A woman with severe mental illness who cycles in and out of Delta County Jail is often placed in solitary confinement by mental health workers after she’s seen eating feces or attacking other people at the facility.
But when she’s isolated, her mental health worsens and she usually begins to harm herself, said Joel Watts, a therapist at the jail who sometimes decides if people with mental illness should be placed in isolation, for how long and when they should be released.
“We have limited resources. If we don’t put them in isolation, they become a danger to themselves, to others and to staff,” he said. “But it’s a Catch-22. In putting them in isolation, we know they’re going to get worse.”
These are difficult decisions, Watts said, because “the way to protect them is the way that harms them the most.”
Watts and his colleagues at the jail face these kinds of ethical dilemmas often — sometimes daily. And the “moral injuries” that result from violating their own personal principles or professional standards are often profound for clinicians trying to treat and assess people in a unique and dangerous setting like solitary confinement, especially if the incarcerated person has a mental illness, they said.
Many states, including Colorado, New Jersey, Maine and New York, have passed laws or written policies prohibiting the use of solitary confinement for people with serious mental illness. But even so, there are still many people with serious mental health conditions who are confined to their cells for at least 22 to 24 hours per day. A 2021 Yale study estimated 41,000 to 48,000 people at prisons across the U.S. were held in isolation, for an average of 22 hours a day for 15 days or more.
The Colorado Department of Corrections rewrote its solitary confinement policy in 2017 to follow the United Nations' Nelson Mandela Rules that limit a person's stay in isolation to no more than 15 days. The 15-day limit can be waived and extended with approval from the director of prisons.
Since the rule was changed, the department has said the use of long-term solitary has declined, but it has never released data to back up the claim.
In a response to an open records request, the state corrections department said on April 11, 1.7% of the prison population — or 279 out of 15,806 incarcerated people — were in restrictive housing, confined to cells for 22 hours per day or more.
Reducing isolation
Rewriting the rules has allowed Colorado to be held up as a leader in prison reform. However, there’s little state oversight on how local jails use solitary confinement.
“There hasn’t been as much of a reduction in solitary confinement in jails,” said Rick Raemisch, Colorado’s top prison official from 2013 to 2019.
“It can be done,” he said. “But the difficulty is, in the older county jails, they have very little or no programming space. So people with mental illness end up in segregation cells because they’re disruptive in other units.”
A few laws in Colorado are helping to reduce the use of solitary, but there’s often a caveat that keeps it in use, Watts said.
For example, a law passed in 2021 will prohibit jails with a capacity of more than 400 people from placing people in restrictive housing or solitary confinement if they are diagnosed with or showing signs of serious mental illness, are pregnant or have just given birth, have dementia or a traumatic brain injury, are younger than 18 or if they have an intellectual or developmental disability.
But the prohibitions described in House Bill 1211 do not apply if a person poses an imminent danger to themselves or others, a loophole that keeps many people with mental illness in solitary confinement.
“People with mental illness are almost exclusively put in solitary. It’s what I’ve seen and observed,” said Meghan Baker, chair of the Colorado Jail Standards Commission.
“I think it’s the only way that they feel that they can manage behaviors, because it’s easier to put somebody in a room by themselves than to actually give them help,” she said. “It’s the way (jails and prisons) have historically managed people and I think they don’t have the tools and resources and funding to provide the mental health care that’s needed.”
The law was supposed to take effect last July, but sheriffs running local jails asked to delay until July 2024.
Raemisch helped rewrite the Department of Corrections' solitary policy in 2017. He said it was a continuation of work started by his predecessor Tom Clements, who began reforming how the state’s prisons were using long-term isolation.
Raemisch was hired to continue those reforms after Clements was assassinated at his front door in 2013 by Evan Ebel, a man who had spent seven years in solitary confinement and had been released early from a Colorado prison because of a clerical error.
“I am passionately against the use of restrictive housing,” said Raemisch, now a consultant working with prisons to reduce the use of solitary. “Restrictive housing manufactures or multiplies mental illness. The data shows that now.”
A moral injury
Addressing the moral injuries that come with a health care provider or counselor’s job is complicated because there are few resources to help them navigate the circumstance when they face it, and because there’s little education about the concept while they are still in school, clinicians interviewed for this story said.
A moral injury occurs after a person witnesses or engages in behaviors that go against their core values and moral beliefs. A moral injury can hinder a clinician’s ability to adequately provide care and drive them out of the profession at a time when many jails and prisons are already struggling to attract and retain their therapeutic staff.
Social workers, human service employees, psychologists, and counselors have an obligation to provide services with integrity, based on solid ethical standards. But abiding by those standards can become nearly impossible while working in a jail or prison, according to a report in the International Journal of Social Work Values and Ethics.
