:: Ethical issues
Medical officers are required to visit prisoners held in segregation units or in seclusion to ensure that their mental state does not deteriorate to unacceptable levels and to check for other health issues. The relevant Prison Service Orders, PSO 1700A and 1700B, deal respectively with the maintenance of humane conditions in segregation units and with the management of prisoners who are segregated for any reason - whether for reasons of good order or discipline, in their own interests or protection or because of dirty protests.
Effects of isolation on mental health
There is a high risk that isolation, seclusion and segregation may damage mental health. There is no direct evidence for the precise psychological mechanisms operating in detention in isolated conditions. However, sensory deprivation experiments provide a situation that is analogous in at least some aspects. These experiments have led to dramatic and bizarre effects including anxiety, visual hallucinations and psychotic-type symptoms. (ref 1) Prisoners held in solitary confinement may suffer similar symptoms, reporting loss of memory and impaired concentration. (ref 2) The English Special Units Study, which looked at the treatment of some disruptive and dangerous prisoners, found that a subgroup had spent long periods in segregation and that psychotic symptoms had emerged, unbeknown to the prison staff. (ref 3) Suicide and all types of psychiatric morbidity are common in prisoners held in isolation. Although the most extreme symptoms may often be associated with the most extreme environmental conditions, there is by no means a uniform effect across individuals. Some individuals can tolerate isolation better than others. Some people who have suffered severe and repeated traumas in childhood and their youth may be especially prone to stress-response syndromes.
Prisoners at increased risk of spending time in isolation
Some prisoners are more likely than others to spend extended periods in isolation or segregation. These include people who are mentally ill and/or have other disorders such as emotionally unstable (borderline) personality disorder, antisocial personality disorder and narcissistic personality disorder. They may be isolated because they present a risk to themselves or others, or because they engage in other difficult or dangerous behaviour. They may be isolated while awaiting assessment or transfer to hospital though, in current practice, individuals with personality disorder but lacking evidence of severe mental illness are unlikely to be transferred to an NHS hospital. Individuals who are seen as deliberately provocative or challenging of authority are also likely to spend long periods in isolation.
Until recently, prisoners considered at risk of suicide were sometimes managed in isolation in 'strip cells'. This is now against Prison Service instructions as it was found to be unacceptable and counter-productive (as it may increase suicidal thoughts). Use of crisis suites or shared cells is preferred. Prisoners assessed as being at a current risk of suicide or with a history of self-harm may receive some degree of protection by their placement in a dormitory. Where the risk of harm to (or from) other prisoners makes this impractical, their placement in a safer (ligature-free) cell is an alternative option (see Assessing and managing people at risk of suicide).
Management of prisoners in isolation
Prisoners who are mentally ill
Individuals who are mentally ill within the meaning of the Mental Health Act 1983 and who are held in segregation or seclusion, as that is the only way they can be safely contained, should be transferred immediately (within 24 hours) to a psychiatric hospital. Immediate transfer is often difficult, given variations in the availability of secure psychiatric beds. Nevertheless, it is an important standard (for NHS services to work towards) that such individuals should be accepted by them within 24 hours. A standard of assessment and, if necessary, admission within 24 hours for emergency cases is commonly set in the community and operates in most Scottish prisons. Where paranoid features of the illness mean that the individual refuses the limited access to exercise that is available, transfer is even more urgent (see Liaison and referral to the NHS and Emergency treatment under common law).
Where the prisoner has any history, or current indication, of mental illness, self-destructive behaviour or substance misuse, an opinion should be sought from a psychiatrist and the appropriateness of relocating the prisoner in the healthcare centre considered. Where any current mental disorder is identified, a treatment plan should be drawn up and implemented.
Prisoners who spend frequent or extended periods in isolation
Prisoners who are not transferred to an outside psychiatric hospital and who are at increased risk of spending frequent or extended periods in segregation or seclusion should be managed as described in Prisoners with complex presentations and very difficult behaviours. Frequent or extended use of segregation, especially but not exclusively transfer from the segregation unit in one prison to that in another in order to provide respite to staff, should trigger a multidisciplinary assessment and the development of appropriate multidisciplinary care plans.
Such prisoners may benefit from admission to specialist units providing humane specialist management approaches such as the 'exceptional risk units' for prisoners with severe personality disorder who are also dangerous (eg at HMP Belmarsh). In whatever environment they are managed in, it is important to bear in mind the factors that characterise a good environment for people with a history of violence and which reduce the chances of violence being repeated. These factors include the following.
- Access to open space.
- Fresh air.
- Privacy, eg, toilet, washing and shower facilities.
- Personal space, including avoidance of overcrowding.
- Control of noise.
- Natural lighting.
- Controls of ambient temperature and ventilation.
See the Royal College of Psychiatrists' Management of Imminent Violence. (ref 5)
Medical officers are required to assess the health of prisoners held in segregation.
There are conditions that are required for adequate health assessments. Examinations of a prisoner's health should be held in adequate conditions in circumstances that allow the prisoner to express him/herself freely and by a healthcare professional who is competent in assessing their mental state. An interview room is required. The prisoner's IMR should be to hand before the examination and the results of the examination entered into it.
The appropriate level and frequency of assessment will vary according to the time the prisoner is held in segregation upon the doctor's clinical judgement of the prisoner's state of health and the requirements of Prison Service standards.
