Losing direction: The abysmal history of mental health care at Pelican Bay State Prison

by Mariposa McCall

From 2010-2011, while working as a contract psychiatrist for the California Department of Corrections and rehabilitation (CDCr) providing supportive therapy and medication management for San Quentin State Prison (SQSP) inmates, I was inspired by the resilience of the human spirit and reminded of our shared humanity. When I returned to CDCr in 2014, I provided the same services via video-conferencing from my San Quentin State Prison (SQSP) office to Pelican Bay State Prison (PBSP) and became more socially conscious.

While my assignment was with a specific PBSP mental health program, I helped out with most programs. I resigned from CDCr PBSP in July 2016 due to a culture of retaliation, a pervasive divide and conquer mentality, and a deliberate indifference that corrupted moral integrity, compromised patient care, violated civil liberties and increased professional liability.

Justice, fairness and ethics seemed to be at times inconveniences for CDCr. Supervisors evoked policies and guidelines when convenient and to insist on their authority. As I voiced legitimate concerns, colleagues whispered stories of the negative outcomes for numerous providers who previously criticized CDCr policies or objected to some supervisor’s misguided “good intentions.” Even the physician union representative warned, “You don’t want to start a war with CDCr.” The unfortunate reality was as James Baldwin wrote, “To act is to be committed, and to be committed is to be in danger.”[i]

I left CDCr wondering how PBSP could remain in shambles after 22 years of court oversight. As I started educating myself about prison reform, I stumbled upon Keramet Reiter’s 2016 book, “23/7: Pelican Bay Prison and the Rise of Long-Term Solitary Confinement.”[ii] Within those pages, I found validation and some disturbing answers. I wish this book had been available to me before I started working in CDCr.

Reiter, an assistant professor at the University of California at Irvine’s Department of Criminology, Law & Society and School of Law, ambitiously attempts to provide a cohesive picture of the historical context that birthed California’s first supermax, PBSP, in December 1989. She cautions that the story she shares remains fragmented due to CDCr’s veiled transparency.

Reiter wanted to understand how the decision to build a supermax was reached, especially considering that courts at the time were condemning lockdown facility conditions and experts were recommending more humane treatment and programming and questioning the existing classification system that was leading to an increase in lockdown units. Shockingly, in researching California legislation, she found no records on the supermax other than a 1988 legislative debate about the naming of it.

She interviewed prison officials, judges, lawyers and some inmates and concluded: “Three factors forged the supermax: fear of uncontrollably violent prisoners, lack of transparency and bureaucratic discretion” (page 203). Furthermore, she argues that prison officials’ “compliant resistance” to court orders has sabotaged prison reform, contributing to more hidden and harsher practices and an overreliance on solitary confinement as a standard management tool (page 72). She urges, as others did in the 1970s, better transparency to improve oversight and provide checks and balances on administrative discretion.

However, I believe we have relied too much on laws and court orders to direct action. The Emancipation Proclamation abolished slavery but did little to change the attitudes or behaviors that continue to divide and oppress. Likewise, the culture of PBSP and CDCr impedes Reiter’s recommendations.

In a culture with a broken moral compass to guide ethical behavior, transparency will be questioned, accountability will be misplaced, oversight will remain minimally effective and mere rhetoric, administrative discretion will be selectively enforced, and real meaningful change will have to wait. Reiter provides multiple examples exposing the politics of transparency is such that those who resist exposure will find ways to actually conceal rather than reveal the truth, and information obtained may be a distorted reality. In reading Reiter’s book, I see PBSP is as it began.

Reiter revealed how a traumatized prison staff held hostage by its violent past has been unable to release themselves from the grip of fear and anxiety. By interviewing key prison officials, she uncovered how the recurrent distressing memories of the revolutionary prisoner George Jackson, the Aug. 21, 1971, San Quentin State Prison riot that led to Jackson’s killing, followed by the Sept. 9, 1971, New York Attica Correctional Facility bloody uprising has provoked defensive actions by prison officials in an attempt to secure more control over their environment and the prisoners.

The evolving community unrest and reactionary hard-on-crime politics contributed to an increase in incarceration, especially of people of color, which in turn created overcrowding that disturbed the already fragile power structure and fueled the perceived need for more protection. In an attempt to curb prison officials’ discretion, the courts in 1976 eliminated the indeterminate sentencing law. According to prison officials interviewed by Reiter, they were no longer able to reward good behavior with potential for early release.

