ISOLATED: ICE Confines Some Detainees with Mental Illness in Solitary for Months

As Immigration and Customs Enforcement (ICE) detains more immigrants than ever before, detention centers have filed more reports of detainees being held in solitary confinement, according to federal records obtained by the Project On Government Oversight (POGO). In solitary, detainees are locked in a cell and isolated from other people for up to 23 hours a day.

The records, obtained under the Freedom of Information Act, cover the last year of the Obama Administration and the Trump Administration through early May 2018. There are 6,559 records, each of which represents the confinement of a detainee in solitary (ICE has placed some detainees in solitary more than once). These records advance reporting on ICE’s use of solitary by the International Consortium of Investigative Journalists and partner news organizations published earlier this year. The records POGO obtained are the first to cover a significant portion of the current Administration.

About 40 percent of the records show detainees placed in solitary have mental illness. At some detention centers, the percentage is much higher.

Many experts view solitary confinement as tantamount to torture under certain conditions, especially if it is prolonged. Prolonged solitary confinement has been defined as longer than 15 days.

Slightly more than 4,000 of the 6,559 records show detainees in solitary for more than 15 days. One quarter of those roughly 4,000 records indicate the detainees in solitary had mental illness. The records show that some detainees were held in solitary for months, and in some cases, for more than a year. One detainee was held in solitary for more than two years.

Viewed alongside official watchdog reports and insider accounts, these records depict an immigration detention system in urgent need of more oversight. Indeed, an ICE policy instituted six years ago mandated the creation of these records so the agency could assess how its 200-plus detention centers use and misuse solitary, officially known as “segregation.” But the records themselves have gaps and inaccuracies, hindering their potential to help overseers.

The problem has garnered bipartisan Congressional scrutiny. “It is imperative that ICE swiftly resolve any lacking oversight or improper documentation pertaining to the use of segregation,” wrote Senators Chuck Grassley (R-IA) and Richard Blumenthal (D-CT) in a letterlast month to the acting head of ICE. This isn’t Grassley’s first time weighing in on ICE’s use of solitary. In 2015, he and then-Senator Al Franken (D-MN) wrote that information they obtained suggested “that ICE continues to place many detainees with mental health concerns in administrative or disciplinary segregation—also known as solitary confinement—contrary to agency directives.”

The release of this data on solitary comes as the current Administration has aggressively enforced immigration laws, including the mass prosecution of people for first-time illegal entry into the U.S., a misdemeanor, under a “zero tolerance” policy carried out along the entire U.S.-Mexico border beginning in April 2018 (the last full month covered by the data). The Administration has also ramped up so-called “interior enforcement” where immigrants, and some U.S. citizens, have been arrested away from the border and ports of entry. The aggressive enforcement has sent the number of people in ICE detention to record highs in recent months, including a growing number of detainees with mental illness. 

ICE detention centers across the country use solitary confinement to house detainees with mental illness and other vulnerabilities apart from the general population. Solitary is also used to punish detainees who assault employees or other detainees, and for violating other rules. Some detainees allege they have been placed in solitary as retaliation for speaking out against forced labor, sexual assault, or other alleged abuses.

ICE provided no comment in response to POGO's queries.

Even when it’s meant to protect rather than punish, placing individuals with preexisting mental illness in solitary confinement can make the psychological issues they are grappling with worse and can increase the risk they will die by suicide.

“There’s no debate that for people with a mental illness, it’s very clear that solitary exacerbates the mental illness,” psychiatrist Terry Kupers told POGO. Kupers has testified in lawsuits involving mental health care in prisons. Among those who were not previously experiencing mental illness, time in solitary can also lead to mental health problems and a rise in suicidal thoughts.

During the first two years of the Trump Administration, at least three ICE detainees who were documented as having schizophrenia and were placed in solitary took their own lives, according to two officialdetainee death reviewsby ICE and an inquiryby a state law enforcement agency in Georgia.

According to a 2015 study by experts at New York University’s medical school, suicide was one of the top causes of death in ICE detention between 2003 and 2015. The study cites criticism of ICE for putting “patients with mental illness into detention instead of allowing them to receive community-based treatment.”