- Prisoners held in segregation for a few hours only pending adjudication. In these circumstances, the assessment may only be about whether the prisoner is 'fit' for adjudication (eg they are capable of rational thought) and of their risk of suicide. It is also useful to look for signs of depression. Depression may sometimes lead to increased irritability and aggression, and have triggered the incident that led to the use of segregation.
- Prisoners held for longer periods in segregation. In these circumstances, a fuller Mental State Examination (MSE) should be conducted, looking in particular for signs of stress-induced psychosis or depression. The doctor's responsibility is to assess the health (including the mental health) of the prisoner and not simply to judge their 'fitness' (eg for punishment).
- Prisoners with long-term behavioural problems should be assessed particularly carefully. They are at increased risk of developing stress-induced psychosis and of self-harm.
- It is recommended that prisoners held in isolation are assessed on a daily basis. Should a mental disorder be identified, the prisoner should be managed as described in Prisoners who are mentally ill above.
Use of physical restraints
Doctors may sometimes be called upon to give advice about the appropriate use of mechanical restraints, which are more likely to be used in Segregation Units than in other parts of the prison. Currently, in prisons in England and Wales, where a patient has a medical condition leading to the violent behaviour, a doctor may order the use of 'medical restraint', ie the use of a 'special cell' or of a loose canvas restraint jacket. In addition, for all forms of violent behaviour, as a very last resort, a prison governor may order the use of 'mechanical restraint', ie the use of a body belt with metal cuffs or the use of special accommodation. Where a governor has ordered the use of either mechanical restraint or special accommodation, the role of the doctor is to assess whether there is any medical reason for not using these and if there is, to order their use to be ended immediately.
In the use of any form of physical restraint, the following are essential points of principle.
- It should be used as a last resort and for the shortest time possible.
- Steps should be taken to ensure the minimum possible invasion of the individual's dignity, eg audiences should be moved away.
- The individual should be treated in a way likely to calm rather than aggravate their aggression, eg speaking to them calmly and with respect.
- The individual's mental state should be assessed regularly and an urgent opinion sought from a psychiatrist if there is any history or current indication of mental illness, self-destructive behaviour or substance misuse.
- Where the patient has a mental disorder, care and treatment should be planned, if necessary and appropriate, under common law (see Emergency treatment under common law). Where indicated, steps should be taken to remove them urgently to a hospital where treatment can be given (see Interface with the NHS and other agencies).
- · Where the patient has a history of very difficult behaviour, a full, multidisciplinary assessment and care plan should be arranged (see Management of prisoners with complex presentations and very difficult behaviours).
The relevant Prison Service instructions contain more detail about the management of prisoners who are segregated or physically restrained. Currently, in England and Wales, they are Prison Service Orders 1600 (Use of Force), 1700A (Management of Segregation Units) and 1700B (The Removal from Association of Prisoners Under Rule 45).
Isolation and mental health: a summary
- There is a high risk that isolation, seclusion and segregation may damage mental health. The English Special Units Study, which looked at the treatment of some disruptive and dangerous prisoners, found that a subgroup had spent long periods in segregation and that psychotic symptoms had emerged, unbeknown to the prison staff.
- Some individuals can tolerate isolation better than others.
- People who are mentally ill and/or have other disorders such as emotionally unstable (borderline) personality disorder, antisocial personality disorder and narcissistic personality disorder are more likely than others to spend extended periods in isolation or segregation.
- Managing people at risk of suicide in 'strip cells' is against Prison Service instructions, as it is unacceptable and counter-productive.
- Prisoners who are mentally ill within the meaning of the Mental Health Act 1983 and who are held in segregation or seclusion because that is the only way they can be safely contained should be transferred immediately (within 24 hours) to a psychiatric hospital. It is an important standard for NHS services to work towards that such patients should be accepted by them within 24 hours.
- Where a prisoner held in segregation has any history or current indication of mental illness, self-destructive behaviour or substance misuse, an opinion should be sought from a psychiatrist and the appropriateness of relocating the prisoner in the healthcare centre considered. Where any current mental disorder is identified, a treatment plan should be drawn up and implemented.
- Frequent or extended use of segregation and, especially but not exclusively, transfer from the segregation unit in one prison to that in another to provide respite to staff, should trigger a multidisciplinary assessment and the development of appropriate multidisciplinary care plans. Such prisoners may benefit from admission to specialist units providing humane management approaches - such as those being developed for prisoners with 'dangerous severe personality disorder'.
- MSEs should be conducted on prisoners held in segregation, looking in particular for signs of stress-induced psychosis or depression. It is recommended that all prisoners held in isolation are assessed on a daily basis.
- Physical restraints should only be used as a last resort and for the shortest time possible. Steps should be taken to ensure the minimum possible invasion of the individual's dignity.
1 Brownfield C. Isolation: Clinical and Experimental Approaches. New York: Random House, 1965.
2 Crassian S, Friedman N. Effects of sensory deprivation in psychiatric seclusion and solitary confinement. International Journal of Law and Psychiatry 1986; 8: 49-65.
3 Coid J. The management of dangerous psychopaths in prison. In Millon T, Simonsen E, Mirket-Smith M, Davis RD (eds), Psychopathy, Antisocial, Criminal and Violent Behaviour. New York: Guilford, 1998.
4 Royal College of Psychiatrists' Research Unit. Management of Imminent Violence: Clinical Practice Guidelines to Support Mental Health Services. London: Royal College of Psychiatrists, 1998.
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