With these growing restrictions and pressures, Reiter found that officials felt a growing loss of control. Repeated lockdowns were becoming routine to maintain order even though the practice was noted to increase tensions and hostilities. The practice of lockdowns, nonetheless, morphed into secretly designing a permanent isolation fixture for “prisoners they perceived to be the most dangerous to prison order – the “George Jacksons” (page 84).

Prison officials withheld that by 1988 “the rate of violent deaths in California prisons had fallen to less than half that of the late 1970s” and exploited the fears of violence to convince legislators that a supermax prison with more restrictive means of control was essential to maintain institutional safety (page 14). Every prisoner could then be threatened directly or indirectly with the security housing unit (SHU), i.e. solitary confinement.

Soon after opening, PBSP prisoners’ alarming letters to legislators exposing abuses resulted in the 1995 federal lawsuit, Madrid v. Gomez, where Judge Thelton Henderson found PBSP violating prisoners’ Eighth Amendment right to be protected from cruel and unusual punishment. The evidence proved: 1) guards’ excessive force against prisoners; 2) inadequate medical and mental health care; and 3) unconstitutional housing of prisoners with mental illness in solitary confinement.

Because of the code of silence among staff condoning these transgressions, a special master was appointed to monitor court ordered remediations. Henderson told her that not enough evidence was presented to find solitary confinement itself unconstitutional.

Court oversight requires honest portrayal of the facts, not a misrepresentation with a desired result. Reiter’s assertion that PBSP has only superficially complied with court orders and has “designed creative workarounds to avoid external oversight” (page 199) is supported by my PBSP experiences. CDCr credentialing staff confided, “Administration turns a blind eye to irregularities until auditors are at the door.”

I saw how within days of a pending court audit, one of the mental health programs which had been operating over capacity for months with some inmates in overflow areas receiving little to no treatment was reduced by 20 patients. Normally, transfers out of PBSP take months, but this pending audit inspired officials to move quickly and make exceptions.

Another blatant maneuver to appear favorably to auditors was when patient treatment plans would be reduced from the usual weekly 14 to a low of two to four with purposeful intention to discuss each plan meaningfully. Supervisors would not have needed to deceive in this manner if the truth was in compliance.

Unannounced court visits would be more revealing of the true functioning of PBSP. Coverup is worse than the crime as it erodes trust. Integrity is not just the absence of lying, but telling the whole truth, as painful as it may be.

Despite court oversight, the provision of psychiatric care in PBSP continued with endless deficiencies that staff were conditioned to tolerate. The mental health program operated in crisis mode, a grave error as its reactionary defensive pattern only increased risks for all and led to conflict.

Planning for program needs seemed to be afterthoughts. It took PBSP two and a half years to get an on-site psychiatrist after its opening. When I left PBSP in July 2016, two full time psychiatrists remained for the entire facility, the same number as when the Madrid v. Gomez case was underway in 1992.

Due to limited psychiatrists, supervisors ordered us to write discharge medication orders for unknown patients in the psychiatric hospital unit without evaluating them first. We would get written up, as I did, if we objected to this unsafe practice.

Despite repeated requests by me, I never got a speaker-phone to provide translation services for non-English speaking patients or a scale to monitor patient’s weight during hunger strikes, paranoia driven refusal of food, or anorexia. I could not order urgent lab tests unless the patient had been admitted to the inpatient unit or sent to an outside facility. Routine labs were restricted to Tuesday and Thursdays.

Chart documentation was often incomplete, with notes not scanned into the electronic system in a timely manner. Access to patients for treatment was limited by the narrow window of opportunity that custody could escort patients to confidential offices. At times guards would say patients refused appointments when they had not.

Space limitations led to restricted services delivered. Even when space was not an issue, the treatment groups available were largely recreational. The “core” groups for trauma, substance use or anger management had long waiting lists.

Therapists were often pulled from one skeletally staffed program to cover immediate needs of another, which disrupted continuity of care everywhere. Patients were hesitant to begin therapy not knowing if their therapist would be gone tomorrow.

The shameful part was that at times, patients were then penalized for not progressing enough or for filing grievances by threatening them to be kicked out of programs. Patients were asking for help, but the system was so chaotic and punitive that it was unable to provide the compassion and consistency that treatment demands.

Patients were blamed for the system’s failures. Supervisors seemed inconsiderate and insensitive to life and death issues. In May 2016, a patient I had yet to meet but who was assigned to me hanged himself a day after being discharged from the psychiatric-medical hospital. I learned of his death through other patients, not through administration or my team. It was complete silence, as if this young man never existed to staff.

