Cloud et al. Health and Justice
(2021) 9:28
https://doi.org/10.1186/s40352-021-00155-5

RESEARCH ARTICLE

Health and Justice

Open Access

“We just needed to open the door”: a case
study of the quest to end solitary
confinement in North Dakota

Check for
updates

David H. Cloud1* , Dallas Augustine1, Cyrus Ahalt1, Craig Haney2, Lisa Peterson3, Colby Braun3 and Brie Williams1

Abstract: Solitary confinement is a widespread practice in US correctional facilities. Long-standing concerns about
the physical and mental health effects of solitary confinement have led to litigation, legislation, and community
activism resulting in many prison systems introducing policies or implementing legal mandates to reduce or
eliminate its use. Yet little is known about the nature and effectiveness of policies that states have adopted to
reduce their use of solitary confinement and exactly how various reforms have actually impacted the lives of
people living and working in the prisons where these reforms have taken place.
Methods: We conducted an embedded case study, analyzing changes in policies and procedures, administrative
data, and focus groups and interviews with incarcerated persons and staff, to describe the circumstances that led to
changes in solitary confinement policies and practices in the North Dakota Department of Corrections and
Rehabilitation (ND DOCR) and the perceived impact of these changes on incarcerated persons and prison staff.
Results: North Dakota’s correctional officials and staff members attributed the impetus to change their solitary
confinement policies to their participation in a program that directly exposed them to the Norwegian Correctional
Service’s philosophy, policies, and practices in 2015. The ensuing policy changes made by North Dakota officials
were swift and resulted in a 74.28% reduction in the use of solitary confinement between 2016 and 2020.
Additionally, placements in any form of restrictive housing decreased markedly for incarcerated persons with
serious mental illness. In the two prisons that had solitary confinement units, rule infractions involving violence
decreased at one prison overall and it decreased within the units at both prisons that were previously used for
solitary confinement. Although fights and assaults between incarcerated people increased in one of the prison’s
general population units, during the initial months of reforms, these events continued to decline compared to
years before reform. Moreover, incarcerated people and staff attributed the rise to a concomitant worsening of
conditions in the general population due to overcrowding, idleness, and double bunking. Both incarcerated
persons and staff members reported improvements in their health and well-being, enhanced interactions with one
another, and less exposure to violence following the reforms.

* Correspondence: David.cloud@ucsf.edu
1
Amend, University of California, San Francisco, School of Medicine, 490
Illinois Street, Floor 8, UCSF Box 1265, San Francisco, CA 94143, USA
Full list of author information is available at the end of the article

BMC

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Cloud et al. Health and Justice

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Conclusions: Immersing correctional leaders in the Norwegian Correctional Service’s public health and human
rights principles motivated and guided the ND DOCR to pursue policy changes to decrease the use of solitary
confinement in their prisons. Ensuing reductions in solitary confinement were experienced as beneficial to the
health and wellness of incarcerated persons and staff alike. This case-study describes these policy changes and the
perspectives of staff and incarcerated persons about the reforms that were undertaken. Findings have implications
for stakeholders seeking to reduce their use of solitary confinement and limit its harmful consequences and
underscore the need for research to describe and assess the impact of solitary confinement reforms.
Keywords: Solitary confinement, Prison reform, Correctional health

Introduction
Solitary confinement is the practice of confining incarcerated persons in a small cell for approximately
22 hours per day. This generic term can be applied to
different types of prison housing assignments, such as
restrictive housing, administrative segregation, disciplinary segregation, and protective custody (Haney, 2018a).
In addition to the deprivation of meaningful social contact, persons who are incarcerated in these units often
have limited or no access to programming and restrictions on the amount and nature of their visits and personal property (Haney, 2020). Generally, they are only
permitted to leave their cells for showers or to recreate
alone in a small closed-in or caged area. People with
serious mental illness, cognitive impairment, those who
are LGBTQ, and members of racial and/or ethnic minority groups are overrepresented in solitary confinement
(Bertsch et al., 2020; Reiter & Blair, 2015; Schlanger,
2012; Ryan & DeVylder, 2020). The stated reasons for
placing someone in solitary confinement range from
punishment and involuntary or voluntary “protective custody,” to safeguarding the “safety and security” of the
institution (which may include isolating persons with
verified or perceived gang affiliation). The amount of
time spent in solitary confinement may extend from days
to decades (Bertsch et al., 2020) and varies depending on
a range of factors, including agency policy, the type of
solitary confinement unit (e.g., disciplinary versus administrative), among others. The most recent survey of state
correctional systems reported that between 55,000 to
62,500 people in U.S. state prisons were in solitary confinement on any given day in 2019 (Bertsch et al., 2020),
another study found that 20% (320,000) are exposed to
administrative or solitary confinement at least once annually (Beck, 2015).
The use of solitary confinement is considered by leading professional medical societies (e.g., the American
Medical Association, 2016, the American Public Health
Association, 2013, the American Psychiatric Association,
2017, the National Commission on Correctional Healthcare, 2016, and the World Medical Association, 2019)
and international human rights organizations (e.g. the
United Nations, Human Rights Watch) to be a pressing

public health and human rights concern (Ahalt & Williams, 2016; Cloud et al., 2015; Gottschalk, 2015; Méndez, 2019). Although some authors have questioned the
extent to which solitary confinement has an adverse impact on health and well-being (e.g., Morgan et al., 2016;
Gendreau & Labrecque, 2018), a number of studies have
found that solitary confinement can produce or exacerbate negative mental health symptoms (Grassian, 2006;
Haney, 2018b; Rhodes, 2004; Smith, 2006), is associated
with increased self-harming and suicidal behavior (Kaba
et al., 2014; Lanes, 2009, 2009), increased morbidity (including PTSD), physical harms (Morgan, 2017; Strong
et al., 2020; Williams & Ahalt, 2019), and even mortality
following prison release for persons who have spent time
in solitary confinement (Brinkley-Rubinstein et al., 2019;
Hagan et al., 2018; Strong et al., 2020; Wildeman & Andersen, 2020). These finding are in line with a large body
of research outside of correctional contexts which demonstrates that social isolation, social exclusion, and loneliness have profoundly debilitating effects on
physiological and psychological functioning (e.g., Haney,
2020; Leigh-Hunt et al., 2017; Williams & Ahalt, 2019).
The concerns about the health-related impact of solitary confinement (based in part on these studies and also
on testimonials of people who have been subject to it),
have led to decades of litigation, legislation, and community activism (Fettig, 2019, Schlanger, 2020) to reduce its
use. Increasing numbers of state prison systems are
introducing policies or implementing legal mandates
intended to reduce or eliminate the use of solitary confinement (Bertsch, L., et al. 2020). Yet little is known
about the types of policies that states are adopting to reduce or eliminate solitary confinement, whether these
policies succeed in doing so, or how these policy
changes are experienced by people who live or work in
the affected prisons.
As a first step in understanding these issues, we describe and evaluate one multi-pronged approach designed to reduce use of solitary confinement undertaken
by the North Dakota Department of Corrections and Rehabilitation (“ND DOCR”). These reforms were inspired
by and based largely on the principles and practices of
the Norwegian Correctional Service. We detail the

Cloud et al. Health and Justice

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nature of the specific policy changes made by the department, assess the degree to which they were implemented, and analyze some of their reported impacts on
the health and well-being of incarcerated persons and
staff.

Methods

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includes a descriptive analysis of the department’s administrative data, including disciplinary, diagnostic, and
housing records that we used to assess changes in the
use of solitary confinement units and rates of disciplinary infractions involving violence (defined as fights or assaults) before and after the reforms began within these
two prisons.

Study design and setting

We employed an embedded case study design to describe and assess the nature and effects of changes in the
ND DOCR’s use of solitary confinement, including
trends in violence (lower-level “fights” and higher-level
“assaults” as defined by correctional officer write-ups in
the administrative disciplinary records) before and after
the policy changes. We chose an embedded case study
approach because it is well-suited for in-depth assessment of the development, implementation, and impact
of interventions and policy changes in real world settings
through researcher-practitioner partnerships (Scholz &
Tietje, 2002; Petersilia, 2008).
The men’s solitary confinement housing units in the
ND DOCR are located in two prisons—the maximumsecurity North Dakota State Penitentiary (NDSP), and
the medium security James River Correctional Center
(JRCC). NDSP is a 1500-person facility built in 1883.
JRCC is a much smaller and newer prison; built in 1998,
it holds approximately 365 incarcerated people. North
Dakota’s women’s prison is operated by a private entity
and not part of this case study. Our analysis of the ND
DOCR’s reform efforts focused on all of the housing
units that prison officials targeted for solitary confinement reform in the two men’s facilities (NDSP and
JRCC), including disciplinary and administrative segregation units, restrictive housing, and a housing unit designated for people with significant mental health
conditions experiencing acute mental and behavioral
health crises. Our goal was to assess the ways that the
department’s policy changes affected the units they defined as solitary confinement; the possibility that different forms of isolated housing may produce different
effects on incarcerated people (e.g., Mears et al., 2019,
2019) was beyond the scope of this study.
Data and data analysis

Our analysis draws on semi-structured interviews with
correctional staff, focus groups with incarcerated persons, and the department’s administrative data. Participants (both staff and incarcerated people) were asked to
describe the nature and effects of the policy changes that
were implemented in the period after North Dakota correctional officials participated in a correctional reform
program that immersed them in the principles, policies,
and practices of the Norwegian Correctional Service in
2015 (Ahalt et al., 2020; Amend, 2021). In addition, it

Semi-structured interviews with prison staff and
incarcerated persons

Our semi-structured interviews with ND DOCR correctional staff and focus groups with incarcerated persons
were conducted in February 2020. To describe the perceived impacts of policy changes on staff, we conducted
14 semi-structured interviews with a purposive sample
of correctional leaders, clinicians, case managers, and
line staff who were directly involved in creating and/or
implementing the reforms. Interviews were conducted in
person or via a videoconferencing call.
We then conducted five focus groups with a total of
32 incarcerated persons (19 from NDSP and 13 from
JRCC) to learn about their experiences with solitary confinement before and after the policy changes, and the
impact of those changes on their health and well-being.
Focus group eligibility included having been incarcerated
in North Dakota for at least 3 years and having experienced solitary confinement. Researchers sent a recruitment flyer and interview script to case managers who
compiled a list of interested participants. Potential participants were randomly selected on the day the focus
groups were held. Focus groups were designed to have
an average of 6 participants; three groups were held at
NDSP (the larger facility), and two groups were held at
JRCC (the smaller facility). Participants were provided
an overview of the case study and written copies of the
informed consent in advance. Researchers read the consent form aloud in person and obtained verbal consent;
one person elected not to participate. Participants were
not provided monetary incentives. Focus groups were
held in a private conference room inside the prisons,
ranged in length from 90 to 120 minutes and were digitally recorded. Staff interviews and focus groups with
incarcerated persons were transcribed and uploaded to
NVivo for qualitative coding and thematic analysis.
Departmental policies and administrative data

We conducted a descriptive analysis of departmental
policies and administrative data beginning in January
2010, based on guidance from ND DOCR officials who
identified this as a point in time when the department
began planning to expand its use of solitary confinement. We defined the “post-reforms” period as beginning in January 2016 when department leaders returned
from their first visit to Norway, implemented immediate

