ghastly signs and tokens are not so palpable to the eye and sense of touch as scars upon the flesh; because its wounds are not upon the surface, and it extorts few cries that human ears can hear; therefore I the more denounce it, as a secret punishment which slumbering humanity is not roused up to stay.”¹⁴

In the twenty-first century, these devastating consequences have been documented with clinical precision. For example, extreme isolation may exacerbate or cause symptoms of psychosis such as hallucinations, paranoia, sleeplessness, and self-harm. More than half of all prison suicides occur in solitary confinement.¹⁵ A study of self-harm incidents at Rikers Island showed that people who had spent time in solitary were almost seven times more likely to try to hurt themselves than prisoners who had not.¹⁶ At the same time, in many solitary units mental health treatment is almost nonexistent. In some places, prisoners stay in their cells or in cages for group therapy, with the therapist sitting in the hallway between or among the cells. Individual therapy, when it exists, may be conducted cell-side. That means either shouting through the steel door while the rest of the tier listens in or bending down to talk through the tray slot, which is typically about waist-high. I have spoken to prisoners through those doors; it’s hard to hear them, and it’s hard to be heard. Even a casual conversation is difficult, let alone something as personal and nuanced as a therapy session.

One of the terrible ironies about solitary is that because of the disciplinary structure of most prisons and jails, people who already have a severe mental illness are often those most likely to be put there. For sick prisoners, this means a two-part trap in which they are punished for their “abnormal” behavior with disciplinary measures that, in turn, make their condition worse. The system works something like this: when a prisoner breaks a rule, a corrections officer gives him a “ticket”—in other words, writes him up for the infraction. The “crimes” that can get somebody sent to solitary range from the ridiculous—having too many pencils in one’s cell or not standing in the right place to receive a food tray—to the serious—assaulting another prisoner or throwing something at an officer. Not infrequently, tickets are given for behavior that is symptomatic of mental illness. There is a hearing to determine the “sentence,” but the judge is usually a high-ranking corrections officer or other prison system employee; to defend oneself in such a hearing, even when possessed of one’s full faculties, is extremely difficult.

In a 2013 lawsuit in Pennsylvania, attorneys cited the case of one prisoner who was repeatedly sent to solitary for “behaviors directly attributable to his serious mental illness, including banging his head against his cell wall, smearing feces on his body and his cell, attempting suicide by making nooses from bedding material in his cell, making himself bleed, and harming himself in other ways.”¹⁷ The man eventually accumulated 2,000 days—nearly five and a half years—in solitary, a period significantly longer than his original court-imposed sentence. Worse, prisoners in solitary can also accumulate new criminal charges and, with them, new sentences, which can turn a relatively brief prison stay into a life sentence.

Time in solitary often triggers more extreme behavior. One prisoner in solitary at a federal supermax prison (the highest security facility), psychologist Craig Haney told Congress, “has amputated one of his pinkie fingers and chewed off the other, removed one of his testicles and scrotum, sliced off his ear lobes, and severed his Achilles tendon with a sharp piece of metal.… Another prisoner, housed long-term in a solitary confinement unit in Massachusetts, has several times disassembled the television set in his cell and eaten the contents.”¹⁸

One case I found particularly heartbreaking was the man in solitary in New Mexico whose family told me he got so paranoid he stopped eating because he was convinced the food was poisoned. The prison would send him to the state hospital, where, removed from the inhumane pressures of an isolation cell, he would quickly regain his faculties, only to be deemed fit enough to be sent back to solitary again. This happened repeatedly over the course of several years.

Such cases, and there are a great many of them, show just how poorly suited current incarceration practices are to dealing with a large population of people with mental illness: not only are we, in a great many of our penal institutions, failing to give these prisoner-patients anything like appropriate treatment; we are also putting them in environments we know will make their symptoms much worse. Indeed, it would be hard to come up with a system more perfectly designed to inflict maximum damage to the psyche than solitary. Worse, we are actually making our sick population grow. One of the most tragic effects of solitary is the extent to which it renders ostensibly sane people mentally ill—sometimes profoundly so.

BRIAN NELSON SPENT TWENTY-THREE YEARS in solitary confinement, most of it at the now-closed supermax Tamms Correctional Center in Illinois, after being convicted of accessory to murder. Before coming to Tamms, he had been in a minimum-security prison in New Mexico. (States sometimes manage overcrowding in their own prisons by sending prisoners elsewhere.) The first time I met him, at a screening of a documentary about solitary confinement, he asked me to bring him a six-pack of beer. He needed the liquid courage, he said, before he could bear to talk about his experiences in segregation.