Per Madrid v. Gomez, patients with serious mental illness are to be excluded from the SHU. CDCr has an exclusionary diagnosis list that does not include, oddly, all of the anxiety disorders, including Post Traumatic Stress Disorder, which is quite common in prisons.

I do not know who came up with this list, but if anxiety disorders were included, perhaps many would not have been legally placed in the SHU. However, even the diagnoses on the exclusionary list were manipulated.

Not infrequently I would be in disagreement with a social worker or psychologist who wanted to down-grade a patient’s diagnosis from major depression to adjustment disorder or regard reported psychotic symptoms as malingering or down-play suicidal ideation as manipulation thereby clearing them for the SHU.

Once in the SHU, prisoners would receive rudimentary monitoring for decompensation every other week largely by a psychiatric technician at cell front. Cell front visits are not at all confidential, so often, understandably, patients will not share much. I learned from those in the SHU that “psych was suspect,” so minimal help was even requested from them.

Those excluded with one of the exclusionary diagnosis but serving a SHU term are housed in the Psychiatric Housing Unit (PSU). Both the SHU and the PSU are required to have an assigned psychiatrist. The last year I was at PBSP, neither had one.

Without an assigned psychiatrist to see them as needed, these very ill PSU patients were cycling back and forth, crisis after crisis, from the PSU to the inpatient psychiatric hospital. I was ordered to participate in the weekly PSU treatment team meetings, even though I never evaluated these patients and therefore could give no meaningfully input. I explained this was not in the patient’s best interest and finally refused to provide PBSP protection when I was asked to do this for another program.

Again, I explained my reservations through the PBSP and CDCr chain of command without support. Instead, as often happens in CDCr, the whistleblower gets accused. I was told I was being irresponsible, not thinking of how my actions affected others, and that I was not a team player.

Their way around this “inconvenience” was to list anyone present in the meetings, even if they did not participate in the discussion. With or without my cooperation, CDCr would fill that psychiatrist line by writing “Dr. McCall present” to comply with regulations. You cannot rationalize unethical behavior based on current needs. Leaders are expected to embody and execute moral integrity.

Solitary confinement placement is at odds with the goal of rehabilitation or the facilitation of social reintegration. As little as 10 days in solitary confinement can cause disruption in the sleep-wake cycle, diaphoresis, dizziness, heart palpitations, headaches, muscle deconditioning, joint pains, weight loss, diarrhea, constipation, fatigue, anxiety, panic, depression, paranoia, anger, impulsivity, hallucinations, obsessive thoughts, compulsive behaviors, memory and concentration difficulties, dissociation, hyper-sensitivity to normal stimuli, startled responses, hyper vigilance, hopelessness, helplessness, suicide and suicidal behaviors.[iii] [iv] [v] [vi] [vii] [viii]

In 2014, 79 percent of suicides were in isolation units (page 163). Inmates in segregation have the highest rates of self-injurious behaviors.[ix] Some of these adverse effects can be long lasting and can be devastating, even in those without mental illness.

Patients would often lament, “There is nothing more dangerous than a man who has nothing to lose.” The SHU creates the “monster” CDCr claims to be protecting us from. When released from the SHU, so filled with rage and resentment, some have assaulted others, which CDCr leveraged to justify such restrictive confinement.

Others in attempts to escape such horrors, snitched, guaranteeing them death, or took their own life or provoked cops to kill them or harmed themselves as a semblance of control over their lives. To think some prisoners have been held in the SHU for over 40 years is unconscionable. Equally unscrupulous is the monthly release of 100 CDCr SHU inmates directly to the community without a transition or support to adjust (page 168).

A weakness of Reiter’s book is the exclusion of the PBSP mental health providers and leaders in the discussion of solitary confinement and how they negotiate their triple loyalties as care-givers, human beings and employees.

Seventeen years after Judge Henderson declared the housing of the mentally ill in the SHU unconstitutional, the American Psychiatric Association (APA) in 2012 advised against segregating those with serious mental illness longer than three to four weeks.[x] Recognizing the harm from SHU placement even for a few days and its $70,000 per year per prisoner expense, it is our clinical obligation to our patients and our social responsibility to all inmates to oppose such dangerous practices much less be involved in any way supporting their continued existence.