Yet there is at least one less policy limit on detaining people with mental illness now than when that study came out. A month after President Trump’s inauguration, the Department of Homeland Security rescinded a 2014 memo that stated ICE should not detain people “suffering from serious physical or mental illness” unless there were “extraordinary circumstances or the requirement of mandatory detention.”

Opponents of solitary confinement have questioned whether its use for long periods of time violates the Constitution’s ban on cruel and unusual punishment. In one case, a federal judge wrote that placing those with mental illness in solitary confinement is akin to “putting an asthmatic in a place with little air to breathe.” The discussion of solitary has predominantly been in the context of prison—a punishment for those found guilty of a crime. Because immigrant detention, unlike prison, is not officially meant to be punitive, prolonged use of solitary may pose additional legal and constitutional concerns.

The ICE data obtained by POGO shows some detainees were kept in solitary for long periods, in nine cases exceeding a year, such as:

• A woman at the ICE detention center in Adelanto, California, who was “diagnosed with Other Specified Trauma and Stressor-related D/O [disorder],” was released from solitary in December 2017 after 454 days;
• Another woman at Adelanto, who was “diagnosed with PTSD/ Major Depressive D/O (Severe),” was released in August 2017 after 372 days;
• A man at Yuba County Jail in California, who was “diagnosed with psychotic disorder,” was released in April 2018 after 413 days; and
• A man detained at the ICE Service Processing Center in Buffalo, New York, was released from solitary in May 2018 after 790 days—more than two years. According to the ICE data, he did not have mental illness.

“Years on end of near-total isolation exact a terrible price,” wrote then-Supreme Court Justice Anthony Kennedy in a 2015 concurring opinion. He cited research showing that “common side-effects of solitary confinement include anxiety, panic, withdrawal, hallucinations, self-mutilation, and suicidal thoughts and behaviors.”

An independent expert on human rights appointed by the United Nations recommended all countries ban the use of “prolonged solitary confinement,” solitary beyond 15 days. “At that point … some of the harmful psychological effects of isolation can become irreversible,” U.N. special rapporteur Juan E. Méndez wrote in a 2011 report.

In recent years, some state prison systems have curbed their use of solitary: Texas has banned solitary as a punishment for breaking rules and Colorado has banned use of solitary exceeding 15 days.

In May, the International Consortium of Investigative Journalists quoted an ICE spokesperson who said solitary “protects detainees, staff, contractors, and volunteers from harm.” Yet state prisons that have reduced use of solitary say it can be done without increasing risk. Officials from five states told the Government Accountability Office in 2013 that moving inmates out of restrictive housing, such as solitary, led to “no increase in violence” and officials from two states said millions of dollars were saved by reducing the number of people held in solitary.

ICE also isn’t the only federal agency under scrutiny for its use of solitary for people with mental illness. In 2017, the Justice Department’s Inspector General wrote that the Bureau of Prisons had “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.” (The watchdog also wrote that the Bureau “states that it does not practice solitary confinement, or even recognize the term.”)

However, in contrast with ICE, as Senators Grassley and Blumenthal wrote in their recent letter, Bureau prisons are in some ways better equipped to deal with the challenges faced by detained populations “who require special attention,” such as those with mental illness. Many ICE detention facilities effectively have two options for holding detainees: keeping them in the general population or isolating them in segregation.

In 2009, an ICE official made a similar observation: “segregation cells are often used to detain special populations whose unique medical, mental health, and protective custody requirements cannot be accommodated in general population housing.” The official further wrote that segregation is “not conducive to recovery.”

Little seems to have changed in the ensuing decade. Andrew Lorenzen-Strait, a former senior ICE official who left the agency in May, told Politico that ICE studied how prisons cared for the mentally ill to devise a 30-bed pilot program at its Krome detention center in Florida. He estimated 3,000 to 6,000 ICE detainees have mental illness.

The reliance on solitary for holding detainees with special vulnerabilities like mental illness reflects a “basic structural challenge for ICE,” Senators Grassley and Blumenthal wrote to the acting head of the agency last month.

Some critics say the most fundamental problem is the detention of people with mental illness. “At the end of the day, the best way to get their treatment is not to be detained,” Hannah Cartwright, supervising attorney at the National Immigrant Justice Center, told Politico.