Now in his fifties, Nelson is a stocky white man with a shaved head and a kind of pulsing anxiety that he attributes to his time in “the Bing.” After the screening, he barely managed to introduce himself before he asked if I’d brought the beer. I handed him a bag with six bottles of Corona and a bottle opener I’d bought at a drugstore on my way over. He took them to the men’s room and downed them in what must have been rapid succession, but he was still too distressed to talk. We ended up meeting the following day in his Times Square hotel. He hadn’t been able to sleep the night before—a lasting effect of his time in solitary, he said—and had spent the night just wandering the streets of Manhattan. We sat in his tiny hotel room, a box of a space not much larger than his old solitary cell, but, as he said, with more amenities. His attorney and boss stood just out of sight near the door, in case Nelson needed emotional support.

Nelson had never been diagnosed with mental illness before he was incarcerated when he was seventeen, he said, but within a year of going into solitary confinement, he was on the mental health caseload. Over the course of his incarceration, he was examined several times by an outside psychiatrist as part of a lawsuit over conditions in the prison. She found that he had major depression, a serious mental illness, but when he was prescribed antidepressants, the doses were far too low to be effective. She also determined that prison medical staff had medicated some of the symptoms—such as insomnia—while missing the underlying diagnosis; they had also described things such as agitation and endless pacing in his cell as intentional exercise.¹⁹ Sitting in his hotel room, Nelson described being put on suicide-watch: the prison took away his clothes—ostensibly for his safety—and put him into a freezing cold suicide-watch cell. “The best therapist [in prison] was a child psychologist,” he said. “She cared, and she would tell you honestly, ‘I don’t know [how to help] but I will try. I will listen to you and try.’” When he talked to her, he had to sit handcuffed and shackled on a cement block.

As preparation for getting out of prison, the administration promised to let him spend the last month of his sentence in general population so he could get used to being around people again. It’s absurd to think that thirty days in a prison dorm—almost always a chaotic place—surrounded by other prisoners dealing with various degrees of social dislocation and quite possibly mental illness could make up for an adulthood spent in a tiny room by oneself. Still, it seems almost anything would have been better than what actually happened.

For security reasons that were not made clear to him, Nelson was never transferred into general population. Instead, when his mother and stepfather picked him up at prison, he came straight out of solitary. He had not touched another human being—let alone been in the same room with one or several—in more than two decades. He was given neither his medications nor a prescription for them. He ended up going cold turkey on five drugs, including Zoloft and Prozac. “It was terrifying,” he said. Ten minutes after they got in the car, his mother suggested stopping for ice cream. Inside the shop, a man walked behind Nelson, and “I panicked. I literally panicked real bad,” he said. “Get away from me! Everybody in the place is like ‘What’s going on?’ For the rest of the ride home, I wouldn’t get out of the car.”

Like moles, which have evolved to have poor eyesight because they don’t need their eyes, people in solitary become hypersensitive to any kind of stimulus. Nelson remembers that when he got out, his mother’s cooking was too intense for him, and she had to cut back on spices for months until he got used to them again. He had spent so long alone in his cramped cell that he had difficulty being in larger rooms with other people; even now, more than five years after his release, he still spends much of his days alone. He couldn’t find a mental health professional who could help him deal with all the trauma: “You go to talk to a shrink, and they look at you like what? They don’t want to deal with it.” He finally found a psychiatrist who is trying to help him—somebody who has experience working with victims of torture. It makes sense. “Considering the severe mental pain or suffering solitary confinement can cause, it can amount to torture,” Juan Méndez, the UN special rapporteur on torture, told the United Nations.²⁰

SOLITARY IS NOT THE ONLY kind of “sanctioned” abuse in jails and prisons. Prisoners, including those with mental illness, are regularly subjected to tactics—such as hog-tying or cutting off water to cells—that are effectively torture in the guise of control. I have heard from prisoners and their families who have long-lasting trauma, post-traumatic stress disorder (PTSD) even, from time spent restrained in cells.

Given the disastrous and increasingly well-known consequences of solitary confinement and other disciplinary practices for prisoners with mental illness, a number of states and counties are contemplating significant changes to their policies. And at the same time, court cases, like those concerning the Rikers deaths of Echevarria and Murdough, have brought harsh light on existing practices and sometimes imposed steep penalties.