Mental health providers should not be declaring anyone cleared for this type of high risk containment. To do so, we give approval and legitimacy to the practice. Even the National Commission on Correctional Health Care (NCCHC) in their April 2016 position stated that “health staff must not be involved in determining whether adults or juveniles are physically or psychologically able to be placed in isolation.” [xi] I agree with psychiatrist Kenneth Appelbaum that the APA, as the moral voice of our profession, needs to oppose publicly and categorically solitary confinement for all human beings regardless of whether or not they have mental illness and modify its current policy.5 Doing so would be more in solidarity with the World Health Organization, NCCHC, the United Nations position which all agree prolonged segregation longer than 15 days is cruel, inhumane, degrading, and harmful to an individual’s health and can constitute torture.[xii] 3,6,7

Aside from solitary confinement, ethical dilemmas abound for a CDCr psychiatrist. Physicians cannot allow ourselves to be used to advance CDCr’s purpose at the expense of our patients or our principles.

Often I was asked to increase patient’s medicines because supposedly, per custody, the patient was manic, paranoid and trying to start a riot. I would assess the patient to be coherent, linear in thinking, calm, perceiving risks realistically and often would see no clinical indication to adjust medications. Obviously, the request was a misrepresentation that was not substantiated through evaluation.

I refused to chemically restrain patients because custody labeled them “agitators” when they were expressing understandable frustration and/or peacefully building support for nonviolent collective resistance. I learned not to take reports at face value. I often reduced the complex non-evidence-based cocktail of polypharmacy patients arrived on.

The greatest measure of success seemed to be “as long as they are not getting rules violations.” It did not seem to matter if the patient was so sedated that he needed prompting to provide for basic care or was not leaving his cell to participate in programming or that the dangerous medication combinations were increasing morbidity and mortality risk.

Recently, a psychologist advised CDCr to do 30-minute welfare checks around the clock on prisoners in segregation with the reported intention to reduce suicides. Sleep deprivation is hazardous to physical and mental health and is a known method of torture.

Most people with reduced sleep will be moody, have reduced tolerance for stress, increased risk for psychosis and lower immunity. This sounds like a recipe for increased suicide, not less. A thoughtful benefit-risk assessment of this practice points to more harm than good, yet it is policy.

The misuse of the medicine and social sciences for political and social control is nothing new. Through the 1940s to 1970s, radiation and hormone experiments were done on United States prisoners.[xiii] 10 At a 1961 conference for the Federal Bureau of Prisons held by none other than the National Institute of Mental Health, psychologist Edgar Schein encouraged the use of psychological coercion methods used by the Chinese and North Koreans on American prisoners of war during the Korean War on United States inmates: “To produce marked changes of behavior and/or attitude … remove the supports to the old patterns of behavior and old attitudes … This can be done either by removing the individual physically and preventing any communication with those whom he cares about, or by proving to him that those whom he respects aren’t worthy of it, indeed should be actively mistrusted … These same techniques in the service of different goals may be quite acceptable to us … (T)hink of brainwashing not in terms of politics, ethics and morals, but in terms of the deliberate changing of human behavior and attitudes.”[xiv]

Schein provided a nauseating laundry list of techniques to, as Reiter says, “effect ‘character invalidation’” (page 181), and solitary confinement was the perfect means to disrupt prisoners’ social support system. In December 2014, Physicians for Human Rights reported that U.S. health professionals were involved in developing and implementing the Central Intelligence Agency torture program against detainees after the Sept. 11, 2001, terrorist attacks.[xv]

Prisoners I worked with were keenly aware of all these historical travesties, and trust was more difficult to establish. Some would refuse treatment or deny symptoms until they couldn’t. Some suffered in silence while some died by suicide. I would often hear from patients how they would avoid certain providers because they were “colluding” with guards. For all these reasons, treating providers must not in any way appear compromising in their commitment to patient care.

The original argument for the SHU was to reduce prison violence. However, data on prison violence before and after the introduction of solitary confinement has shown that the isolation of prisoners labeled as dangerous or disruptive did not result in a reduction of prison violence.[xvi]

Reiter argues that the SHU has “succeeded in eliminating the widespread collective resistance characterized by George Jackson and Attica in the 1970s” (page 194), but this too is not supported by history. The SHU inmates proved they could not be silenced as they peacefully organized the 2013 hunger strike of 30,000 prisoners across California in protest of the CDCr gang validation policy and SHU conditions. We are left perplexed as to the real purpose of the SHU.