What is clear is use of solitary in ICE detention is on the rise and more needs to be done to oversee how it is used and to stop its misuse and overuse.

As some state prison systems have shifted away from using solitary, the ICE data shows an increase in the reporting of use of solitary in immigrant detention centers from January 1, 2016, through May 4, 2018. The number of reports indicating the detainees in solitary have mental illness also went up, though declined slightly as a proportion of the whole.

There are 2,565 reports of use of solitary confinement with a placement date during 2016, the last full year of the Obama Administration. Of those, 40 percent (1,030) indicate the detainees in solitary had mental illness.

There are 2,944 reports of use of solitary confinement with a placement date during 2017, most of which was during the Trump Administration. Of those, 39 percent (1,160) indicate the detainees in solitary had mental illness.

In the first third of 2018, out of a total 1,050 reports, 37 percent (389) indicate the detainees in solitary had mental illness. (If the rate of reporting held steady through the rest of 2018, total reports of use of solitary that year would top 3,100 and those involving mental illness would be about the same as in 2017.)

During the period covered by the data, ICE’s detention center in Adelanto, California, accounted for the most reports of placements in solitary, perhaps in part because the facility has one of the largest detainee populations. (Another large detention center, in Stewart County, Georgia, ranks second in reporting use of solitary.)

Adelanto also reported more detainees in solitary confinement lasting longer than 75 days—five times the maximum time the U.N. expert recommends governments use isolation—including some with severe mental illnesses, than any other ICE detention center. Adelanto filed 112 reports where a detainee was in solitary for at least 75 days. Across all detention centers, there are 485 reports of detainees in solitary for 75 days or more.

The GEO Group, the private prison corporation that holds close to one out of every three ICE detainees nationwide, wrote this year that about a third of the nearly 2,000 detainees at its immigration facility in Adelanto are “chronic medically ill, chronic mentally ill, or seriously mentally ill.” Yet it appears that at Adelanto a disproportionate number of detainees with mental illness are being kept in solitary versus in the general population: two-thirds of Adelanto’s reports indicate that the detainees being isolated have mental illness.

Over the last decade, ICE has strengthened its standards for detention centers, including standards dictating the minimum conditions for those being held in solitary, but some detention centers, such as Adelanto, haven’t always fully complied. For instance, last year, the Department of Homeland Security Inspector General found during an unannounced inspection of Adelanto that “some detainees were not offered any recreation or showers while in segregation.”

Adelanto detainee Osmar Epifanio Gonzalez-Gadba, a 32-year old Nicaraguan man, is one of the three detainees with mental illness who had been put in solitary and died by suicide during the current Administration. He used a bedsheet as a noose to hang himself in March 2017.

Last year, in 15 out of 20 Adelanto cells visited, an inspector general team “observed braided bedsheets, referred to as ‘nooses’ by center staff and detainees, hanging from vents,” according to a report by the watchdog. Given that more than a year had passed since Gonzalez-Gadba’s death, “ICE’s lack of response to address this matter at the Adelanto Center shows a disregard for detainee health and safety,” the inspector general wrote.

The inspector general team also found people wrongly placed in disciplinary solitary when they requested solitary for protective reasons (the conditions in disciplinary solitary are more harsh), the improper handcuffing and shackling of detainees in solitary, and “cursory” medical checks of some people in solitary, rather than the required once-daily “face-to-face” evaluations.

GEO Group did not respond to POGO’s request for comment.

In contrast to Adelanto, some large detention centers report substantially less use of solitary, and for shorter periods of time and involving a lower percentage of detainees with mental illness, suggesting that solitary can be and is used far less at other facilities (see the table, “Top 15 Immigrant Detention Centers Reporting Use of Solitary”). However, given questions about how complete and accurate the data is—as described in detail in the next section—this data alone cannot provide a full picture of the state of solitary in ICE’s detention complex.

The records also describe other ways ICE uses solitary. For instance, 1.8 percent state that detainees in solitary were LGBT individuals in protective custody, and 4 percent indicate that solitary was used to isolate individuals with medical problems (aside from mental illness).