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releases from administrative segregation, began revising
their solitary confinement review protocols and disciplinary rules, and first established a housing unit for
people who engage in violence as an alternative to solitary confinement. We ended our analysis of the postreform observation period on December 31, 2019, prior
to the COVID-19 pandemic.
We analyzed ND DOCR’s operating policies over time
(e.g., rules governing use of disciplinary housing units,
resident handbooks, officer job descriptions, action plans
for solitary confinement reforms, training materials, data
analyses, and presentations describing the reforms) to
document changes in the department’s use of solitary
confinement, inform interview and focus group guides,
and contextualize our analysis of administrative data.
We used the department’s administrative records of
disciplinary actions filed by correctional officers to quantify and determine trends in solitary confinement sanctions. We also analyzed housing records (“movement
files”) to describe admissions to, and to compare lengths
of stay in, different housing units over time.
Using the ND DOCR’s administrative data we then described the average rates and counts of correctional officer reports of violent infractions before and after the
reforms began. For this analysis, we included all disciplinary events recorded in the department’s administrative
data in which officers charged a person with a rule violation involving some degree of violent behavior. All “violent infractions” include any correctional staff-issued
rule violation charges for behaviors involving physical
violence (regardless of severity). The administrative data
further characterize interpersonal violence into two
levels of severity, these are: (1) “Fights Among Residents”
which are considered less severe acts and include
charges for “fighting” defined as “punching, kicking,
striking or wrestling with another person in an aggressive manner” and (2) “Assaults between Residents”
which are considered more severe acts and include “an attack upon any other person … causing mental or bodily
injury, or causing offensive contact.” We also reported acts
categorized as an “Assault and battery on staff” defined as
any “attack upon a volunteer, employee, officer, or official
of the ND DOCR [including] sexual assault, causing mental or bodily injury, or causing offensive contact.”
Next, to further assess the relationship between
changes in the use of solitary confinement and behavioral infractions for interpersonal violence, we calculated
Incidence Rate Ratios (IRR) between the monthly rates
of solitary confinement and each indicator of violence
using negative binomial regression with fixed effects. We
chose this technique because our outcome(s)—monthly
rates of each indicator of violence—were not normally
distributed across the observation period and were overdispersed (Hilbe, 2011). We included a fixed effect in the

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model to account for unobserved heterogeneity between
the units in the two different prisons (NDSP and JRCC),
since these institutions are distinct in many ways that
we could not measure (Alison, 2002).
Additionally, we conducted an interrupted-time
series (ITS) analysis and Prais-Winstein Regression to
assess whether there were significant changes in
trends of fights and assaults before and after ND
DOCR began implementing three key components of
their reforms: enactment of new disciplinary policy
policies to limit placements in solitary confinement
for most rule infractions; enhancements to the staffing and clinical services for people with mental health
needs assigned to the Special Assistance Unit (SAU)
at JRCC; and establishment of the Behavioral Intervention Unit (BIU) as a last resort housing area primarily for people who commit serious assaults. Each
of these reforms is described in more detail in later
sections. We selected May of 2016 as the point of
intervention for ITS based on consultation with ND
DOCR leadership confirming the start of each aforementioned reform. ITS is widely-used for evaluating
the effects of laws, policies, and interventions on
health outcomes, because it allows for examining differences in slope and intercept between the series
data before and after a policy change or intervention
occurs, while including autocorrelation terms (Biglan
et al., 2000; Bernal et al., 2017).
We acknowledge that retrospective administrative data
is an imperfect way to study violence in prisons. For example, charging officers may have different thresholds
for classifying an incident as more severe (in this case
causing “mental injury or bodily injury”) versus less severe. We therefore reported differences in the rates of
each of these levels of charges both collectively and separately over time when relevant. All quantitative analysis
was conducted using STATA Version 16. This study was
approved by the Institutional Review Board at the
University of California, San Francisco.

Results
Solitary confinement in North Dakota 2010–2015

Like many prison systems in the United States, North
Dakota’s prison population increased dramatically over
the last several decades. Between 1980 and 2010, the
number of people incarcerated in the ND DOCR increased sevenfold and the state’s prisons were plagued
by overcrowding and escalating violence (Bertsch et al.,
2020). In 2012, a prison expansion nearly doubled the
number of long-term solitary confinement cells at
NDSP, and the median length of stay in solitary confinement increased from 109 days in 2012 to 136.5 days by
the end of 2013. According to a former warden, after the
expansion:

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It was like that old adage. If you build it, they will
come. It was almost night and day. Anybody who
caused any type of trouble that disrupted the norm
for general population… they were put into segregation [solitary confinement].
Both incarcerated people and staff said that the expansion led to a sharp punitive turn in ND DOCR’s culture.
One staff noted there was “a big shift into more command, control, and lock down,” and that violence and
unrest increased. An incarcerated person recalled, “there
was crazy fights and chaos all the time... There used to
be stuff happening every single day here. There was
group tension, actual hatred.”
Before 2016, correctional officers in North Dakota had
discretion to impose solitary confinement for a wide
range of behaviors. Incarcerated people described its use
for “petty” activities (disobeying an order, tattooing, talking back to an officer, having unauthorized property).
One recalled: “if you even tried to have a debate with an
officer that didn’t like you, then they could just take you
to the hole.” A staff member acknowledged his own tendency to use solitary confinement in scenarios where
there was a minor disruption. He stated “if somebody
was a nuisance person, or whatever the case may be, I
would push to have them put back in segregation just
because I didn’t want to deal with them. I had so many
other people I had to deal with.”
Lengths of stay in solitary confinement were indeterminate. Staff were required to review each person’s eligibility for return to the general population every month
for the first 90 days and bimonthly thereafter. Staff and
incarcerated people relayed that decisions regarding release from solitary confinement were subjective without
clear requirements. One incarcerated person remarked,
“in the old system, you’re back there until they are done
being mad at you. The door ain’t ever open. There
wasn’t a concrete way to work your way out.” Another
stated, “They used to just leave you back there for
months, just see you when they saw you … get to you
when they got to you... It was rough.”
Many staff and incarcerated persons who were interviewed about this period in ND DOCR’s history characterized the solitary confinement units at both of its main
prisons as dehumanizing, volatile, and traumatizing. Officers acknowledged that they were not trained to build
positive relationships with incarcerated people nor expected to do so. One ND DOCR leader said that officer
trainings reinforced the notion that getting to know an
incarcerated person actually jeopardized staff safety:
We just continued to go down that path which
ended up being like ‘don’t talk to inmates. That’ll be
the number one way for you to make sure that

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you’re safe. That became the training mantra. Don’t
trust them. It became us versus them from the very
onset.
An NDSP officer lamented “I felt the best I could do
was [act] like a flight attendant … meeting their basic
needs, giving them food, toilet paper, or whatever they
needed, but not helping them.” In addition, officers were
taught that their safety depended on keeping people in
solitary confinement or fearful about being placed there.
Officers and incarcerated persons alike described their
interactions as infrequent, hostile, and aggressive. An incarcerated person who was in solitary confinement during this time recalled:
They treated guys like shit. It was just constant.
They’d ignore them … . Just walk by them. They
used to yell, lie to your face, “Oh, I’ll talk to [treatment staff]. They’re going to come and see you.”
And they don’t come back. It sends us into a damn
trauma state.
Persons housed in these units were locked in their cells
at least 23 hours per day, and access to clinical care, educational opportunities, and rehabilitative programming
was limited or non-existent. One man who spent several
years in solitary confinement during this period at NDSP
recalled, “There were times that I sat in the hole for such
a long period of time … It was fucking psychological torture. I can’t think of anything worse.” Another man, in
solitary confinement in his early twenties, still grapples
with the emotional toll: “When you’re a kid, you’re free
and innocent and the whole world’s ahead of you. Then
all of a sudden, you’re in a hole for months and months.
It scarred me and changed my life forever.”
During this time, JRCC’s Special Assistance Unit
(“SAU”), a housing area established for people with serious mental health conditions, devolved into what one
clinical administrator described as “solitary confinement
by another name.” Staff acknowledged that SAU patients
received sporadic and inconsistent mental health services, and that clinicians spent more time reacting to crises than providing therapeutic services. People who
decompensated in solitary confinement at NDSP were
frequently moved to the SAU at JRCC for more clinical
assistance. However, “the expectations were pretty unclear … and a lot of times if people acted out, we had a
punitive prison response, versus a therapeutic response.”
Staff described the environment as stressful and traumatic for them as well. A clinical psychologist recalled:
For years and years and years, there was just a ton
of trauma in that unit. We had many people who
tried to kill themselves, a lot of self-harm, a lot of

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staff injuries. Some very, very major and serious assaults on staff that left people very disabled. And
just a lot of consistent crises.
One SAU clinician noted that there was:
“Lots of infighting, lots of blaming other people for
things going wrong, lots of distrust between staff.
There were lots of amygdalar [reactive] decision
making, avoidance, and all the other things that
happen when you’re just saturated in chronic toxic
stress.”
Another psychologist remembered working conditions
in the SAU as “just eating up people alive” and causing
burnout and turnover among clinicians and security
staff.
Early solitary confinement reform efforts (2012–2014)

In 2012, ND DOCR leadership enrolled several staff
members in National Institute of Corrections trainings
to explore approaches to solitary confinement reform.
This led to the department adopting individualized behavioral health plans and a “level-system” intended to
help transition people out of administrative segregation
at NDSP and the SAU at JRCC. However, these National
Institute of Corrections-inspired changes did not reduce
the use of solitary confinement. Instead, solitary confinement punishments actually increased from 3.30 sanctions per month per 100 incarcerated personss in 2012
to 4.72 in 2014, and the median length of stay in NDSP’s
administrative segregation increased from 109 days in
2012 to 136.5 days in 2013.
Involvement with amend/Norway and a new approach to
solitary confinement reform

In August 2015, officials from the ND DOCR began participation in a novel cross-cultural exchange program
led by Amend at the University of California San Francisco (UCSF) in collaboration with the Norwegian Correctional Service. Amend is a public health focused
program that aims to reduce the debilitating health effects of US prisons on incarcerated people and staff
(Ahalt et al., 2020; Amend, 2021). Initially begun as a
joint program of UCSF faculty and the Prison Law Office
in California, it later formalized as a partnership between
UCSF faculty and the Norwegian Correctional Service.
Amend provides U.S. prison systems with educational
curricula, immersive training programs, and technical
assistance for correctional officials and staff members to
initiate and implement changes in policies and practices
that are based on the Norwegian Correctional Service
principles of dynamic security (fostering positive interpersonal relations between staff and incarcerated

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persons), normalization (creating correctional conditions
that resemble as closely as possible the community conditions to which an incarcerated person will return), and
progression (continuously moving incarcerated persons
to less restrictive environments) (Table 1).
Norway’s correctional system is often heralded for its
humanistic philosophy, beginning with the assumption
that the deprivation of liberty—going to prison—is the
punishment imposed by a court for having committed a
crime, not the occasion for imposing more punishment.
In addition, the Norwegian Correctional Service also assumes that the function of a prison is to promote rehabilitation, health, and successful community return
through intensive rehabilitative services and a welltrained, professional correctional workforce (Høidal,
2019; Justice, N. M. o.,, and Police, T, 2018). Despite
criticism for its use of solitary confinement during pretrial detention—a controversial practice among a number of Scandinavian countries—the Norwegian correctional service employs solitary confinement far less
frequently, and for a much shorter duration, than is the
norm across U.S. prisons (Høidal, 2019; Norwegian Parlimentary Ombudsman, 2019).
ND DOCR officials cited their immersion in the public
health-focused values, principles, and practices of the
Norwegian Correctional Service as a catalyst that inspired their efforts to end solitary confinement. A
former warden recalled, “before Norway, we were talking
about changing restrictive housing and administrative
segregation [solitary confinement]. There were already
things happening, but this was just that bomb that
landed in the middle of all of it.” Another ND DOCR official explained that lessons learned in Norway inspired
immediate actions upon their return:
There was a sense of urgency that we couldn’t just
hang on and talk about it. You hate to be part of a
system that does harm to people we are supposed
to be helping. We just needed to open the door, put
people back into the [general] population because
we were using [solitary confinement] for purposes
that we said we weren’t … punishment, not safety.”
ND DOCR named their Norway-inspired initiative to
change correctional culture Increasing Humanity for
People in Prison. (See Fig. 1 for timeline of Amend-led
activities and Fig. 2 for a list of policy changes included
in ND DOCR’s initiative.) One prison official described
learning about the health consequences of solitary confinement as a motivating factor for initiating reforms,
Now I think that longer term staff acknowledge that
some residents have been permanently damaged by
being locked up in restrictive housing for so many

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Table 1 Key Principles of the Norwegian Correctional System (Labutta, 2016)
Dynamic
Security

Positive interpersonal relationships between correctional staff and incarcerated people are essential for safety and wellbeing in
prison; the investment of time, resources, and services that nurture human relationships is essential to reducing the risk of conflict,
disruption, and violence.