While working at PBSP, I was repeatedly told that inmates in the SHU “earned their way there” for violent offenses. To learn from the book that the majority were there for allegedly being associated with gangs in the absence of any rule violation or violent behavior was unsettling.

Reiter found little evidence to support the myth of “worse of the worst.” She describes beautifully and respectfully how these prisoners developed discipline of mind and body through strict routines, how some learned new skills or a new language, how some drew life into their barren cells or wrote descriptively to escape the constraints of prison.

As we hear of the unnecessary struggles they face in and out of the SHU, we begin to see these criminals as human beings. To realize that CDCr perpetuated the falsehood of the “worse of the worst” reminded me of when prison officials staged a riot during one of Judge Henderson’s 1990s PBSP visits in a desperate attempt to manipulate the judge’s attitudes by altering reality to support their own agenda.

PBSP’s past mirrors its present. With this and other examples Reiter provides, we are warned to be careful what narrative we believe.

Reiter writes that the three “independent source items” sufficient to classify someone as a gang associate or member could not be reviewed by the accused inmate, and the decision to use the source as “evidence” was left to prison officials’ discretion without any due process. Equally alarming was to learn that some of the “evidence” was culturally based, such as pictures or books of Malcolm X or Che, cultural music, the Mexican or Puerto Rican flag, Aztec calendar, certain tattooes, letters, the eagle of the United Farm Workers or Mexico.

By censoring these items in the name of institutional safety, CDCr could simultaneously legally strip you of your identity and criminalize your culture and sentence you to an 8-by-10-foot box indefinitely. A SHU survivor said to me, “CDCr throws gang titles around to dehumanize prisoners to the public” so they are forgotten and not worthy of the fight for justice. We must never forget Dr. Martin Luther King’s words: “Injustice anywhere is a threat to justice everywhere.”[xvii]

Prison is a by-product of society’s racist underpinnings, and the SHU has been a tool for social control. This oppression reminded me of how colonizers defined Native Americans as uncivilized savages in need of “saving” through Christianization and re-education with the real intent to steal their lands and demean, marginalize and slowly exterminate them.

The 2015 Ashker v. Brown settlement, which now prohibits CDCr from placing inmates into a SHU based solely on gang affiliation or validation status, may remedy this grave injustice. According to the Center for Constitutional Rights, “the numbers of California prisoners in indefinite solitary confinement has dropped by 99 percent” one year after the settlement.[xviii]

This astonishing reduction illustrates the arbitrariness and looseness of CDCr’s criteria and how few prisoners merited continuation in such restrictive environment. The newly adopted two-year step-down program and the alternative to SHU, the Restrictive Custody General Population, may be more efficient instruments of repression. Vigilance is in order.

Prison is a tentacle of society and, without addressing what feeds and maintains CDCr, there can be little transformative systemic change. As long as we ignore the contradictions of our nation, we will continue to have racism and discrimination that creates oppressive economic, social and political policies that legitimize a hypocritical system.

Our country preaches “democracy” and “freedom” yet incarcerates the most, especially the most vulnerable and marginalized. Our prisons and jails are the de facto mental health hospitals for our mentally ill. Twenty-five percent of the prison population have mental illness compared to 4 percent in the general population.

The 1963 Kennedy Community Mental Health Act prematurely closed psychiatric hospitals without building the intensive services the mentally ill needed to be empowered and integrate into the fabric of our communities. As a result, many patients have become homeless, criminalized and traumatized as they enter the jail-prison system.

This is a disgraceful abandonment. Incarceration is not treatment, and cycling through different systems – legal system to mental hospitals – speaks of the fragmentation, costing much suffering and money. As long as we the people fail to do our civic duty and hold our leaders accountable, nothing will change and our situation will only get worse.

Keramet Reiter’s book is an essential read for anyone wanting to better understand the complexities of the California prison system and PBSP in particular. Reiter masterfully provokes us to question the very existence of solitary confinement.

Each discovery Reiter uncovers reminds me of the detachment and compartmentalization that many staff utilize to survive the daily demoralizing prison experience that removes them from the urgency of action. Staff is so busy putting out fires that it becomes very easy to look away and avoid discussing the ethical dilemmas of some policies and actions, while supervisors create more ill planned programs that never unfold into the promise of healing and at times bring more harm than good.

Staff delude themselves into thinking that they are doing something when they are just contributing through their silence to the apparatus of deceit. In the end, this book’s message to me was that we are equally accountable for what we do and fail to do. As harrowing as this book is, it is inspiring.