In the Echevarria case the corrections officer in charge, Terrence Pendergrass, was convicted and sentenced to five years in prison for violating the prisoner’s civil rights. The US Attorney’s office brought civil rights charges because it couldn’t build a criminal case against the officer: Pendergrass hadn’t directly done anything to Echevarria that led to his death. Nonetheless, as the evidence and the outcome showed, Pendergrass was at the head of the chain of command that failed to get Echevarria the medical care that he, medical staff, and even corrections officers themselves had asked for and that could have saved the man’s life. The charges were unusual: the first time in at least a decade that the US Attorney for the Southern District of New York had pursued such a case in connection with Rikers. Later that year, the Echevarria family also brought a civil case against the city, the jail, and Pendergrass, for which it won a $3.8 million settlement from the city.

Still, as with police officers, the penalties for the corrections officers involved have generally not been especially harsh. In the case of Murdough, the Rikers prisoner who died of heat exposure, the warden of the jail where he died was demoted and transferred to a unit that does not house people with mental illness. A corrections officer was suspended for thirty days in connection with Murdough’s death, and the supervisor of mechanics, who had failed to fix the heat, was barred from working in housing units.²¹ More notable is that the city ended up settling with Murdough’s family for $2.25 million. And no charges of any kind were filed in the death of Darren Rainey in Florida.

Although this kind of abuse has never been condoned, growing awareness of the consequences of solitary confinement and other abusive practices has been pushing change. In September 2017, Colorado took it a step further by ending the use of long-term solitary confinement, the only state to do so. Fifteen days is the longest a prisoner will be in solitary, and then only for serious charges such as assault. “When did it become O.K. to lock up someone who is severely mentally ill and let the demons chase him around the cell?” wrote Rick Raemisch, head of Colorado’s Department of Corrections, in an op-ed in the New York Times, describing his decision to end the practice. “What is wrong with us?”

Other states, including Pennsylvania, South Carolina, and New York, have changed laws in order to keep people with mental illness out of solitary confinement. That does not always mean that they are, though. In a recent report looking at the federal prison system, monitors from the Office of the Inspector General wrote the following: “Although the [Bureau of Prisons] states that it does not practice solitary confinement, or even recognize the term, we found inmates, including those with mental illness, who were housed in single-cell confinement for long periods of time, isolated from other inmates and with limited human contact.”²² In some places, prison officials and others have simply found ways around the rules, or flexible interpretations of them, to allow existing practices to go on in another form.

In 2008, the New York state legislature passed a law requiring prisons to take people with serious mental illness out of solitary. Between 2008 and 2011, the overall number of people in the system who were diagnosed with mental illness dropped dramatically, from nine thousand to fewer than eight thousand. In that time the overall prison population dropped by just over 6 percent; the population of prisoners with mental illness dropped by more than 12 percent. And among people who still had a diagnosed mental illness, the number with serious mental illnesses, such as schizophrenia, also dropped significantly, while the number of those diagnosed with less serious illnesses, such as anxiety disorders, increased even more. In other words, the prisons presumably changed patients’ diagnoses in order to be allowed to punish them more harshly.²³

New York has found other work-arounds. Take medication, for example. It’s against the law to punish a prisoner who refuses to take medication. There are many reasons that people may refuse psychotropic medications, even when they are medically indicated: an inability to recognize that one is sick, paranoia that the medication is poison, or simply not being able to handle the often severe side effects. Nonetheless, New York’s statute allows for this bizarre distinction: “Misbehavior reports will not be issued to inmates with serious mental illness for refusing treatment, however an inmate may be subject to the disciplinary process for refusing to go to the location where treatment is provided or medication is dispensed” (emphasis added).²⁴ So you’re free not to accept treatment, but you can still get in trouble if you don’t show up for it.

Likewise, prisoners in New York usually won’t get sent to solitary confinement for attempting suicide, but the statute leaves room for interpretation: “[T]here will be a presumption against imposition and pursuit of disciplinary charges for self-harming behavior and threats of self-harming behavior, including related charges for the same behaviors, such as destruction of state property, except in exceptional circumstances” (emphasis added).²⁵

Indeed, in New York and elsewhere, solitary is a common punishment for self-harm or suicide attempts. One attorney who specializes in prisoners’ rights in New York told me about a man who tried to commit suicide by swallowing a razor blade. Although he wasn’t punished for the suicide attempt itself, he was charged with possession of contraband after he passed the blade in his stool. Her office has seen numerous similar cases: a man charged with destruction of state property after tearing a sheet to use as a noose, another who set fire to his cell in an attempt to commit suicide. In the latter case, the man wasn’t punished for the suicide attempt, but he was accused of damaging state property and was fined about $1,000 for damages. He was also put in solitary.