Normalization

The goal of prison is to return a “better neighbor” to society, therefore living conditions inside a correctional institution should
resemble life outside the facility to the maximum extent possible; incarcerated people retain all other human rights aside from the
loss of liberty. Policy, practice, and the architecture of a prison should promote individual autonomy and responsibility for making
choices necessary in a community setting (e.g., shopping for groceries, preparing meals, earning income and managing finances,
enrolling in school or vocational training, and participating in civic duties and activities)

Progression

During incarceration people should gradually advance toward greater freedoms in their
living circumstances, responsibilities, and environments as they progress from admission to reentry into society.

Timeline of Amend Activities in North Dakota

August 2015
Amend team visited North Dakota to assess facilities and explore leadership's goals for a partnership.

I
October 2015
Delegation of North Dakota policymakers traveled to Norway to participate in Amend's immersive program

I
November 2015
The ND DOCR leadership team launched the "Increasing Humanity for People in Prison" by bringing together
~ I 00 staff, currently incarcerated people (in street clothing), formerly incarcerated people, family members of
incarcerated people and department leaders to a working dinner event in a Bismark restaurant where ND DOCR
leaders described the Norwegian correctional principles, clients and staff described the harms inflicted by prison, and
then guests worked with others at their table to imagine how to build prison policies anew with an effort to help
people instead of banning them. This was repeated the next month with a new group of participants.

I
November 2015 -June 2016
Amend provided feedback about ND DOCR's new policies, and pilot programs, and media strategies.

I
June 2016
A Norwegian leader from Halden prison visited North Dakota prisons and provided feedback on changes inspired
by the Norwegian approach to corrections.

I
July 2016-May 2017
Amend staff continued providing feedback to ND DOCR leadership on Norway-inspired reforms.

I
June 2017
ND DOCR Director participated in ao innnersion program developed by Amend aod Trinity College Dublin, Irish
Penal Reform Trust, and Irish Prison Service about solitary confinement and international prison oversight.

I
July 2017-May 2018
Amend staff continued providing feedback to ND DOCR leadership on Norway-inspired reforms.

I
September 2018
ND DOCR Director returned to Norway for additional Amend programming, networking, and to serve as a mentor
to new participants in the program

I
October 2019
Two ND DOCR officers attended Amend programming in Norway to eobance knowledge and develop curriculum to
transform officer training practices.

I
February 2020
Officer training (5-day program including 3x prison site visits by Norwegian and Amend staff; Amend hosts town
ball event for all staff aod 300 residents ofNDSP; 3-day training program for 40 participaots

Fig. 1 Timeline of Amend Activities in North Dakota

Cloud et al. Health and Justice

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Key Components of North Dakota's Solitary Confinement Reforms
0

0

Created action plan with Amend for addressing solitary confinement guided by Nordic principles of dynamic security,
normality, and progression.
Immediately reviewed and released as many people as possible from long-term administrative segregation before
instituting formal policies

0

Developed individualized plans to transition people out of administrative segregation

0

Engaged line-level staff and incarcerated people in planning reforms

0

Revised disciplinary policy to limit placements in restrictive housing to mostly violent and serious rule violations

0

Enhanced due process (e.g. expedited reviews) for people separated from the general population

0

Developed mental health screening and assessments to prevent placements of people with serious mental illness in
restrictive housing at NDSP

0

Created the Behavioral Intervention Unit (BIU) for people requiring separation from general population with
additional behavioral health services, specially-trained staff focused on rehabilitation goals, increased out-of-cell time,
and greater access privileges and property.
Developed Administrative Transition Unit (ATU), transitional housing unit to ready people for return to general
prison population
Increased clinical services in the Special Administrative Unit (SAU) for people with serious mental illness and
behavior management issues and created a transitional unit to ready people for release to the general population.
Enhanced reliance on positive-behavior reports (PBRs) for residents as a motivational tool and for officers as a
component of staff evaluations
Enhanced training in, and reliance on, mediation to resolve common conflicts and fights

0

0

0

0
0

Implemented system-wide trainings for officers on dynamic security, motivational interviewing, and harms of solitary
confinement

0

Changed hiring/recruitment processes and job descriptions for correctional officers

0

Tracked and reported data on violence to increase buy-in among staff

0

Increased transparency for local advocacy and media organizations

Fig. 2 Key Components of North Dakota’s Solitary Confinement Reforms

years, after listening to the personal stories of some
of our residents talk about what it had done to
them. It made me cry, thinking what we had done
to people before we made these changes.

Solitary confinement reforms in North Dakota (2015–
2019)

ND DOCR officials took a number of specific steps designed to implement significant changes in their correctional culture and to reduce their reliance on solitary
confinement. We discuss each of them below, including
what staff and incarcerated people reported to us about
the impact that changes in these policies and practices
had on their health and well-being.

to the general population. A warden recalled, “we literally just opened up the door. We met with the guys and
told them we don’t have a plan, but our success is based
on your success, and we need to figure out something.”
Over the ensuing weeks, clinical staff spent more time
building rapport with incarcerated people, learning
about their life histories, needs and goals, and developing plans for them out of solitary confinement. A clinical
administrator recalled:
At the beginning, it was basically just running trial
by error … All we wanted to do was for staff to be
able to work with the people in segregation, more
one-on-one, more frequently, and offering more life
skills and more how to handle conflicts and manage
emotions. That’s where we started.

Immediate releases from solitary confinement

In the weeks immediately following their 2015
immersion experience in Norway, ND DOCR officials
returned 30 people from long-term solitary confinement

Not surprisingly, perhaps, a number of staff members
were initially uncomfortable with these changes. A security officer described their concerns about the rapid

Cloud et al. Health and Justice

(2021) 9:28

release of people from long-term solitary confinement: “I
thought the roof was going to fall off. Things were going
to blow up and be so dangerous, but that really wasn’t
the case.” An incarcerated person remembered “I was literally in administrative segregation when it transitioned
from the old way. They started turning it into more of a
one-on-one and started to pull us out of our rooms. It
was just the beginning. That was a tipping point.”
Creation of a transition unit

In October 2015, top ND DOCR officials recruited staff
members who had experience helping incarcerated
people prepare for community reentry to develop a unit
that prepared persons to transition from solitary confinement to the general population. One officer recalled
that behavioral health and security staff prioritized building rapport with people on the unit, gaining an understanding of each person’s concerns and challenges, and
developing individualized plans for moving them back to
a dormitory setting. Next, ND DOCR accelerated the review process to once a week. Staff reported that more
frequent reviews, and increased releases, had a noticeably positive effect on interactions between staff and incarcerated people. A case manager remarked that these
changes provided “a little bit more light at the end of
the tunnel... That’s when I definitely felt a big change.”
Changes in disciplinary policy

In 2016, ND DOCR officials codified these changed
practices into actual policies designed to limit the use of
solitary confinement, increase reliance on mediation to
resolve disputes, and to rescind rules that had little correctional purpose but could nonetheless result in disciplinary sanctions (e.g., requiring people to tuck in their
shirts). Disciplinary infractions that can result in solitary
confinement in the ND DOC are now limited primarily
to serious acts of violence resulting in injury. Officials
also changed the nature of the units in which persons
could be isolated from the general population. For example, at JRCC, persons who commit violent rule violations or manifest an acute behavioral health need are
sent to one of two program- and treatment-intensive
specialized units—a Behavioral Intervention Unit (“BIU”)
and a Special Assistance Unit (“SAU”) (both of which
are described in further detail below).
In an effort to modify the atmosphere inside these
treatment-oriented units, ND DOCR officials greatly expanded an already existing initiative in which staff were
encouraged to file positive behavior reports (“PBRs”) that
recognized incarcerated people for displaying empathy
and kindness to others and/or prioritizing their own
educational or clinical goals. One clinician described
PBRs as a

Page 9 of 25

systematic way of recognizing people and the good
things that they do and the positive parts of themselves, to help them invest in themselves more. Staff
now have to sit down and talk about the good
things and that actually shifts staff culture a lot …
the way that people see their jobs here … and
breaks through some of that negative mindset that
can happen when you’re constantly dealing with situations where you feel a lack of the total control
and turn to fear-based responding.
In fact, as one measure of the shift in focus from punishing negative behaviors to acknowledging positive
ones, NDSP officers issued more than twice as many
PBRs as rule violations in the BIU (493 PBRs versus 225
rule violations) between 2015 and 2019.
Improved mental health screening and Services for People
with serious rules violations

The ND DOCR established a “checks and balances”
process to limit admissions to BIU (the Behavioral Intervention Unit at NDSP) and the SAU (the Special Assistance Unit at JRCC) that included mental health screens
and required officials to review placements within 2
workdays. Correctional officials must now decide between
three possible outcomes within 48 hours: immediate
release from restrictive housing, referral to behavioral
health staff for assessment for placement in the BIU
program, or transfer to the SAU.
In addition, to facilitate the enhanced emphasis on
treatment, oversight of the SAU (the Special Assistance
Unit at JRCC) at JRCC was changed from custody staff
to a licensed clinical psychologist. Policy now dictates
that clinical and security staff collaborate to stabilize incarcerated persons' mental health conditions and expedite their return to general population. Two “human
relations counselors” provide therapeutic services on the
unit (e.g., coaching, group counseling, crisis deescalation, and observation reassessments), and incarcerated people are offered individualized clinical care, group
counseling, and congregate activities (e.g., art therapy,
television, games) at least daily.
Staffing credentials and staff training within the SAU
at JRCC were changed as well. Officers are now assigned
to unit based on their temperament and commitment to
working with people with acute mental health needs and
receive training to assist with delivering the individualized behavioral health plans developed by JRCC clinicians. Annual SAU staff training was redesigned to focus
on identifying and responding to self-harm, in addition,
supervisors and clinicians now receive specialized crisis
assessment training, and the SAU’s crisis intervention
team is now comprised of both trained incarcerated
people and staff. Staff psychologists must create an

Cloud et al. Health and Justice

(2021) 9:28

individualized treatment plan for anyone held for more
than 5 days that allows for daily out-of-cell time and
participation in structured activities.
Transforming “solitary confinement” into the behavioral
intervention unit

Following their return from Norway, ND DOCR reconfigured some NDSP cells built during the 2013 solitary
confinement expansion into “preferred housing,” in
which incarcerated people are housed in a single cell but
are otherwise given access to programs and privileges
available to general population prisoners. In 2016, the
remaining cellblocks were converted into the “Behavioral
Intervention Unit” (BIU) to be used as a “last resort” for
people deemed to need physical separation from the
general population, usually for committing serious
assaults.
The goal of the BIU is to reduce violence through
mental health services guided by motivational interviewing, cognitive behavioral therapy, and positive psychology. Since its inception in 2016, the BIU committee—
comprised of a Deputy Warden, behavioral health supervisor, chief of security, and unit manager—have conducted individualized, in-person reviews of each person’s
case every 7 days including their behavior plan, engagement in programming, progress towards their goals, and
the likelihood of violence if they return to general population. The review committee is required to provide a
written explanation to each person stating a rationale for
holding or releasing them from the BIU. In a transitional
tier in the BIU, people are expected to continue to participate in counseling, but are allowed more property
and privileges and eat meals and recreate with people
from general population in preparation for returning to
general population.
ND DOCR policy states that the BIU “offers residents
as much meaningful out of cell time and enrichment activities as possible to minimize distress and isolation to
people living in the unit.” Both staff and incarcerated
people described ways in which the BIU is less harsh
than the solitary confinement units were before reforms,
including increased counseling, more meaningful out-ofcell time, use of privileges and property to reinforce
positive behavior, and better interactions between staff
and incarcerated people. One imprisoned person said, “I
just got out of there … Now, it doesn’t even feel like
punishment.” Releases from BIU are guided by staff’s efforts to recognize positive behaviors rather than punish
undesired ones. One official explained:
It used to be that when it came time to consider release from restrictive housing, we had to rely mainly
on the fact that a person had not done anything
“bad” during their stay in restrictive housing. But