Clinical staff working in jails and prisons often feel a moral injury when their ethical obligation to a client comes into conflict with the jail or prison policy. Some, such as the use of solitary confinement, can help keep people who work or live in jails and prisons safe and secure, however, the practice creates or contributes to dangerous conditions for people held in restrictive housing, a setting increasingly considered cruel, say therapeutic staff and others in government and advocacy roles.
Correctional institutions and prison workers are not bound by the same ethical or professional standards as clinicians. The “fundamentally incompatible ideologies” that correctional staff and clinical staff must navigate while working together, as one former jail mental health worker described it, creates a work environment difficult for many therapeutic providers.
“Health care professionals behind bars are like a quiet but critical presence, and they easily become complicit, and the reason is because it’s very difficult to maintain your ethical standards in there,” said Mary Buser, who was a mental health worker at Rikers Island Jail in New York, and is now a co-founder and director at Social Workers & Allies Against Solitary Confinement, which works to abolish the use of solitary with support from social workers.
Many clinicians, particularly those who work in county jails, are expected to decide when a person, especially those with mental illness, should be placed in solitary confinement.
When a clinician’s evaluation documents that a person is not able to handle solitary, they may be placed in a holding cell to prevent suicide or self-harm and stripped of their clothing and other personal items, according to the report.
These kinds of evaluations create a no-win ethical dilemma for the clinician. The only ethical choice left is to refuse to complete this kind of evaluation at all. However, many clinicians who refuse to conduct such an evaluation can face retaliation or repercussions, Buser said.
“They go into the profession hoping to help people, but then they’re asked to do things that go against human dignity and human rights,” said Mariposa McCall, a psychiatrist who worked at California's San Quentin and Pelican Bay state prisons, who has worked in the community with people previously held in solitary confinement.
“Clinical staff are asked to clear people to go into a damaging setting,” she said. “We’re almost legitimizing the practice, going to see them (in solitary) and knowing we can’t help them. The impact this has on another human being to place someone and keep someone in conditions like solitary is a problem that needs to be magnified.”
A dangerous setting
Solitary confinement is the practice of isolating people in closed cells for 22 to 24 hours per day, with little or no human contact, for periods of time ranging from days to decades, according to Solitary Watch, a news organization that investigates solitary confinement and other harsh conditions in U.S. prisons.
Many studies have demonstrated the harm caused by the practice. Even though people in solitary confinement comprise 6% to 8% of the total U.S. prison population, they account for about half of those who die by suicide, according to the National Religious Campaign Against Torture, an interfaith organization working to end all forms of torture in America.
If a person enters solitary without a mental health condition, it’s possible for them to develop one from the effects of isolation, that in the most severe cases includes agitation, self-destructive behavior and psychosis, according to Dr. Stuart Grassian, who has studied the psychiatric effects of isolation.
There are three main reasons why solitary is used: institutional security, protection and punishment.
However, many prison systems in the U.S. are concluding that prolonged solitary confinement is inconsistent with their mission, is often applied disproportionately on people of color and people with mental illness, does not reduce severe misconduct, and ultimately, does not make correctional systems or communities safer, according to the International Journal of Social Work Values and Ethics.
Those who spend time in solitary confinement while incarcerated are more likely to commit additional crimes, which clashes with two of the primary purported correctional goals: rehabilitation and community safety, according to the report.
“I am perplexed, and it does grieve me in some serious ways,” Watts said. “We have to make a decision on what hurts them less and what is best for everyone, and that is tough, because you just don’t know how it’s going to wind up.”
When therapist Andrew Henderson visits the Delta County Jail in Delta to provide individual counseling to people held in solitary confinement, he struggles to conduct the sessions confidentially. The cells are close enough together that a person one door over can hear the entire counseling session, even if Henderson and his client speak quietly. A correctional officer usually stands outside for safety, often with the door slightly ajar.
There is tremendous stigma attached to mental illness, particularly in prison. An incarcerated person may not feel comfortable speaking openly with a therapist, which makes it hard to provide adequate care.
Some therapists ask to see their patients in an office with more privacy, but often, correctional leaders say there’s not enough staff to make that happen.
This is in violation of Senate Bill 176, legislation passed in 2011 that requires Colorado mental health workers to provide treatment in a private setting rather than at someone's cell.
8-by-9 cells
The moral injuries that came with treating people in solitary confinement at Rikers Island in the late 1990s is what pushed Buser to leave her job as an assistant mental health chief.
On her first day working with people in solitary confinement, the then-mental health chief told Buser, if people in isolation had no mental health issues before they entered solitary, they usually developed them soon after.
People were confined in 8-by-9 cells with a daily shackled walk to an hour of recreation in an outdoor cage, Buser has said.
Mental health workers were a constant presence in the solitary confinement unit there because self-harm was rampant and suicide threats were made constantly. Clinicians either left the jail from a moral injury or stayed and hardened, she said.
“When I got there, and started working there, and seeing up close what this was, I was appalled at the level of suffering that solitary confinement induces,” she said. “I was furthermore appalled that I was a part of this.”
