Total Confinement: Madness and Reason in the Maximum Security Prison
by Lorna A. Rhodes

University of California Press
329 pp., $23.95 (paperback)

Reviewed by Kate Amiel, McGill University

Over the last few decades in North America, there has been a trend towards significant de-institutionalization of psychiatric patients, and prisons have thereby become home to many people suffering from mental illness. The number of offenders incarcerated in the United States has increased dramatically since the 1980s and approximately 10-15% of those convicted are mentally ill; as a result, these prisons have been called “the asylum of last resort”. In Total Confinement, anthropologist Lorna Rhodes takes readers inside a Washington State maximum security prison to examine the goals of the institution and the methods by which these goals are reached. It quickly becomes clear that the purpose of such “control units” is controversial even to those within the administration – do prisons (and, in particular, maximum security units) serve to punish offenders or rehabilitate them, and are these two goals at all compatible? The debate which follows from this is whether or not prisoners should be held accountable for their actions in such an environment, especially if they are mentally ill. The way in which these issues are addressed within the prison system can be used as a mirror to examine society’s attitudes towards offenders, psychiatry and its patients. Overall, it seems clear that the objectives of such institutionalization must be clarified in order to bridge the divide between punishment, rehabilitation, and treatment of mental illness in the future.

In the first part of the book, Rhodes describes the living conditions for offenders in the maximum security unit in order to demonstrate how they affect the inmate’s ability to make rational choices. The prisoners are held in single cells measuring 8 x 10 feet containing a concrete bed and an immoveable sink/toilet for over 23 hours per day. Their cells are closed by large metal doors with a small opening known as a “cuff port” used to apply handcuffs and to exchange food trays.

Movies and popular culture depict these units as housing rapists or serial killers, but interestingly they do not always hold the “worst of the worst” – a large portion of its inmates are those who have committed other minor offenses while in the “general population” (a less secure prison). Once in the control unit, prisoners are subjected to total social isolation with no rights and no privacy – the staff are responsible for bringing them meals, communication from family, and basic hygiene materials. “Well-being here is so minimally defined, and the lack of contact with other people so complete, that this dependency – which officers complain makes them feel like servants – can turn any inmate request into a ‘bid for attention’” (p 30). The only choice that inmates truly have is whether or not to obey orders to return their food tray, and their only recourse to demonstrate dissatisfaction or defiance is to throw feces at the prison staff through their cuffport.

In reading about this behavior, one wonders what kind of human being would be capable of making such use of their own excrement – would one have to be mentally ill, or just desperate? Rhodes wonders at the end of the chapter whether the act of ‘throwing’ is a marker of insanity, or whether, somewhat counter-intuitively, it is a particularly sane response to an inhuman situation. How would someone considered “sane” react to these living conditions? From this book, it seems that one of the goals of the control unit is to remove all possible choices from the inmate – to, in effect, control everything about his life, both for security purposes and for punishment. It would therefore follow that even a sane adult might resort to throwing his or her own feces to regain some control in this environment. The question one is left with is how this is affecting the potential rehabilitation of the inmate; and if anyone who has experienced such a lack of boundaries with oneself can ever go back to leading a ‘normal’ life in the community. Rhodes asks if inmates are capable of rational choice, but when confronted with two irrational options under irrational conditions, no decision seems rational, and it seems unfair to hold offenders accountable for such choices – ironically, “the prison tends to secrete the very things it tries most to eliminate” (p 29).

As mentioned above, a significant number of inmates in the maximum security unit have been diagnosed with mental illness. The issue of psychiatry in this setting is a complex one – the use of such labels is debated as treatment often clashes with the philosophy of punishment and security. When an offender arrives on the unit, they are screened by mental health in order to fit them into either the “mad” or “bad” categories. Severely ill prisoners may be housed on the mental health unit, but more often than not, offenders will be diagnosed and then sent to live in a cell among the rest of the population. Once labeled as mentally ill with a “ding jacket”, also known as a “mental jacket”, the inmate can find it difficult to rid himself of this identity and may even find that it is used against him (p 115).

For prison staff, whose infraction system operates on the principle that inmates are held responsible for their actions, mental illness presents a difficulty in the interpretation of behaviours and their intentions. Disruptive behaviours are thus interpreted differently depending on the unit in which they occur and the patient’s mental health status. Rhodes states of a young man who threatens to kill another inmate: “[on the mental health unit] his words are less likely to be taken as signifiers of intended actions; instead they are simultaneously signs of his willingness to open up, of his illness itself, and of the difficulty of detecting that he is ill.” (p 120) Tension develops within the control unit regarding these different philosophies – mental health workers in the control unit believe that it is necessary to form relationships with inmates, whereas correctional officers on other units are highly discouraged from doing so due to safety concerns.

Even within the mental health field, the use of diagnosing inmates with ‘Axis I’ disorders versus an ‘Axis II’ “characterological” problem creates conflict, raising the question of whether or not behaviors caused by a personality disorder (with the implication that these disorders are untreatable) are more responsive to the infraction system. It is clear that the control unit is not an ideal place for individuals with mental illness due to the aforementioned conflicts between treatment and security, but in the present system, there seem to be no other institutions which are appropriate for the criminally insane. Perhaps this group of offenders merits the development of a specialized treatment facility that meets the security requirements demanded by the justice system in order to remove this tension from control units.

In the third and final part of her book, Rhodes addresses the total exclusion that offenders are subjected to in maximum security prisons and the effects that the system has on the inmates. Earlier in the book, she described the expanded sense of personal space that develops as a result of being isolated for long periods of time, but it is not only the physical boundaries that change the offenders – the psychological boundaries may be just as harmful: “the preoccupation with control that makes up the texture of the system – its compulsions – becomes as well the compulsion of the prisoner.” (p 174) In their struggle for control, respect, and survival in the control unit, prisoners can become “dangerous” or “monsters” (p 175). Rhodes explains that “the immense human dignity fostered by the insistence that ‘being’ – not just bare need – be recognized congeals into a kind of hyperrationality, a sharpness of thought that precipitates out of this form of confinement.” (p 174) The system and the prisoner thus become entrenched in a vicious cycle of competing for control and survival, and the system tends to label these individuals as “evil” or “psychopaths” (p 186) without considering how these personalities came to exist. Maximum security prisons may therefore have the opposite effect of rehabilitation, ironically creating more danger than they contain.

Though Rhodes does finish Total Confinement on a somewhat positive note, mentioning new prison policies which allow inmates to become educated and form relationships with staff, the overall picture painted of the control unit is nevertheless a bleak one. She convincingly argues that if rehabilitation is in fact an objective of the correctional system, it is not being met in maximum security units. The custodial concerns for safety and security outweigh the need to treat mentally ill prisoners and maintain the ‘sanity’ of the others. In this threatening environment of distrust and force, prisoners become less human and therefore (presumably) more dangerous to society. Total Confinement is an important insight into the world of maximum security prisons which will undoubtedly stimulate much discussion regarding the objectives of the correctional system as a whole and the treatment of mentally ill offenders in the justice system.

Kate Amiel is currently a fourth year medical student at McGill University and will be beginning a residency in pediatrics at the University of Toronto next year. She has a strong interest in social pediatrics, student leadership, and international medicine.