Page 10 of 25

they also did not have any opportunities. Now, we
don’t rely only on the absence of negative behavior,
and instead focus on the presence of positive behavior. With that, the mantra “progress not perfection”
is something we remind ourselves of often.
Both staff members and individuals who had experienced BIU firsthand reported that people were no longer
being kept in their cells for 22–23 hours or more each
day, and now were allowed more personal property (e.g.,
televisions, reading materials), programming options,
and family communication. Mental health professionals
were given a larger role in unit operations as well as
interacting with incarcerated people more frequently
and conducting group therapy sessions three times per
week.
To further limit BIU stays for persons who continuously violate minor rules in the general population, officers are now required to summarize the alternative
sanctions short of confinement that have been applied,
articulate the expected benefits of placing the person in
the BIU, and articulate individualized plans that incorporate positive reinforcement strategies to address negative behaviors. In addition, the warden is now required
to review each case of every person who has been held
“continuously” in the BIU for the previous 4 months.
Any BIU placement that reaches 12 months must be
reviewed by the ND DOCR director.
Despite these policy changes, some ND DOCR officials
have acknowledged that long BIU stays remain a pressing concern. According to administrative data, 445
unique individuals spent at least 1 day in the BIU between 2018 and 2019, of which 5.39% spent between 100
and 180 days, 4.04% between 180 and 365 days, and 0.9%
more than 1 year. Incarcerated people shared mixed reactions to the BIU’s cognitive behavioral therapies and
skills training. Some reported that they had experienced
clear benefits. For example, one person said that engaging in skills training “has helped me in the long run.
I’m more cool-headed. I’ve developed that time to slow
down and actually think before reacting.” Others observed that the usefulness of skills training tended to diminish after leaving the BIU, because people are no
longer supervised by the more knowledgeable and better
trained BIU staff. They felt officers working in general
population units sometimes fail to appreciate their attempts to use the skills that they had developed in the
BIU, and some general population officers act more
abrasively towards them than when they were posted in
the BIU. As one incarcerated persont told us:
The whole program’s gone, once you get out. COs
act one way back in BIU, and they come out and
they start working in the West, and they’re a whole

Cloud et al. Health and Justice

(2021) 9:28

other CO. They’re no longer how they were taught,
back there.
Although the BIU was described by incarcerated
people and staff as being less isolating and punitive than
before reforms were implemented, the people who are
confined there continue to experience significant day-today restrictions (e.g., they are restrained when leaving
their cell, eat meals and recreate alone, and are allowed
limited property). In addition, as one NDSP staff member noted, living conditions in the BIU remain bleak,
“it’s just the staleness of the area and the cages, no
greenery. Many of the things that we shouldn’t have … is
what it [BIU] is.”
Officers and clinicians candidly acknowledged that,
despite reforms, the level of social isolation that is still
being imposed in the BIU was problematic and likely
had adverse effects on some people. They reported that
some incarcerated people do not benefit from the skills
training and "behavior modification plans", and instead
deteriorate mentally during their time in the unit. A BIU
officer who provides skills trainings said, “With some individuals, when they come back here, they’ll stop taking
their meds and that kind of sends them backwards.” An
individual who had been placed in BIU multiple times
found the positive-reinforcements and cognitive-based
skills training "superficial" and ineffective and said the
conditions in the BIU were still socially isolating and dehumanizing. He stated: “The less human you treat me,
the less human I’m going to behave. I want to be treated
like a human. I want to have those things that make me
comfortable. Without those things, I can’t be who I want
to be.”
Other officials recognized that the BIU, and other reforms, were works-in-progress, subject to structural
forces in the larger prison system beyond their control
(such as overcrowding and financial constraints) that
prevented them from moving as fast or far as they would
have liked. One official stated, “We’re not out of the
woods yet. Being in BIU can still have a negative effect. I
don’t think we do enough out-of-cell time or provide
enough interventions to counteract what is still fairly
isolating.” A person imprisoned at NDSP who had spent
time in the BIU echoed this sentiment, “I think we’re
close here, but there’s going to be 15 very important
parts and we probably have 10 of them whereas there
used to be about two of them.”

Page 11 of 25

1.) The new correctional officer role included an explicit
commitment to build trust and positive relationships
with incarcerated people, to treat them with respect, and
to focus on the reinforcing positive behaviors, rather
than punishing undesirable ones. To socialize and instill
officers in this new role, ND DOCR officials instituted
department-wide trainings in dynamic security, motivational interviewing, and mediation, and encouraged
staff to apply these principles and tools to proactively resolve conflicts rather than resorting to solitary confinement. In the BIU, for example, psychologists began
training officers to administer individually tailored positive reinforcements and BIU officers were instructed to
practice newly acquired cognitive and behavioral skills
with each person on the unit at least once per shift.
As part of the process of modifying the nature of the
correctional officer role, staff were trained to use mediation in response to physical altercations to help those
involved identify and reconcile the issues leading to conflict. Although altercations and fights between incarcerated persons still sometimes precipitate immediate
physical separations (in the BIU or SAU), they now typically last for no more than 1–3 days, until mediation is
completed. At that point, people are usually returned to
the general population. Incarcerated persons described
the benefits of the mediation process as much preferred
to solitary confinement. According to one individual:
Say him and I got into a fight … they will make us
sit and talk to each other with two other staff members. It’s pretty much just to clear things out and
make sure... there is not going to be animosity.
People cool down, shake hands and forget about it.
And I’d say, nine out of ten times that’s exactly what
happens, everything’s fine.
Staff reported that they came to regard mediation as
an effective response to altercations that previously
would have resulted in time spent in solitary confinement. A case manager explained:
We’ll give them [incarcerated people] the chance to
speak both sides, to talk, and explain what they were
thinking, what they were feeling at the time. I can’t
even think of the last time that we had a mediation
between two people who fought that still chose to
fight again afterwards.

Changing the nature of the correctional officer role

Reconfiguring correctional officer training

Following their return from Norway, ND DOCR officials
also took steps to transform the nature of the correctional officer role by explicitly incorporating the Norwegian Correctional Service principles of “dynamic
security,” “normalization,” and “progression.” (See Table

The ND DOCR modeled its new recruitment and training protocols on those of the Norwegian Correctional
Service. As one correctional official explained, “As we
got more formal about [reform], I came to realize that a
lot of the stuff we were doing would never be sustainable

Cloud et al. Health and Justice

(2021) 9:28

in the pouring rain if we did not embed it into our training.” Therefore, the department developed system-wide
trainings to enhance officer skills in motivational interviewing, positive reinforcement, and dynamic security
and simultaneously educated them on the psychologically harmful effects of solitary confinement. Staff reported that these trainings not only were important for
increasing officer engagement but also gave them a
framework with which to understand why people sometimes deteriorated psychologically and engaged in selfharm while in solitary confinement. An officer
explained:
So, we have a person that’s back here [BIU] right
now that’s been back in segregation off and on
through my entire career and before. And even
people that I came up with, they’re even starting to
see, wow … something’s going on with him. He
wasn’t like this before. And I can actually point to
look how many times he’s been in Segregation. Look
at the duration that he was in Segregation. I can explain to them what happens with the brain if you’re
in Segregation with limited stimulus. More and
more people are starting to see that now.
The department also revised its job descriptions and
recruitment strategies to be more consistent with the
Norwegian approach, making it clear at the outset that
they were seeking potential employees who were committed to rehabilitation. In order to teach the panoply of
additional skills necessary to perform in the new correctional officer’s role, and to enhance professionalism in
the officer corps, the length of the new officer training
program was significantly increased—from 3 weeks to 6
months. In describing the kind of person the department
now sought to hire in the new correctional officer role,
one official said:
We don’t really want cops. Rather than an authoritarian, we want people who are more of the educator, social worker, behavioral health person –
someone that just wants to work with people.” A
case manager expressed the hope that these
organizational changes would bring “new generations of officers that are a lot more receptive to reforms … I’m looking for someone who can
communicate well, who can leave their ego at the
door, and not hold grudges.
The impact of policy changes on the ND DOCR’s use of
solitary confinement

ND DOCR officials reported that the host of Norwayinspired policy changes that they implemented, as we
described above, helped them achieve dramatic

Page 12 of 25

reductions in the numbers of persons housed in solitary
confinement. Specifically, between January 2016 and
December 2019, the ND DOCR reduced the total number of people held in solitary confinement-type units
(placements in the SAU or BIU) in NDSP and JRCC by
74.28% (compared to the pre-reform period, January
2010 through December 2015). The monthly rate of solitary confinement sanctions decreased by 99% at JRCC
and 59.1% at NDSP over this same timeframe (Fig. 3).
Most admissions into SAU or BIU were shorter than before the reforms were implemented. In 2015, the median
length of stay for people housed in a cell designated for
administrative segregation was 89 days; it dropped 59%,
to 34 days, over the next 4 years (between January 2016
and December 2019).
In addition to these reductions in the frequency and
duration of solitary confinement, ND DOCR officials
and staff reported that Norway-inspired policy changes
helped them modify other aspects of the way their
prison system operated. We describe the most important
of these modifications below.
Reductions in the number of people with serious mental
illness in solitary confinement

Many officers reported that the increased clinical services that were now being provided to incarcerated
people—ones in accord with the Norwegian principle of
“progression” that continuously seeks to move people
who are incarcerated to better, less restrictive living conditions — has contributed to significant reductions in
the number of people with serious mental health needs
housed solitary confinement. A former Warden
explained:
We have people right now that we never thought
would stay out of a segregation unit. For years, 10
years, 12 years, back and forth between segregation,
general population. Many of those guys today, since
the changes have happened in restrictive housing,
they’ve never come back.
From 2016 through 2019, the ND DOCR achieved a
substantial decline in the number of solitary confinement sanctions imposed on people with a documented
history of serious mental illness (i.e., schizophrenia, bipolar disorder, major depression, and/or PTSD), Fig. 4.
For instance, before reforms were implemented (between
January 1, 2010 and December 31, 2015), there was an
average of 11.39 solitary confinement placements among
people with serious mental illness per month between
both prisons. In the post-reform period (January 1, 2016,
to December 31, 2019), it decreased 630% to an average
of 1.56 placements per month. Clinical staff attributed
this reduction to more in-depth mental health

Cloud et al. Health and Justice

(2021) 9:28

Page 13 of 25

Monthly Average Rates of Solitary Confinement (per 100 incarcerated persons)
NDSP & JRCC (January 2010- December 2019)