ICE did not answer POGO’s multiple, detailed queries about the data or use of solitary in detention, including how many people are represented by the records POGO obtained—a question the agency has the data to answer.

A 2013 New York Timesinvestigation on ICE’s use of solitary reported that federal data covering a five-month period showed “about 35 detainees were kept for more than 75 days” in solitary at the 50 biggest detention centers. The data was “the first public snapshot of the number of immigrants held in solitary confinement, how long they were there and how many had mental health problems—about 10 percent.”

Within days, that article sparked reactions from lawmakers, and the then-Secretary of Homeland Security Janet Napolitano told reporters she would seek a review of the agency’s policies. ICE issued a policy later that year stating that for detainees with special vulnerabilities, including mental illness and pregnancy, solitary “should be used only as a last resort.” It mandated more oversight of the use of solitary in immigration detention and more reporting to ICE headquarters when detainees are placed in solitary.

That 2013 policy directed ICE headquarters to use these records to continually review how detention centers use solitary confinement and to curtail its overuse and abuse. (This is a different policy from the one rescinded in the first months of the Trump Administration.)

But the records on ICE’s use of solitary in recent years are not complete, according to both POGO’s analysis of them and a 2017 Department of Homeland Security inspector general report.

Incomplete and inaccurate data can skew and impede oversight of solitary.

“Missing instances of segregation and late reporting of segregation of detainees with mental health conditions are of particular concern, especially for detainees who have been segregated multiple times or for longer lengths of time,” wrote the inspector general. Gaps in the information mean it is harder for ICE to “mitigate the risk of deteriorating detainees’ mental health,” which can “put detainees and facility staff at risk of harm.”

Additionally, a detention facility that provides complete, accurate information about its use of solitary may look like it uses solitary more often than a detention center that underreports its use of solitary. Thus, the available data may not truly reflect reality and could misdirect where overseers direct their attention.

Scrutiny of data from afar isn’t the only way solitary confinement in immigration detention is officially overseen, but those other means of oversight, such as preannounced inspections, can fall short too, allowing problems to persist. (The inspector general began conducting surprise inspections in 2017, but preannounced inspections by ICE and one of its contractors are far more common.)

The 2013 ICE policy also gave the agency’s Health Service Corps (IHSC) a role in evaluating whether detainees with mental illness should be in solitary. “Such detainees shall be removed from segregation if the IHSC determines that the segregation placement has resulted in deterioration of the detainee’s medical or mental health, and an appropriate alternative is available,” the policy states. But at remotely located detention centers, the Health Service Corps has struggled to hire and retain mental health professionals.

The 2017 inspector general review examined a sample of data on the solitary confinement of 127 detainees with mental health conditions between October 2015 and June 2016 at seven detention centers, including the aforementioned facilities in Adelanto and Buffalo.

Of the 46 30-day reports that should have been in the system, six were missing. The inspector general also found nearly three-quarters of reports required within three days of placing individuals with mental illness in solitary were missing or “not properly documented.”

In January 2017, two weeks before President Trump was inaugurated, ICE headquarters sent a message to field offices “reiterating that segregation cases need to be reported within 3 days,” according to the inspector general.

Even after ICE’s message and the September 2017 inspector general report, the data is still incomplete. POGO found signs of missing and inaccurate data from the seven-month period following the release of the report.

For instance, in six of the 14-day reports filed after the September 2017 report, the placement and release dates are the same, suggesting at least one of the dates is incorrect.

There is also a reporting loophole in ICE’s 2013 policy. While detention centers have to report any use of solitary within three days if the detainee has a “special vulnerability,” detention centers do not have to report use of solitary for detainees deemed not to have such vulnerabilities until they have been in solitary for 14 days. (This may at least partially explain the lower percentage of reports of detainees with mental illness at the 15-day mark and beyond.)

“The data are very important to problem-solving, because one of the ways you figure out whether you have a problematic institution is by looking at its solitary confinement usage rate,” Margo Schlanger, a former head of the Department of Homeland Security’s Office for Civil Rights and Civil Liberties, told The Intercept.

“If the data are crappy, you can’t evaluate usage. You need the data to be correct in order to use it in a diagnostic way,” Schlanger said.