Now more than ever, with Donald Trump as president, we as a people must expect more from ourselves and our leaders. We need to define and defend our values.

Nurture hope and connections instead of fear and hatred. “Redefine felons as people first and criminals second” (page 64). Heal through restorative justice programs. Protest injustices.

Eliminate the discretionary application of the law that disproportionately negatively impacts people of color. Latinos and African Americans make up one third of United States’ general population yet make up nearly two thirds of the prison population.

Improve our education system and teach a cohesive, inclusive history. Teach and demonstrate understanding and respect rather than retaliation. Dare to see people of color as assets, not potential threats.

Support self-determination, not destruction. Provide jobs that can sustain families. House our people.

Bolster our community mental health clinics and substance use programs. “O, let America be America again – / The land that never has been yet – / And yet must be,” as Langston Hughes wrote.[xix]  The struggle continues until the promises are fulfilled.

In solidarity with our shared humanity,

Mariposa McCall

Mariposa McCall is the daughter of immigrant parents from Mexico. She has been practicing psychiatry since 1999 and has worked in a variety of settings including community clinics, nonprofit clinics, Kaiser, California Prisons and the Veteran Administration. She currently works for Contra Costa Health Services in San Pablo serving the underserved, uninsured, low income, immigrant and Spanish speaking monolingual communities. She can be reached at [email protected]. This commentary is to be published in the Social Justice Journal in coming months.

[i] James Baldwin (1963) “The Fire Next Time,” 294

[ii] Keramet Reiter (2016) “23/7: Pelican Bay Prison and the Rise of Long-Term Solitary Confinement”

[iii] Keramet Reiter (2016), ibid.

[iv] World Health Organization, http://apps.who.int/iris/bitstream/10665/128603/1/Prisons%20and%20Health.pdf

[v] Vera Institute of Justice (VIJ) “Solitary Confinement: Common Misconceptions and Emerging Safe Alternatives,” http://archive.vera.org/sites/default/files/resources/downloads/solitary-confinement-misconceptions-safe-alternatives-report_1.pdf

[vi] Kenneth Appelbaum (2015) “American Psychiatry Should Join the Call to Abolish Solitary Confinement,” J Am Acad Psychiatry Law 43:406-15

[vii] United Nations (2011) “Solitary Confinement Should Be Banned in Most Cases, UN Expert Says,” http://www.un.org/apps/news/story.asp?NewsID=40097

[viii] National Commission on Correctional Health Care (April 2016) “Position Statement: Solitary Confinement (Isolation),” www.ncchc.org/solitary-confinement

[ix] Appelbaum KL, Savageau JA, Trestman RL, et al. (2011) “A national survey of self injurious behavior in American prisons,” Psychiatry Services 62: 285-90

[x] American Psychiatric Association (2012) “Position Statement on Segregation of Prisoners With Mental Illness,” http://www.dhcs.ca.gov/services/MH/Documents/2013_04_AC_06c_APA_ps2012_PrizSeg.pdf

[xi] National Commission on Correctional Health Care (April 2016), ibid.

[xii] World Health Organization, ibid.; United Nations (2011), ibid.; National Commission on Correctional Health Care (April 2016), ibid.

[xiii] Jessica Mitford (1973) “Kind and Usual Punishment: the Prison Business”

[xiv] Edgar H. Schein (1962) “Man against man: Brainwashing,” Correct Psychiatr J Soc Ther 8(2):90-7

[xv] The Physicians for Human Rights (2014) “Doing Harm: Health Professionals’ Central Role in the CIA Torture Program,” https://s3.amazonaws.com/PHR_Reports/doing-harm-health-professionals-central-role-in-the-cia-torture-program.pdf

[xvi] Briggs et al. (2003) “The effects of supermaximum security prisons on aggregate levels of institutional violence,” Criminology, Vol.41 (4) pp 1341-1376

[xvii] Martin Luther King (1963) “Letter from Birmingham Jail,” http://kingencyclopedia.stanford.edu/encyclopedia/documentsentry/annotated_letter_from_birmingham.1.html

[xviii] Center for Constitutional Rights, https://ccrjustice.org/home/blog/2016/10/18/one-year-pelican-bay-settlement-long-term-solitary-drops-99

[xix] Langston Hughes, https://www.poets.org/poetsorg/poem/let-america-be-america-again