2010

2011

2012

2013

I-

2014

2015

NDSP

2016

-

2017

2018

2019

2020

JRCC

Fig. 3 plots the monthly rates of solitary confinement placements (per 100 incarcerated persons) at NDSP (blue) and JRCC (red) from January 1,
2010 through December 31, 2019. It illustrates the sharp decline starting in the Fall of 2015 when North Dakota started implementing the policy
changes described in this manuscript

screenings, enhanced mental healthcare in the general
population, and the option to divert people with serious
mental illness to the more treatment-oriented SAU. One
clinician noted, “there is even more awareness that
someone with a serious mental illness shouldn’t be in
[solitary confinement].” Staff and incarcerated people
said that mental healthcare has improved in SAU alongside declines in self-harm events and less violence
against staff. The 24 treatment beds in the SAU mostly
remain at full capacity, occupied by many individuals
who, in past times, would have been placed in solitary
confinement.
Most participants agreed that mental health services
have improved, noting that psychologists now handle situations that previously were addressed by security staff.
One imprisoned person noted, “the treatment department is empowered to work with people like humans.”
Several acknowledged the role of the behavioral health
staff in helping long-term residents progress out of isolation. Another person who spent 28 out of 30 years incarcerated in solitary confinement said:

I went all those years without the treatment department working with me. For a long time, they didn’t
have my meds straightened out … I was feeling I
had to act out or whatever. But now it’s easier to
deal with things. They’re actually going out of their
way to work with you now.
Staff also acknowledged the value of another Norwayinspired approach —giving incarcerated people who had
successfully transitioned to the general population after
solitary confinement a specialized role as “peer mentors,”
to help support other incarcerated peoples improve their
problem-solving and coping strategies to avoid future
BIU placements. One staff member noted that “having
45 people that take care of other residents in some fashion” has greatly enhanced access and quality of behavioral health services, while improving the well-being of
the peer mentors themselves. Another official explained:
They’ve [peer mentors] become part of the team.
That wouldn’t have ever happened without the

(2021) 9:28

Cloud et al. Health and Justice

Page 14 of 25

Monthly Placements in Solitary Confinement Among People with Serious Mental Illness
NDSP & JRCC (2010-2019)

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Fig. 4 displays the total number of incidents each month (between January 2010 and December 31, 2019) in which an individual with a
diagnosis of serious mental illness (i.e. schizophrenia, bipolar disorder, major depression, and/or PTSD) was placed in solitary confinement (i.e.
sanctioned to disciplinary segregation or referred to administrative segregation) following a rule violation conviction. It shows a significant
decrease beginning at the end of 2015 and a total reduction that was sustained through the post-reform observation period

foundation of dynamic security and coming in and
saying it’s normal for people to take care of people.
We’ve seen huge, huge changes in people; not only
the people that are being cared for but the guys, the
mentors. All of a sudden, they have purpose. They
have hope. It just completely changes their outlook.

Improved staff-incarcerated persont interactions

Both staff and incarcerated people acknowledged that
their interactions with one another had improved in the
wake of these overall reforms. ND DOCR officials attributed some of the improved interpersonal interactions to
increased staff awareness about the psychological harms
of solitary confinement, especially for those individuals
who had long histories of solitary confinement and/or
BIU enrollment. Staff also reported enhanced job satisfaction, reduced day-to-day stress, and increased perceptions of personal safety. An officer credited the infusion

of dynamic security principles into department policy,
training, and daily practice as leading to a less volatile
environment at NDSP: “It is calmer. Staff talk to people
all the time. We’re stopping many, many incidents before they happen because there’s a rapport. I’ve seen so
much change in some of the guys that have been here
for a long time.”
Clinicians and administrators also observed the benefits to staff that accrued from working in a less stressful
and noxious environment in the SAU, where many fewer
cell extractions took place. One stated “it’s a more positive experience now. It doesn’t smell, it’s not loud,
there’s not SORT [Special Operations Response Team]
coming in every other day. It’s just a different vibe.”
In addition, staff reported that there was less hostility
and conflict between them and people assigned to the
BIU, compared to the administrative segregation units of
the past. They attributed these changes to overall reductions in the use of solitary confinement and the fact that

Cloud et al. Health and Justice

(2021) 9:28

even those person who were housed in BIU now had
more opportunities for human interaction and time out of
their cell. An NDSP staff member noted that the changed
policies and practices had drastically decreased deployments of SORT and crisis teams in the BIU:
It’s an amazing thing. Our special operations teams
in our segregation unit are basically zero. Our crisis
negotiations teams, if we have a situation, all of
those things have been impacted … you actually
start forgetting about it, because it just doesn’t
happen.
Similarly, a clinician described the benefits of the new
dynamic security approach this way: “[There is now] a
lot more relationship building, more talking to people
when they’re struggling, intervening sooner, working
through prevention, and being flexible around things
that we used to be very static about.” These transformations in the interactions between staff and incarcerated
people fostered what many of the persons whom we
interviewed described as a deeper change—the creation
of a more compassionate culture in the units themselves.
One clinician stated:
For me personally, the measure of success that I see
is the actual growth and change that we’ve seen in
the residents. Those things are harder to measure.
But the fact that we had guys who were just consistently angry, able to feel good, and let go of some of
that anger, and just have moments where they are
enjoying life despite being locked down is the big
success.
Staff also reported that being trained to better help
people solve personal problems, understanding the traumas and adversities endured in their life histories, and
witnessing their improvements following the policy
changes had a positive impact on their job and perspective of incarcerated people. A case manager, initially
skeptical of the reforms, said:
It’s made my working relationships with the residents... and actually even with the staff... a lot better.
I don’t take things to heart or look at it as an attack
on me. I just look at it as what it is. It’s a behavior.
Behaviors are learned. Behaviors can be unlearned.
Let’s find out why this happened and try to figure
out a better way.
Many staff reported discovering a deeper sense of responsibility and purpose in their profession. One BIU officer emphasized the importance of empathy,
respect, and professionalism to counteract the “us versus

Page 15 of 25

them” mentality that pervades correctional culture. Another BIU officer explained:
A lot of times when they come down here, excuse
my language, they’ll just say “you’re just a fucking
blue shirt, I don’t trust you.” But you just show
them respect or show them human decency. People
that come down here just crave respect and a conversation. Like an intelligent conversation. Regardless of what shirt I’m wearing, regardless of what
you think I represent, I’m here to help. So, the oneon-one rapport and being able to see that change,
just little by little. That is rewarding.
Incarcerated people agreed that many officers became
less punitive and more skilled at resolving conflicts
through mediation. They confirmed that many infractions that previously would have resulted in solitary confinement, particularly minor fights or conflicts, now do
not. One man, imprisoned for 17 years, said:
In the past, let’s say you got into a fight, you were
in the hole for 30 days, maybe the first time and
then the second time, six months or a year in a
lockdown situation. Now, it’s a lot less time in the
hole. They just make sure that the situation is not
going to get out of control. It might only take a day
or two, and you’re not just locked into a cell.
Staff also reported that incorporating dynamic security
into their policies and practices has resulted in a positive
change in workplace culture. One officer explained:
Now staff sit down, think, and talk thoroughly about
the positive things happening. That shifts staff culture and way that people see their jobs a lot. It
breaks through some of that negative mindset that
can happen when constantly dealing with situations
where you feel a lack of control and turn to fearbased responding.
A clinician illustrated one of the ways that incorporating dynamic security into ND DOCR’s practices had
changed the staff perceptions of workplace safety: “You
will hear staff say things though like, ‘It’s not the cuffs
that keep you safe, it’s the relationship you have with a
person,’ and that type of thing. And it’s just a really great
principle that’s spread across the whole entire facility.”
Trends in institutional violence following solitary
confinement reforms

As noted, ND DOCR’s Norway-inspired policy reforms
were initially met with skepticism by some staff members and officials who feared that the changes would

Cloud et al. Health and Justice

(2021) 9:28

Page 16 of 25

lead to increased violence and ultimately endanger staff.
One clinician described colleagues as being, “very worried that doing anything that’s not punitive or authoritarian is going to end up with them hurt.” Similarly, one
security official recalled:
There was this narrative that we were going to make
things more dangerous in the general population by
not allowing people to be locked up in solitary confinement. And that was something that we really
had to show in the data, really keep track of violence and fights and acknowledge the staff’s fear.
However, contrary to these expectations, most of the
staff and incarcerated people whom we interviewed
agreed that the reforms appeared to them to have either
reduced violence levels or that they remained the same.
Both groups reported that assaults resulting in serious
injury had been reduced. Some incarcerated people did
not perceive any difference in the number of assaults
against staff, stating that people with histories of assaulting staff are typically the ones who still engaged in that
behavior. One individual said, “I don’t necessarily think
there [are] less staff assaults. It’s not like random inmates [sic] are beating up [correctional officers] now, it’s
the same people.”
Overall rule infractions for violence across both prisons

Our analysis of the ND DOCR’s data indicated that perceptions that violence decreased or remained the same
following the reforms to solitary confinement were largely
mirrored in the administrative data. When we analyzed
the department’s administrative records of disciplinary
actions filed by correctional officers to quantify trends in

interpersonal violence before and after reforms, we found
that there were no statistically significant changes in the
average monthly rates of all violent infractions (per 100
incarcerated persons) across the two prisons before and
after the reforms (fights among residents, assaults among
residents, violence against staff, or overall Table 2). The
monthly rate of all combined disciplinary events involving
violence across both prisons showed a slight and statistically insignificant decrease from 3.5 incidents per month
before reforms (January 1, 2010, through December 31,
2015) to 3.44 per month following the reforms (January 1,
2016, through December 31,2019) (p = 0.66). There also
were no statistically significant changes in the monthly
rate of assaults on staff following the reforms (0.24 vs.
0.32 events per month, p = 0.203), nor in assaults between incarcerated people (0.70 vs. 1.16 assaults per 100
incarcerated persons , p = 0.31).
To further assess the relationship between changes in
the use of solitary confinement and behavioral infractions for interpersonal violence, we calculated Incidence
Rate Ratios (IRR) between the monthly rates of solitary
confinement and each indicator of violence using negative binomial regression with fixed effects. Overall, there
was a small, statistically significant, positive association
between monthly rates of solitary confinement and overall violent infractions across both prisons (IRR = 1.012,
p < 0.05), meaning that in months where the use of solitary confinement decreased there was a small and significant associated decrease in the monthly rate of
violent infractions (Table 3).
Rule infractions for violence at NDSP

At NDSP, we found that fights between incarcerated
people (the lower severity level of rule infractions involving

Table 2 Facility-wide Monthly Rates of Disciplinary Events Involving Physical Violence (Per 100 incarcerated persons ) NDSP, JRCC, &
Combined Pre-reform (January 2010–December 2015) vs. Post-Reform (January 2016–December 2019)
NDSP
Indicator

Monthly Mean

JRCC
p-value

Monthly Mean

Combined
p-value

Monthly Mean

p-value

All Violent Infractions
Pre-reforms

2.85

Post-reforms

3.49

2.17
0.46

1.98

3.50
0.00*

3.44

0.66

Violence Against Staff
Pre-reforms

0.24

Post-reforms

0.32

0.16
0.49

0.10

0.23
0.24

0.26

0.23

Fights among Residents
Pre-reforms

1.29

Post-reforms

1.98

2.91
0.04*

2.44

1.89
0.32

2.15

0.93

Assaults between Residents
Pre-reforms

0.70

Post-reforms

1.16

0.75
0.31

0.62

0.71
0.39

0.96

0.51

Cloud et al. Health and Justice

(2021) 9:28

Page 17 of 25

violence) increased across all housing units from over 1 to
just under 2 incidents per 100 incarcerated persons per
month 1.29 vs. 1.98, p < 0.001), Table 2. This finding appears to have been driven by an increase in fights which occurred in the first year after the reforms were implemented
in 2016, followed by a downward trend for the remainder
of the observation period, Fig. 5a. It is important to note
that the BIU was not operational and revised disciplinary
policies were not in effect until May of 2016, when the
downward trend began.
Figure 5a shows actual and predicted linear trends in
the monthly counts of fights (left) and assaults (right) at
NDSP, before and after ND DOCR implemented policy
changes to limit use of solitary confinement in response
to most rule violations and the established the Behavioral Intervention Unit (BIU). The vertical line denotes
the intervention point of May 1, 2016, when these reforms were operating and was selected in consultation
with ND DOCR leadership.
For the graph on the left, the upward slope of the prediction line, before the intervention, suggests that
monthly assaults increased from January 2010 to May of
2016 (B = 0.06, p = 0.221, CI = − 0.03, 0.14), but not to a
statistically significant degree. It also depicts that during
the early months after reforms, fights increased significantly (B = 11.78, p > 0.0001, CI = 5.46, 18.11). However,
Table 3 Incident Risk Rations from Negative Binomial
Regression with Fixed Effects for Monthly Rates of Solitary
Confinement & Violent Infractions (2010–2019)
Incident Rate 95% CI
Ratio

pvalue

NDSP
All Violent Infractions

1.0001

0.992 1.009 0.886

Violence Against Staff

1.003

0.980 1.026 0.781

Fights between incarcerated
people

0.995

0.983 1.006 0.363

0.995

0.979 1.011 0.551

1.034

1.019 1.052 0.00*

Assaultsbetween incarcerated
people
JRCC
All Violent Infractions
Violence Against Staff