Under the 2013 ICE policy, Schlanger’s former office, sometimes known by its acronym, CRCL, is the only federal office outside of ICE that has regular access to the data on use of solitary. The policy carved out a role for the Office for Civil Rights and Civil Liberties in overseeing solitary confinement as part of ICE’s Detention Monitoring Council, which is mostly made up of senior ICE officials and was created to review detention centers’ compliance with policies and standards.

The office strives to ensure detainees, “particularly those with special vulnerabilities,” are “appropriately cared for and monitored while placed in segregation to prevent mental decompensation and long-lasting harm,” according to its latest annual report, covering fiscal year 2017. The office cited its regular examination of reports that ICE shares with it.

But the 2013 policy also limited how the office could use information that ICE provided, stating the office “shall not use information ICE shares” with it as part of its involvement in the Detention Monitoring Council “in any CRCL investigation or inquiry.”

Ellen Gallagher, a whistleblower who previously worked in the Office for Civil Rights and Civil Liberties and is now at the inspector general’s office, has said her former office was mostly focused on getting complete data and wasn’t doing enough to keep detention facilities from routinely violating the rights of detainees or ICE’s 2013 policy on solitary confinement. She pressed for her office to get more information from ICE on why detainees were put in solitary, and to intervene in individual cases when warranted.

“To place detainees with severe mental disabilities (e.g., schizophrenia or bipolar disorder) in segregation for the length of time indicated in ICE reports seems extremely concerning, to me at least,” she wrote in an internal government email in 2014, published by the International Consortium of Investigative Journalists.

Others involved in examining conditions in detention facilities share similar concerns about how ICE is using solitary, and cite missing information as an ongoing oversight issue.

“It’s a black hole. We don’t have good statistics about the health status of people in ICE detention and that’s a serious problem,” said Marc Stern, a professor at the University of Washington’s School of Public Health, in an interview with POGO.

Stern studies health care in prison settings and has conducted reviews of health care in ICE detention facilities on behalf of the Office for Civil Rights and Civil Liberties. He could not speak to the specifics of what he has found in those reviews because of nondisclosure agreements he signed with the Department of Homeland Security. (POGO has sued the Department under the Freedom of Information Act to gain access to these reviews.)

Stern said he doesn’t have “a quantitative answer about how many people with schizophrenia get appropriate mental healthcare.”

“We just don’t have the data,” he said.

Some suicides in detention show that ICE and its contractors are not sufficiently curbing the use of solitary when detainees have mental illness, and that ICE is not always providing adequate care even when there are numerous warning signs.

A December 2017 Department of Homeland Security inspector general report raised concerns that ICE detention centers may have “misused” their solitary confinement units by isolating detainees without proper documentation and failing to provide assurance to the inspector general that the detainees in solitary had received daily meals and medical care.

The Stewart Detention Center, an all-male facility in Georgia, was among those the inspector general report cited. Its solitary confinement cells have also been the site of two suicides by detainees with mental illnesses in the past two years.

Jean Jimenez-Joseph was taken into ICE custody around the beginning of March 2017. In the months before, he had been involuntarily hospitalized multiple times for schizophrenia and psychosis, and made repeated threats of and attempts at suicide. Jimenez-Joseph’s family has alleged in a lawsuit that contrary to agency policies, when ICE officers took custody of him, initially at a county jail, they did not transfer over his “prior detention records, medical records, and his vitally necessary prescription medication for schizophrenia and psychosis.”

He was transported to ICE’s Stewart Detention Center. There, according to the lawsuit, Jimenez-Joseph eventually did receive an antipsychotic medication but he repeatedly requested that the dosage be increased because “the voices in his head were getting worse.”

But due to “systemic, chronic understaffing” at Stewart, the lawsuit states, particularly for medical and mental health positions, this never occurred. Instead, he was placed in solitary confinement multiple times as his psychiatric symptoms worsened, including for the 20 days before he died. Jimenez-Joseph hanged himself shortly after midnight on May 15, 2017. According to the lawsuit, on the eve of his death, there were ample warnings that his psychological state was dire. The lawsuit states, “Jean had written ‘Hallelujah The Grave Cometh’ in large, dark letters on the wall” of his solitary confinement cell.