MANY PEOPLE WHO WORK IN the criminal justice system have described to me the conflict between the security imperative of correctional facilities and the ever-increasing therapeutic function these institutions have as health care providers. According to psychologist Craig Haney, “Modern prisons are largely about control… the control of prisoners, their behavior, the degrees of freedom with which they can act, their level of contact with the outside world, and so on.” Prisoners with mental illness who refuse—or are unable to abide by the rules—threaten the prison’s order. And, continued Haney, “When prisons are at risk of losing this control, those in charge feel compelled to intervene.”²⁶ By contrast, mental health care, at its best, must be shaped around empathy, trust, and positive human connection.

This leaves anyone working in a correctional environment full of sick people with a frequent dilemma. Take the officers at the LA County Jail: their professional remit is expressly aimed at maintaining order and security and enacting disciplinary measures, yet, as with their colleagues in many other jails and prisons, they are constantly called upon to act as de facto mental health care staff, whether it is identifying a prisoner’s mental illness or “cutting down”—literally cutting the noose—of somebody who has tried to hang himself.

These clashing responsibilities are felt even more acutely by medical staff, whose professional work—and Hippocratic duty as physicians—is supposed to be strictly therapeutic. First of all, there are the legitimate security concerns. Jails and prisons can be dangerous places, and medical staff depend on corrections officers for protection. “We are guests in their house” is a common refrain among correctional medical staff, meaning they are at the mercy of security staff for everything, namely access and safety, so they had better comply with what corrections officers and other officials demand of them lest they find access to their patients limited or their own safety compromised. “In jails, you really see how bad [it] is,” Homer Venters, a physician who was medical director at Rikers for several years, told me. “Clinicians can’t make decisions that security staff don’t like. If you’re a psychologist in jail, you have to walk in and out every day. You will not be able to continue to do that job if you continue to annoy the security staff.”

This dual loyalty—the tension between medical staff and the correctional work environment—affects all aspects of the job but is little discussed.²⁷ Venters compares the situation to infection control in hospitals. In that case, everybody knows the hospital is full of germs, acknowledges it’s full of germs, and spends time and resources to train every person who works in that hospital how to minimize their spread. By contrast, dual loyalty “is linked to massive loss of life. [But we] don’t ever talk about it. Of five thousand jails and prisons, you’d be hard-pressed to find five where anybody talks about it. We bury our heads in the sand, don’t give it a name, don’t call it anything. All of these bad outcomes, we chalk up to other things, we look to prosecute an individual, but we go through all these flips and twists so we don’t have to say we have this problem.”

There are many ways that this tension can manifest itself.²⁸ Health care workers may be asked to search patients for contraband; they may witness, or even participate in, force against prisoners. A doctor or therapist may be asked to decide whether somebody with symptoms of mental illness can “safely” be put into solitary confinement, making the clinician complicit in a practice that is especially damaging to people with mental illness. In that case the clinician not only decides who will get punished, but by saying that some people should not be put in segregation, the implicit message is that other people may be safely put there.²⁹

Situations in which a clinician is involved in a disciplinary action may also compromise the clinician-patient relationship—particularly necessary in psychiatry. For many mental disorders, effective treatment depends on the patient developing a strong rapport and high degree of trust with the care provider, and a patient is likely to be deeply reluctant to trust a care provider he believes has compromised him in some way.

A psychiatrist who spent four years working in the Michigan prison system—he was employed by a company that was contracted to provide mental health care—told me that by the end of his tenure there, the whole mission began to feel futile: “There’s the rehabilitation initiative that has been largely lost, or there’s still this unwillingness to see that what’s being provided is not rehabilitation. I think there’s still that old mentality that punishment is rehabilitation. That if you make someone feel pain, that’s enough to rehabilitate [him].”

Clinicians may also be asked, explicitly or implicitly, to restrict or otherwise change care as a way to control costs.³⁰ (Some argue that this is no different from what insurance companies do in the outside world, but ordinary patients usually have options, whether it’s negotiating with the insurance company or getting a second opinion from another doctor.) All of this is complicated by the fact that in many jails and prison facilities, the medical staff are employed—whether directly or indirectly—by the county or state corrections department. So refusing to do something the prison or the correctional workers ask may be difficult or impossible.

It’s easy to see how a system that allows the kind of “official” abuse such as solitary confinement or restraints could also end up leading to the kind of unofficial abuses that Echevarria, Mitchell, and others were subjected to. Problems like overcrowding and understaffing only make the conditions more ripe for such abuses, as angry and overworked corrections officials are made to deal with angry and frustrated prisoners. Add in the kind of “difficult” behavior that is often seen in people with mental illness, and the results can be disastrous. In Alabama the combination turned into something close to a complete collapse of the system.