1.050

1.016 1.085 0.003*

Fights between incarcerated
people

1.026

1.006 1.047 0.011*

Assaults

1.011

0.985 1.037 0.412

1.012

1.005 1.019 0.001*

Combined
All Violent Infractions
Violence Against Staff

1.016

0.999 1.033 0.064

Fights between incarcerated
people

1.006

0.997 1.016 0.150

Assaults between incarcerated
people

1.003

0.990 1.015 0.683

as the downward slope of line illustrates, following these
policy changes there was a significant overall decrease in
monthly trends of fights at NDSP, between May 2016
and the end of 2019 (B = − 0.38, p > 0.0001, CI = − 0.60,
− 0.16). For the graph on the right, as the nearly flat
slope of the pre-intervention line depicts, monthly assaults did not change to a statistically significant degree,
between January 2010 and May of 2016, (B = 0.004, p =
0.893, CI = − 0.54, 0.06). As with fights, it shows that
during the early months after these reforms, assaults between incarcerated people increased significantly (B =
8.80, p > 0.0001, CI = 4.57, 13.04). Similarly, however, the
downward slope of line after the intervention point suggests a significant overall decrease in the monthly trend
of assaults at NDSP between May 2016 and the end of
2019 (B = − 0.22, p > 0.001, CI = − 0.37, − 0.07).
Furthermore, when we examined the associations between monthly rates of solitary confinement and rule infractions related to violence following reforms, we found
that none of the associations reached statistical significance (monthly rates of solitary confinement and resident fights, IRR = 0.995, p = 0.363); monthly solitary
confinement and assaults between incarcerated people
(IRR = 0.995, p = 0.551); and monthly solitary confinement and assaults on staff (IRR = 1.003, p = 0.781). The
relationship between monthly solitary confinement and
all violent infractions was also not statistically significant
(IRR = 1.0001, p = 0.886) at NDSP).
The lack of an association between monthly rates of
solitary confinement and infractions related to violence
mirrored the perceptions of staff and incarcerated people
expressed during interviews and focus groups in which
neither group attributed the slightly increased average
frequency of fights at NDSP to the solitary confinement
reforms. Instead, most suggested that the increases were
likely due to persistent overcrowding in the ND DOCR
including, at NDSP, increased double celling, more
crowded dining and recreational areas, and a lack of
privacy and personal space over those years. For example, one incarcerated person observed, “there’s some
guys that just can’t have a cellie. They just can’t mentally
or physically have that extra body inside with them.” Another noted that things at NDSP “got really violent because they doubled us up in the cell.” Others explained
that over-crowding, combined with lack of programming, educational, and job opportunities, and reduced
privileges resulted in constant idleness among general
population. One person imprisoned at NDSP said that
crowding had resulted in people without constructive
options to spend most of their day locked-down and reduced yard time schedules. That is: “In locked down 18plus hours a day. For rec time, more often than not,
they’re [staff] late to let you out [of one’s cell], but
they’re always on time to lock you back in.”

(2021) 9:28

Cloud et al. Health and Justice

Page 18 of 25

a. Interrupted-Time-Series of Resident Fights & Assaults Using Prais-Winstein Regression
Post-Implementation of Disciplinary Policy Changes and BIO-reforms at NDSP
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Fig. 5 a shows actual and predicted linear trends in the monthly counts of fights (left) and assaults (right) at NDSP, before and after ND DOCR
implemented changes to limit use of solitary confinement in response to rule violations and the established the Behavioral Intervention Unit
(BIU). The vertical line denotes the intervention point of May 1, 2016, when these reforms were operating and was selected in consultation with
ND DOCR leadership. The graph on the lefts suggests that monthly assaults increased from January 2010 to May of 2016 but did not reach
statistical significance (Β = 0.06, p = 0.221, CI = − 0.03, 0.14). It also shows that during the early months after reforms, fights increased significantly
(Β = 11.78, p > 0.0001, CI = 5.46, 18.11). However, the downward slope of line after the intervention point suggests a significant overall decrease in
the monthly trend of fights at NDSP between May 2016 and the end of 2019 (Β = − 0.38, p > 0.0001, CI = − 0.60, − 0.16). The nearly flat slope of
the pre-intervention line on the graph to the right that suggests monthly assaults did not change significantly between January 2010 and May of
2016, (Β = 0.004, p = 0.893, CI = − 0.54, 0.06). As with fights, this plot also shows that during the early months after reforms,
assaults between incarcerated people increased significantly (Β = 8.80, p > 0.0001, CI = 4.57, 13.04). However, the downward slope of line after the
intervention point suggests a significant overall decrease in the monthly trend of assaults at NDSP between May 2016 and the end of 2019 (Β =
− 0.22, p > 0.001, CI = − 0.37, − 0.07). b shows actual and predicted linear trends in the monthly counts of fights (left) and assaults (right) at JRCC,
before and after ND DOCR implemented changes to limit use of solitary confinement in response to rule violations and enhanced staffing and
services in the Special Assistance Unit (SAU), a housing area for people with acute psychiatric needs. The vertical line denotes the intervention
point of May 1, 2016, when these reforms were operating at JRCC and was selected in consultation with ND DOCR leadership. For the graph on
the left, the upward slope of the prediction line, before the intervention, suggests that monthly fights increased significantly prior to May of 2016
(Β = 0.30, p < 0.0001, CI = 0.19,0.39). By contrast, the downward slope of line after the intervention point illustrates a significant decrease in the
monthly trend of fights in the initial months, post-reforms (Β = − 10.32, p > 0.0001, CI = -0.69,-0.19), and a significant monthly decrease from May
2016 through December 2019 (Β = − 0.45, p > 0.01, CI = − 0.69, − 0.19). For the graph on the right, the downward slope of the line, before the
intervention, suggests that monthly assaults decreased prior to reforms, but was not statistically significant ((Β = − 0.13, p = 0.377, CI = − 0.43, 0.02).
Similarly, the downward slope of the line after the intervention point illustrates a small increase in assaults in the initial months post-intervention
(Β = 1.34, CI = − 0.80, 3.48), followed by a decrease in the monthly trend of assaults in the post-reform period (Β = -0.21 p = 0.574, CI = − 0.9, 0.05)
that was not statistically significant

Cloud et al. Health and Justice

(2021) 9:28

Incarcerated persons said that fights and assaults occur
most frequently in the communal spaces of the East and
West units, because people spend most of their day
locked down and staff assigned to the unit is less experienced to meet their needs and constructively respond to
grievances and conflicts. As another person imprisoned
at NDSP explained,
I live in the East. I've lived everywhere in the institution. My unit is much more violent. They call it the
ghetto. They treat it like that. The guards don't want
to be down there. They always put the brand-new
guards who don't know nothing. I don't care who
you are but you're going to be slow at your job and
all that breeds is that constant animosity, the
screaming, everything else.
Another incarcerated person lamented that crowding
people who have spent the majority of their day idle in a
cell with another person in a prison recreation space inevitably breeds tension and conflict.
I'm sorry, I don't care if we all get along or not. You
put 200 dudes in a room that's meant for 50 people,
there’s two benches and there's 25 people that want
a [weight] bench. These people aren’t going to care
that you don't bother nobody...You've been here for
years doing the same routine. This guy’s come over
and wants to work out too, who are you to tell him
what to do. He's got nothing to lose.
Staff members also pointed to the overall overcrowding in the ND DOCR rather than solitary confinement
reforms as being primarily responsible for the increased
number fights in general population. One clinician said,
“it takes a lot to live in a place that’s the size of a bathroom, with a toilet in it, and another person.” Similarly,
an NDSP official attributed most of the additional “disruptive behavior” and even slight increases in violence to
factors other than the solitary confinement reforms, including things over which the prison system had little
control, such as sentencing laws, crowding-related declines in living conditions, and the expansion of NDSP
in 2013. As this official put it:
It’s not just a prison problem. It’s a society problem.
Over-incarceration … the lengths of sentences are
too long. We expanded from 550 beds to 850 beds.
We didn’t add any dining room space. We didn’t
add any recreation space. We didn’t add any classrooms, no extra programming, and we actually cut
the yard down by 40%. We just keep smashing
people in. It gives people no privacy.

Page 19 of 25

Rule infractions for violence at JRCC

At JRCC, fights were rising precipitously before reforms
were implemented, but dropped substantially at the start
of 2015 and reached a low point at the end of 2019, Fig.
5. These perceptions were mirrored in the JRCC administrative data analysis. While the monthly rate of solitary
confinement sanctions decreased by 99% over the course
of this case study, there were no increases in the average
monthly rate of fights or assaults among incarcerated
people, or assaults on staff, at the facility level. Instead,
rule infractions involving violence decreased significantly
from just over 2 to just under 2 events per month per
100 residents (2.17 to 1.98, p < 0.05); the monthly rate of
fights between incarcerated people, assaults between incarcerated people, and assaults on staff showed no statistically significant change (Table 2). We also found that
with each additional decrease in the monthly rate of solitary confinement at JRCC, the rate of monthly violent
infractions decreased by about 3.4% (IRR = 1.034, p <
0.05), with about a 5% decrease in staff assaults (IRR =
1.050, p < 0.05) and a 2.6% decrease in fights between incarcerated people (IRR = 1.026, p < 0.05).
All of the incarcerated people we interviewed at JRCC
reported that the solitary confinement reforms had contributed to lower levels of hostility and violence throughout the prison. One focus group participant explained
that when he first arrived at the prison “you couldn’t go
a week without there being a fight. Now, they’re few and
far between. It’s chilled out quite a bit. People get along
more, a lot more social interaction.” Another noted that
disciplinary policy changes and improvements in how officers interact with incarcerated people “has made less
people angry, more people happier, there’s a better vibe
here and as a result there’s just been less violence and
no stabbings here.”
Figure 5b shows actual and predicted linear trends in
the monthly counts of fights (left) and assaults (right) at
JRCC, before and after ND DOCR implemented changes
to limit use of solitary confinement in response to rule
violations and enhanced staffing and services in the Special Assistance Unit (SAU), a housing area for people
with acute psychiatric needs. The vertical line denotes
the intervention point of May 1, 2016, when these reforms were operating at JRCC and was selected in consultation with ND DOCR leadership. For the graph on
the left, the upward slope of the prediction line, before
the intervention, suggests that monthly fights increased
significantly prior to May of 2016 (B = 0.30, p <
0.0001, CI = 0.19,0.39). By contrast, the downward
slope of line after the intervention point illustrates a
significant decrease in the monthly trend of fights in
the initial months, post-reforms (B = − 10.32, p > 0.0001,
CI = -0.69,-0.19), and a significant monthly decrease from