Now, Buser educates the public about the use and harms of solitary because many people don’t know it exists or what it entails. When she conducts training about ethical dilemmas, Buser uses solitary confinement as a vehicle to discuss the issue. “You lay out what you’re faced with and how you might reconcile with or resolve ethical dilemmas.”
At Watts’ office in Delta, he and his colleagues sit privately and process their feelings about the decisions they must make, and what is in the best interest of their clients. It encourages a healthy workplace and accountability among staff, he said.
Moral injuries will likely always be a part of a clinician’s career, especially if they’re working with people in solitary confinement or with people mandated by the court to undergo treatment or other requirements as a condition of parole, in lieu of jail time, as a condition of early release from prison or to receive custody or visitation of their children.
“If I no longer feel like my decision could be wrong, then I am going to mess up. The decision we make to put someone in isolation can never be final,” he said. “We have to always question it.”
Helping therapists and other clinicians resolve the conflicts is crucial, he said.
“The better way is to ask, ‘What can we do to offer help to therapists going through some of those things, especially those working with underserved populations or mandated clients? How do we help navigate that and bring to light, among my profession, that this is a harder level of work than others? You need to have help, outlets and the ability to talk to somebody,” he said.
Alternatives to solitary confinement could help reduce the moral injuries clinicians face, he said.
When a person is arrested, there should be two tracks, Watts said: One, where the person faces charges for their actions, and another, more restorative approach for people with mental illness who are in psychosis when they break the law.
“There are people who are a public safety risk, absolutely, and that’s where I think that our jails and prisons should focus,” he said.
Many others are in jail because of substance abuse, or mental health issues, he said. In some cases, people with mental health issues have been isolated in their jail cells for months, he added.
“If we start them now, that first time they’re arrested, and we look at rehab, inpatient and residential services, then the charges should be dismissed,” he said. “And I’m not talking about diversion. I’m talking about a true, honest way of looking at it from a scientific, evidence-backed way of dealing with people who are arrested because their mental health has allowed them to break a law.”
He’s hopeful the model is possible, especially at the community level. Watts’ community mental health clinic, Integrated Insight Therapy in Delta, offers services to people in six counties who are on Medicaid, on probation, involved in child welfare cases or in need of mental health treatment. Providing those low-cost services, he said, helps to reduce the impact of his own moral injuries.
Breaking the cycle
Scott Fritzche, who works with Watts, spent several stints in solitary confinement in jails in Ohio in the 1990s. His longest stay in solitary was 120 days, correctional officers told him.
He spent a week in solitary the first time he was ever placed there, after corrections officers said he had filled out too many “kites,” or requests for help from a social worker or counselor for his deteriorating mental health. “I was asking for help and my asking for help got me punished,” he said.
When he was released from solitary, Fritzche said he became more combative. Soon after he was released from his first stay in solitary, he assaulted the corrections officer who placed him there for filling out too many kites, which landed him back in solitary a second time, he said.
“I got my shot and I took it. This isn’t good behavior. This isn’t a bragging thing. But that’s the reality of what it was,” he said. “If you treat someone like a dog for long enough, they’re going to act like a dog and if you treat that dog poorly, it will bite. That doesn’t make it right. I’m not trying to justify the behavior. It’s just the reality of the circumstance.”
In jails and prisons, clinicians are not the only people who experience a moral injury, he said. So do incarcerated people. People in jail or prison are often forced to do things they don’t think are moral, just to survive and function, he said.
“You don’t want to be the one guy who is not giving the corrections officer grief, because if you do, then you instantly isolate yourself and you’re already isolated there,” he said. “If you’re a kiss up, you’re not going to get along in that pod very well. Whether the repercussions are physical or whether they’re verbal is irrelevant because it feels exactly the same.”
Now Fritzche said it feels cathartic to relate to the clients he works with at Integrated Insight Therapy in Delta, where he teaches life skills to people after they are released from jail or prison. His experience in jail gives him credibility as he works to help his clients break the cycle of recidivism, he said.
Industry leaders from groups such as the American Psychological Association and the National Association of Social Workers should be supporting clinicians by highlighting the damaging effects of moral injuries on helping professionals and the patients they’re caring and advocating for, McCall said.
But finding that kind of help may be difficult in Colorado. Representatives from the Colorado Counseling Association and the Colorado Medical Society said their organizations don’t offer resources for clinicians facing a moral injury.
Representatives from the Colorado Society for Clinical Social Work and the Colorado Psychological Association said they would ask organization leaders to comment but did not return with any information.
The National Association of Social Workers, the American Counseling Association and the Association of Clinicians for the Underserved did not respond to requests for comment.
This story was produced with support from the Center on Media, Crime and Justice, at New York’s John Jay College of Criminal Justice, which hosts an annual fellowship to help journalists report in-depth stories about solitary confinement.