Efraín De La Rosa, another detainee with a history of severe schizophrenia and psychosis, hanged himself in solitary confinement at Stewart in July 2018. An employee of ICE’s Health Service Corps wrote in an email to agency leadership later that year that De La Rosa “could have been saved” if ICE had responded adequately to “a total of 12 SEN [Significant Event Notifications] reports prior to his death, depicting suicidal ideation and psychosis.”

According to the email, which was recently obtained by The Young Turks, “Mr. De La Rosa was not being treated with psychotropic medication; instead, he was remanded to segregation.”

Private prison company CoreCivic, which runs Stewart, declined to answer questions regarding De La Rosa and Jimenez-Joseph, citing pending legal claims. “What we can tell you is the safety and well-being of the individuals entrusted to our care is our top priority, and we take seriously our obligation to adhere to federal Performance Based National Detention Standards (PBNDS) in our ICE-contracted facilities,” emailed a company spokesperson. She wrote that issues found in the December 2017 inspector general report “were quickly and effectively remedied.”

“Prior to November 2018, CoreCivic did not provide medical or mental healthcare services or staffing at Stewart Detention Center,” the spokesperson wrote, referring POGO to ICE for comment on care provided by ICE’s Health Service Corps.

ICE did not respond to POGO’s request for comment.

Azadeh Shahshahani, an attorney at Project South, a civil rights organization that has represented Stewart detainees, told POGO, “We’re seeing a pattern emerging of solitary confinement leading to people’s deaths, especially people in a fragile, emotional mental health situation.”

“Solitary is the modus operandi when someone is experiencing mental health care problems rather than giving them the help they need,” she said.

Congress should codify the policy in the Department of Homeland Security’s now-rescinded 2014 memo which mandated that ICE not detain people “suffering from serious physical or mental illness” unless there were “extraordinary circumstances or the requirement of mandatory detention.” Further, the Department should formally reinstate that policy in the interim.

The Department of Homeland Security should revise the 2013 ICE policy on oversight of solitary confinement to eliminate the restriction on what the Office of Civil Rights and Civil Liberties does with information it receives in the course of its participation on the Detention Monitoring Council.

ICE, after consulting with independent subject matter experts, should collect adequate and appropriate data on the provision of mental health care to detainees with psychological issues and on the impact of detention on their mental illness. An independent entity should evaluate the data, and the data and independent evaluation should be made public.

ICE should revise its 2013 policy to require detention centers to report, within 72 hours, every time solitary is used, even when the detainee is not deemed to have a special vulnerability.

Congress should review and restructure the Department of Homeland Security’s Office for Civil Rights and Civil Liberties to maximize its effectiveness and transparency. 

Congress should mandate that ICE’s Detention Monitoring Council function more transparently; for example, the findings from its “heightened reviews” of ICE facilities should be posted publicly on the agency’s website.

The Department of Homeland Security Office of Inspector General should conduct an audit of a much larger and statistically significant sample of the segregation data from 2018 and 2019 to ensure ICE is completely and accurately reporting its use of solitary confinement. This audit would go well beyond the limited sample size used in the 2017 inspection report. The Office of Inspector General should also evaluate what ICE has done with the segregation data (for example, whether it has ever curtailed the use of segregation in favor of less restrictive alternatives and how often).

ICE should mandate that more detention centers follow its higher detention standards, contained in its Performance-Based National Detention Standards 2011 (as amended). Any detention center holding substantial numbers of immigrant detainees should be held to the higher standards. For instance, the York County Prison in Pennsylvania held 690 ICE detainees on an average day in fiscal year 2017 and is one of the top detention centers reporting using solitary. Yet ICE holds the York County Prison to its lower 2008 standards.

Caterina Hyneman, Vanessa Perry, and Nicholas Trevino contributed research.

About the Data

Top 15 Immigrant Detention Centers Reporting Use of Solitary

From January 1, 2016, through May 4, 2018. Each record represents one detainee’s placement in solitary. Some detainees have been placed in solitary more than once.

^{Data sources: ICE solitary records obtained by POGO under the Freedom of Information Act (See “Methodology” for more details); population records from the ICE “Facility List” Report dated November 6, 2017, obtained by the Immigrant Legal Resource Center using FOIA.}