Cloud et al. Health and Justice

(2021) 9:28

May 2016 through December 2019 (B = − 0.45, p > 0.01,
CI = − 0.69, − 0.19). For the graph on the right, the downward slope of the line, before the intervention, suggests
that monthly assaults decreased prior to reforms, but
was not statistically significant (B = − 0.13, p = 0.377,
CI = − 0.43, 0.02). Similarly, the downward slope of the
line after the intervention point illustrates a small increase in assaults in the initial months post-intervention
(B = 1.34, CI = − 0.80, 3.48), followed by a decrease in the
monthly trend of assaults in the post-reform period
(B = -0.21 p = 0.574, CI = − 0.9, 0.05) that was not statistically significant.
Rule infractions for violence in the BIU and SAU

Our analysis of the ND DOCR’s institutional data for
the solitary confinement units themselves (the BIU
and SAU) showed reduced levels of violence following
the reforms. For example, we found that physical violence occurred less frequently in the BIU than it had
in the NDSP solitary confinement units before reforms were initiated. Specifically, in the 4 years before
reforms were implemented (January 1, 2012, through
December 31, 2015), there were 53 assaults on staff
in the solitary confinement units at NDSP, charged
against 13 different people. By contrast, no staff assaults
were reported during the first 2 years of the BIU program.
Although staff assaults increased to 21 in the BIU over the
next 2 years, most (85.7%) involved just one incarcerated
person. Assaults between incarcerated people also decreased after the BIU reforms were implemented: a total
of 17 such assaults occurred between 8 individuals from
2012 through 2015 in the traditional solitary confinement
units, as compared to 10 such assaults involving 3
individuals in the BIU post-reforms.
When asked about violence in the BIU, a security official said “it ebbs and flows. There’s times where we’ll
have very little going on, and then there’s other times
where it seems like the roof’s caving in.” Another NDSP
staff member perceived fewer BIU emergencies than occurred in the solitary confinement units of the past:
All of a sudden, the trauma and emergencies, the
things that happen on a daily basis just continue to
reduce specifically in that unit. You’re still going to
have bad days, but the bad day today is different
than the bad day it was [before].
There were also perceived and measurable decreases
in disciplinary incidents involving physical violence in
the SAU following reforms. Monthly average incidents
involving violence in the SAU decreased by 52.17% and
were significantly lower post reforms (1.15 to 0.55 per
month, p = 0.00). The monthly rate of staff assaults decreased by 62.82% (0.78 to 0.29, p < 0.05).

Page 20 of 25

Behavioral infractions for violence among peoples with
serious mental illness

We also found reductions in charges for rule infractions
for violence by persons with serious mental illness (SMI)
diagnoses across both NDSP and JRCC. In the prereform period—from 2010 to 2015— 28.02% of all violent rule infractions involved a person with an SMI diagnosis. This decreased to 14.95% in the post-reform
period, despite an increase in the total number of people
diagnosed with SMI in the prison population.
Clinicians and security staff reported that multiple
incarcerated people with serious mental health needs
who had previously spent most of their imprisonment in
the SAU or in solitary confinement due to assaultive
behavior were now living in dormitories without incident. One official said: “Guys who had never lived in GP,
have been in GP for years, and are just doing so much
better. And aren’t doing the assaultive behavior.” A mental health clinician for patients with severe mental health
needs and histories of assaults reported that the changes
within the SAU and the creation of BIU both helped
people receive more intensive clinical services and stay
out of segregation. She said that there were:
A bunch of people who we saw no movement on
for a very long time, moved out and we got them
out quickly and they have stayed out and done well.
I just got a calendar notification about one of our
guys who struggled for a long time going in and out
[of solitary confinement] for violence and he’s been
nonviolent for two years and is doing great.

Discussion
This case study describes the policy and programmatic
changes made by the North Dakota Department of Corrections and Rehabilitation (ND DOCR) that included
efforts to substantially reduce and ideally eliminate its
use of solitary confinement in the state's two largest
prisons. ND DOCR officials reported that these changes
were inspired and guided by public health and human
rights principles foundational to Norway's approach to
public safety, during their participation in the Amend
program at the UCSF School of Medicine. Since their
first visit to Norway in 2015, ND DOCR a adopted diverse and interactive set of policy changes, an initiative
ND DOCR called Increasing Humanity for People in
Prison, that resulted in a 74.28% reduction in the overall
use of solitary confinement.
Prison staff and incarcerated people described how the
system’s previous heavy reliance on solitary confinement
as a punishment for a wide array of rule violations
had profoundly adverse impacts on the health and wellness of incarcerated persons, a finding that echoes those
in previous studies (Haney et al., 2020; Reiter et al.,

Cloud et al. Health and Justice

(2021) 9:28

2020; Smith, 2006;). Participants also acknowledged that
working in these units contributed in a variety of ways
to workplace burnout and stress among officers, including distress at witnessing the psychological deterioration
of incarcerated people and feeling powerlessness to attend humanely and effectively to their serious needs.
Their observations are consistent with, and contribute
to, a growing literature on the role of carceral environments contributing to high rates of stress-related disease
and early mortality reported among correctional officers
(Finney et al., 2013; Morse et al., 2011; Regehr et al.,
2019; Spinaris 2012).
Incarcerated persons and correctional staff described
ND DOCR’s Norwegian-inspired policy changes as having improved the health and wellness of both groups.
Among other things, the provision of enhanced clinical
services for people with serious mental illness who engaged in disruptive and/or violent behavior reportedly
helped to reduce the overall use of solitary confinement.
So, too, did the implementation of policies designed to
improve the frequency and quality of interactions between staff and incarcerated people. Staff reported enhanced job satisfaction, reduced stress, and increased
safety in the wake of these reforms. Incarcerated persons
and correctional staff both perceived the reforms as responsible for increased trust and less antagonism between the groups. Staff members also noted that the
creation of a much-modified and enhanced correctional
officer role, including the emphasis on the Norwegian
practices of dynamic security (in which they proactively
interacted with incarcerated people) and progression (in
which staff helped incarcerated people move to less restrictive environments outside of solitary confinement),
increased workplace satisfaction and provided officers
with an elevated sense of purpose.
Contrary to the initial concerns of some staff members, who feared that the solitary confinement reforms,
especially, would lead to major increases in violence, our
analysis of institutional data indicated that this fear, by
and large, did not materialize. We observed a statistically
significant increase in the average monthly rates of fights
among people imprisoned in the general population at
one prison (NDSP) following the reforms (from just over
1 incident per 100 incarcerated persons per month to
just under 2 per month), however this level of violence
in the lowest level of behavioral infractions for violence
(fights as opposed to assaults) was not commensurate
with the dramatic 74.28% reduction in the ND DOCR’s
overall use of solitary confinement. In interviews, staff
and incarcerated people alike perceived this increase in
fights in NDSP’s general population as having been
caused by factors other than the solitary confinement reforms, including overcrowding and an increased use of
double-celling. Although it may be possible that some

Page 21 of 25

people who were released from solitary confinement
contributed to this uptick in fights, when we examined
the associations between monthly rates of solitary confinement and behavioral infractions related to violence,
we found no statistically significant association between
decreased use of solitary confinement and any indicator
of violence, including at NDSP, suggesting that change
in use of solitary confinement over this time was not a
primary driver of increased fights. Furthermore, results
from interrupted-time-series analysis indicates that at
NDSP, once the BIU was operational and policy limiting
the types of rule violations eligible for placement in restrictive housing was enacted, there were initial increases
in fights and assaults, followed by an overall downward
trend for both infractions. By contrast, at JRCC, this
analysis shows that following improvements to the SAU
and aforementioned changes to disciplinary policy, initially fights declined and assaults increased. Though, as
with NDSP, both trended downward over the postreform period. Together, this analysis bolsters the perceptions of staff and people imprisoned at these facilities
that solitary confinement reforms were not followed by
substantial or meaningful increases in violence, and
that the benefits of reform outweighed any initial
consequences.
We also found that staff and incarcerated people
perceived the policy changes as resulting in less tension
between one another, and overall improvements in the
conditions within these prison environments. This perspective was also born out in the analysis of administrative data in the unit designated for clinical mental
healthcare (the SAU), where there were significantly
fewer staff assaults following efforts to enhance clinical services and reduce isolation for imprisoned people
with more severe psychiatric conditions. Such findings
are consistent with other studies that have found that
solitary confinement is an ineffective and counterproductive long-term strategy for addressing violence in
prison settings (Lovell et al., 2007; Luigi et al., 2020;
Mears & Bales, 2009; Pizarro et al., 2014) and can take
a grave toll on the well-being of incarcerated people
(Grassian, 2006; Haney, 2018b; Haney et al., 2020; Reiter
et al., 2020; Rhodes, 2004; Smith, 2006; Strong et al.,
2020). Moreover, some incarcerated people reported experiencing improvements to their psychological health
and well-being as a result of North Dakota's efforts to
minimize exposures to isolation while enhancing access
to clinical and social services. Subsequent research
should continue to examine potential benefits to the
health and wellness of people directly affected by policies
that reduce or seek to eliminate exposures to solitary
confinement.
Of course, solitary confinement reform does not and
cannot occur in a vacuum, any more than its increased

Cloud et al. Health and Justice

(2021) 9:28

use over the last several decades did. In fact, ND DOCR
officials candidly acknowledged that, despite an ongoing
commitment to continue reducing, and perhaps eventually even ending solitary confinement altogether, achieving and sustaining this goal was and is subject to
structural impediments outside the control of ND
DOCR officials. In the recent past, those forces have included legislative and judicial decisions to impose
lengthy prison sentences, a lack of prison diversion programs in the state’s larger criminal legal system, social,
racial, and economic inequities, and a short supply of
resources to provide meaningful and equitable access to
educational, vocational, and mental health services in
communities with high incarceration rates as well as
within the prison system itself. The challenges ND
DOCR face are not unique to them and underscore the
way in which the movement to end solitary confinement
is interconnected with broader efforts designed to reverse society's reliance on incarceration in response to
complex social issues, while embracing the values of
human rights, dignity, and public health in interventions
to abate deleterious prison conditions (Ahalt & Williams,
2016; Haney et al., 2020; Lobel & Smith, 2019; Sakoda &
Simes, 2021).
Our findings also have several limitations. We
employed a case-study design to provide an in-depth description of North Dakota’s multi-dimensional efforts to
decrease its use of solitary confinement. As a result, although we report on differences in the observed rates of
violent rule infractions before and after reforms, our
methods do not establish causal relationships between
the two. We attempted to provide further context by
conducting an analysis to explore the nature of associations between rates of solitary confinement and rule infractions involving violence over the study period and
found that the large and sustained decreases in solitary
confinement were not associated with significant increases in these measures of violence. In fact, at JRCC in
particular, decreases in solitary confinement were significantly associated with decreases in violence. Future research should focus on examining whether and how
specific policy components of solitary confinement reforms affect relevant indicators of institutional violence
(e.g., use-of-force) and interpersonal violence (e.g., selfinjury) while accounting for the potential interplay of
other factors. Such studies might consider adopting
more robust quasi-experimental designs, including
interrupted-time-series (Briggs et al., 2003; Labrecque,
2015) to estimate the effects of distinct policies more
precisely on incarcerated people and staff by accounting
for individual and institutional level confounders and covariates. Second, our qualitative findings were derived
from participants chosen on the basis of their direct involvement in designing and/or implementing reforms

