The Implications of Atul Gawande’s article “Hellhole”: Solitary confinement, isolation, and schizophrenia

“For unpredictable stretches of time, he was granted the salvation of a companion… and he noticed that his thinking recovered rapidly when this occurred. He could read and concentrate longer, avoid hallucinations, and better control his emotions..." Click to read more

Upon reading Gawande’s article “Hellhole”, published in the Mar. 30, 2009 issue of the New Yorker, it was as if a light bulb went off. The symptoms observed in prisoners of solitary confinement were my symptoms, of schizophrenia, my worst symptoms during my illness corresponding almost exactly to the worst symptoms seen in the worst cases of solitary confinement. In fact, a doctor studying just such prisoners observed that a third of them “developed acute psychosis with hallucinations” (43). I have heard constant auditory hallucinations, or voices, for over six years now. The worst hallucinations I have suffered were at the onset of my psychosis, when the voices spoke to me from TV’s, spirits of the underworld played human ballcourt and other evil games with me, and the grim reaper chased me from my dorm room onto the streets of Boston. One prisoner’s experience described in the article sounds almost exactly like my own that final month of school, after enduring nearly a month of self-imposed isolation, and a semester of extreme social withdrawal:

After a few months without regular social contact, however, his experience proved no different from that of the P.O.W.s or hostages, or the majority of isolated prisoners whom researchers have studied: he started to lose his mind. He talked to himself. He paced back and forth compulsively, shuffling along the same six-foot path for hours on end. Soon, he was having panic attacks, screaming for help. He hallucinated that the colors on the walls were changing. He became enraged by routine noises – the sound of doors opening as the guards made their hourly checks, the sounds of inmates in nearby cells. After a year or so, he was hearing voices on the television talking directly to him. He put the television under his bed, and rarely took it out again (40).

Gawande describes the effects of social isolation on baby monkeys: “Twelve months of isolation almost obliterated the animals socially… They became permanently withdrawn, and they lived as outcasts – regularly set upon, as if inviting abuse” (36). Similarly, a companion of Terry Anderson in solitary “could not follow the guards’ simplest instructions. This invited abuse from them, in much the same way that once isolated rhesus monkeys seemed to invite abuse from the colony” (38). This was also my experience with the experience of schizophrenia. Once, I was at a party in the woods of Upstate New York for the weekend. I stood gazing out on the lake there from the dock, oblivious to all around me. A hyped-up party goer bounded up to me, said some words, and then, plussed at my nonresponsiveness, asked, “Do you even move?” I was admittedly zoned-out, in my own world, and possibly even slightly catatonic, as I was rather stuck in place there. The kids standing around us within earshot broke into laughter – I suppose I looked rather strange, in my 18th century peasant garb costume-dress. (And then, as if to prove his point that I was immobile, he spotted a caterpillar that was inching along my shoulder).

Too, my “voices” are best at taunting and ridiculing me, and take every occasion to do so. Even when people are not actually making fun of me, the voices will, just to fill the void. These repeated experiences and feelings of persecution are a hallmark of schizophrenics – something of a natural social law, which Gawande seems to have revealed in his article, in print, for my eyes for the first time, the principle that being down and out will elicit, invariably, viscerally expressed responses of abuse from some members of the human community. It’s similar but even darker than the mood expressed by Eric Clapton when he sings, “Nobody loves you when you’re down and out”.

It follows that perhaps schizophrenics are not merely paranoid about being made fun of by others: it’s quite possible that having the disease indicates a severe illness or operational defect, and as such, they become targets for natural and social chastisement, whether actually verbalized or merely intuited from nonverbal cues of those around them.

It’s rather unsettling to think that I could have -- in the midst of my time at Harvard college, just before graduation, and nestled in the center of the vibrant, lovely town of Cambridge, Massachusetts -- sequestered myself so thoroughly from any beneficial human contact, as to precipitate a mental illness of the magnitude of schizophrenia, and of the duration of many years (even persisting after rehabilitating and reintegrating myself into “normal” society). Clearly, I was not a P.O.W or any resemblance to a prisoner in this environment. Or was I, of a sort? There were no external impositions or limits on my freedom, a fact I fully grasped as I contemplated dropping out during my final few months. It was an option I seriously entertained, although ultimately I would not decide to do so. But not because I felt compelled by any external forces – no parents or deans were pushing me to finish; in fact, they only expressed concern at my well-being, and a willingness to negotiate the terms (I couldn’t see their concern as benign at the time, as I was displaying signs of acute psychotic thinking). In the end, it was simply my own internal governing system that imposed conditions that were so extreme as to precipitate a complete psychotic break with reality.

Gawande’s article describes the work of psychology professor Craig Haney, who found that “after months or years of complete isolation, many prisoners ‘begin to lose the ability to initiate behavior of any kind – to organize their own lives around activity and purpose… Chronic apathy, lethargy, depression, and despair often result… In extreme cases, prisoners may literally stop behaving,’ becoming essentially catatonic” (40). This is the condition of many of the world’s “back ward” patients in mental hospitals, suggesting that, although not an environment of total isolation, the hospital environment can function almost identically to the world’s few supermax facilities.

Gawande writes that “perversely, then, the prisoners who can’t handle profound isolation [i.e. those who continue to resist it] are the ones who are forced to remain in it. ‘And those who have adapted,’ Haney writes, ‘are prime candidates for release to a social world to which they may be incapable of ever fully readjusting’” (41). The economy of the mental institution functions in the same way: those patients who cannot follow the code of behavior, or who do not acquiesce to the institution’s rules, are those who are forced into the quiet room, whose privileges are revoked, and who may also return or even stay in the institution indefinitely, sometimes years and decades. Like the solitary confinement prisoners who lose the ability to function in the real world, because their self-organizing abilities are obliterated, the mental institution doesn’t serve the patients interest in recovery – they function as convenient, hidden-away holding tanks for society’s unwanted – the misbehaved, the non-behaving. Worse, while in the mental institution, real world skills are not practiced, and sometimes, are destroyed from lack of use and continued days spent in an environment where almost no self-organizing tasks are required of a patient, not even really personal care.

Perhaps solitary confinement holds the missing clues to why some people develop schizophrenia. Perhaps it is a primarily socially-instigated disease, namely one precipitated by a lack of meaningful relationships and human contact. This can be seen in the similarities between the symptoms of those placed in solitary confinement, and those suffering from mental illness. Perhaps also, Gawande’s article points to a need to change the model of ultimate care from the traditional mental hospital, to institutions that are interactive, open, responsibility-generating, and relationship-oriented, rather than the current practice of simply locking the mentally ill away.

Indeed, it makes intuitive sense that to rehabilitate and recover from a debilitating mental illness requires substantive social contact, relationships, and taking an active role in the details of life-management. What is needed is a model that will engage patients in their own recovery, and give them the tools – interaction and decision-making opportunities -- to make that recovery become a reality.