Page 22 of 25

(staff) or because they were directly affected by these
policy changes (incarcerated people). Others who were
not directly affected by the policies or involved in their
implementation may have different perspectives. In
addition, the retrospective nature of this study could
lead to recall bias, however it is reassuring that the
administrative data analysis largely corroborated our
qualitative findings. Also, although we know of no
specific reason to question the quality of ND DOCR’s
institutional data, we cannot ensure its reliability and
validity, as is often the case with correctional data
that has not been collected explicitly for the purpose
of research. Our use of the case study design, which
includes analysis of administrative data, qualitative
data and policy, minimizes reliance on non-research
administrative data. Relatedly, although much of the
institutional disciplinary infraction data we analyzed
was quantitative in nature, it was not necessarily “objective.” That is, it was the product of interactions between staff and people in their custody that were
subject to staff’s interpretations (i.e., whether a person's actions constituted an infraction and, if so,
what kind and severity) that themselves might be influenced by other forces in the environment. Future
studies should use qualitative methods or proactively
collect data on rule violations to analyze infraction reports over time to assess their internal validity and
reliability.
Finally, despite ND DOCR’s notable progress in significantly reducing the number of people exposed to
solitary confinement and improving the living conditions
to which they are subjected, staff and incarcerated persons identified many remaining opportunities for continued improvement to the health and well-being of
persons living and working in North Dakota prisons.
Most notably, the BIU, which now functions as a unit of
last resort that is mostly reserved for people who engage
in serious acts of violence, is still a bleak and desolate
environment described by both incarcerated people and
staff as isolating and highly restrictive. Staff members
continue to express concerns that it is likely to harmful
to people who endure this type of environment, especially those who experience it on a prolonged basis.
Moreover, there is always an ongoing risk that even a
reform-oriented prison system like the ND DOCR eventually will regress to pre-reform practices, especially
when discredited practices, such as solitary confinement, are viewed by prison officials as a necessary tool
of last resort (Rubin & Reiter 2018). A commitment to
sustaining and expanding the reach of the policy changes
that we have described, through ongoing monitoring of
prison conditions and the status of policy changes that
have been instituted, as well as implementation of additional legal and policy mechanisms to address remaining

Cloud et al. Health and Justice

(2021) 9:28

issues can serve as safeguards against potential reversals
(e.g., Haney & Pettigrew, 1986).

Conclusion
This case study describes how participation in an immersive exposure to the Norwegian Correctional Service’s principles, policies, and practices helped catalyze
and guide one state prison system’s efforts to drastically
reduce the use of solitary confinement and alleviate
many of its worst effects by significantly modifying the
way such units were structured and operated. Those efforts resulted in a host of positive changes in a range of
policies and practices that were reported as beneficial to
the health and well-being of both incarcerated people
and staff. The reductions in the use of solitary confinement were dramatic, and with the exception of one
measure of low-level fights between incarcerated people
in the general population units of one of the prisons, the
impacts on infractions related to violence generally
showed no change or actual improvements.
Decades of litigation, hunger strikes led by incarcerated people, and community-based advocacy have
prompted prison systems to begin reducing their reliance on solitary confinement (Ahalt & Williams, 2016;
Earle, 2020; Gottschalk, 2015). In 2019 alone, 28 state
legislatures introduced, and 12 passed, bills seeking to
halt or limit the use of solitary confinement in prisons
(Fettig, 2019). As these efforts continue and likely intensify, corrections officials, community advocates, and other
stakeholders seeking to bring about significant solitary
confinement reforms might benefit from the ND DOCR’s
recent experience, which represents a set of initial steps
that can be taken to alleviate at least some of the adverse
consequences brought about by this practice.
Acknowledgments
We thank the North Dakota Department of Corrections and Rehabilitation
(ND DOCR) for their ongoing partnership with Amend, transparency, and
support for this case study. We are grateful to all of our colleagues at the
Norwegian Correctional Service for their guidance and commitments to
systemic change in the U.S. correctional system. We are especially grateful to
the incarcerated men and correctional staff who shared their experiences
and perspectives with us.
Authors’ contributions
DC led the data collection, analysis, and writing for this manuscript. DA
contributed to analysis and writing of results section. LP and CB contributed
to data collection, writing, editing, and reviewing the manuscript for
accuracy in describing the policies and practices of the North Dakota
Department of Corrections and Rehabilitation. CA and BW are the cofounders of Amend. CA, BW, and CH led the Norwegian immersion program
and technical assistance efforts, and contributed to writing, editing and mentoring the data collection, analysis, and editing processes. The author(s) read
and approved the final manuscript.
Funding
This research was supported by the Jacob and Valeria Langeloth Foundation,
The Charles and Lynn Schusterman Family Philanthropies, and other private
donors.

Page 23 of 25

Availability of data and materials
Data supporting the findings of this study are held by ND DOCR and is not
publicly available due to privacy restrictions. Data may be available upon
reasonable request to the authors and with permission of ND DOCR.

Declarations
Ethics approval and consent to participate
This study was approved by the Institutional Review Board at the University
of California, San Francisco (UCSF). All incarcerated people and correctional
staff participating provided informed consent.
Consent for publication
The North Dakota Department of Corrections and Rehabilitation (ND DOCR)
has reviewed this manuscript and consented to publication.
Competing interests
Authors DC, DA, CA, and BW are members of the Amend team at UCSF. CA,
BW, and CH co-facilitated the Norwegian exchange program. LP and CB are
employed by the North Dakota.
Department of Corrections and Rehabilitation.
Author details
1
Amend, University of California, San Francisco, School of Medicine, 490
Illinois Street, Floor 8, UCSF Box 1265, San Francisco, CA 94143, USA.
2
Department of Psychology, University of California, Santa Cruz, 1156 High
Street, Santa Cruz, CA 95064, USA. 3North Dakota Department of Corrections
and Rehabilitation, 3100 Railroad Avenue, P.O. Box 1898, Bismarck, ND
58502-1898, USA.
Received: 14 January 2021 Accepted: 10 September 2021

Publish ed online: 18 October 2021
References
Ahalt, C., Haney, C., Ekhaugen, K., & Williams, B. (2020). Role of a US–Norway
exchange in placing health and well-being at the center of US prison reform.
Ahalt, C., & Williams, B. (2016). Reforming solitary-confinement policy--heeding a
presidential call to action. The New England Journal of Medicine, 374(18),
1704–1706. https://doi.org/10.1056/NEJMp1601399.
Allison, P. D., & Waterman, R. P. (2002). Fixed–effects negative binomial regression
models. Sociological methodology, 32(1), 247-265
Amend (2021). https://amend.us/
Beck, A. J. (2015). Use of restrictive housing in US prisons and jails, 2011–12.
Washington DC: US Department of Justice.
Bernal, J. L., Cummins, S., & Gasparrini, A. (2017). Interrupted time series
regression for the evaluation of public health interventions: A tutorial.
International Journal of Epidemiology, 46(1), 348–355. https://doi.org/10.1093/
ije/dyw098.
Bertsch, L., Choinski, W., Kempf, K., Baldwin, J., Clarke, H., Lampert, B., & Zoghi, A.
(2020). Time-In-Cell 2019: A Snapshot of Restrictive Housing based on a
Nationwide Survey of US Prison Systems.
Biglan, A., Ary, D., & Wagenaar, A. C. (2000). The value of interrupted time-series
experiments for community intervention research. Prevention Science, 1(1),
31–49. https://doi.org/10.1023/A:1010024016308.
Briggs, C. S., Sundt, J. L., & Castellano, T. C. (2003). The effect of supermaximum
security prisons on aggregate levels of institutional violence. Criminology,
41(4), 1341–1376. https://doi.org/10.1111/j.1745-9125.2003.tb01022.x.
Brinkley-Rubinstein, L., Sivaraman, J., Rosen, D. L., Cloud, D. H., Junker, G.,
Proescholdbell, S., … Ranapurwala, S. I. (2019). Association of restrictive
housing during incarceration with mortality after release. JAMA Network
Open, 2(10), e1912516. https://doi.org/10.1001/jamanetworkopen.2019.12516.
Cloud, D. H., Drucker, E., Browne, A., & Parsons, J. (2015). Public health and solitary
confinement in the United States. American Journal of Public Health, 105(1),
18–26. https://doi.org/10.2105/AJPH.2014.302205.
Earle, C. S. (2020). “More resilient than concrete and steel”: Consciousness-raising,
self-discipline, and bodily resistance in solitary confinement. Rhetoric Society
Quarterly, 50(2), 124–138. https://doi.org/10.1080/02773945.2020.1714704.
Fettig, A. (2019). 2019 was a Watershed Year in the Movement to Stop Solitary
Confinement. Retrieved from https://www.aclu.org/news/prisoners-rights/201
9-was-a-watershed-year-in-the-movement-to-stop-solitary-confinement/

Cloud et al. Health and Justice

(2021) 9:28

Finney, C., Stergiopoulos, E., Hensel, J., Bonato, S., & Dewa, C. S. (2013).
Organizational stressors associated with job stress and burnout in
correctional officers: A systematic review. BMC Public Health, 13(1), 1–13.
https://doi.org/10.1186/1471-2458-13-82.
Gendreau, P., & Labrecque, R. (2018). The effects of administrative segregation: A
lesson in knowledge cumulation. In J. Wooldredge, & P. Smith (Eds.), The
Oxford handbook of prisons and imprisonment, (pp. 340–366). New York:
Oxford University Press.
Gottschalk, M. (2015). Staying alive: Reforming solitary confinement in US prisons
and jails. Yale LJF, (vol. 125, p. 253).
Grassian, S. (2006). Psychiatric effects of solitary confinement. Wash. UJL & Pol'y, (vol.
22, p. 325).
Hagan, B. O., Wang, E. A., Aminawung, J. A., Albizu-Garcia, C. E., Zaller, N., Nyamu,
S., … Fox, A. D. (2018). History of solitary confinement is associated with
post-traumatic stress disorder symptoms among individuals recently released
from prison. Journal of Urban Health, 95(2), 141–148. https://doi.org/10.1007/
s11524-017-0138-1.
Haney, C. (2018a). The psychological effects of solitary confinement: A systematic
critique. Crime and Justice, 47(1), 365–416. https://doi.org/10.1086/696041.
Haney, C. (2018b). Restricting the use of solitary confinement. Annual Review of
Criminology, 1(1), 285–310. https://doi.org/10.1146/annurev-criminol-032317092326.
Haney, C. (2020). The science of solitary: Expanding the harmfulness narrative.
Northwestern University Law Review, 115(1), 211–256.
Haney, C., & Pettigrew, T. (1986). Journal of Community Psychology, 14(3), 267–277.
https://doi.org/10.1002/1520-6629(198607)14:3<267::AID-JCOP2290140305>3.
0.CO;2-G.
Haney, C., Williams, B., Lobel, J., Ahalt, C., Allen, E., Bertsch, L., … Vollan, M. (2020).
Consensus statement from the Santa Cruz summit on solitary confinement and
health. Nw. UL Rev, (vol. 115, p. 335).
Hilbe, J. M. (2011). Negative binomial regression. Cambridge University Press.
https://doi.org/10.1017/CBO9780511973420.
Høidal, A. (2019). Prisoners’ association as an alternative to solitary
confinement—Lessons learned from a Norwegian high-security prison. Solitary
confinement: Effects, practices, and pathways toward reform, 297.
Justice, N. M. o., & Police, T (2018). Punishment that works—Less crime—A safe
society: Report to the Storting on the Norwegian correctional services
(English summary). Federal Sentencing Reporter, 31(1), 52–57. https://doi.org/1
0.1525/fsr.2018.31.1.52.
Kaba, F., Lewis, A., Glowa-Kollisch, S., Hadler, J., Lee, D., Alper, H., … Parsons, A.
(2014). Solitary confinement and risk of self-harm among jail inmates.
American Journal of Public Health, 104(3), 442–447. https://doi.org/10.2105/A
JPH.2013.301742.
Labrecque, R. M. (2015). The effect of solitary confinement on institutional
misconduct: A longitudinal evaluation (Doctoral dissertation, University of
Cincinnati).
Labutta, E. (2016). The prisoner as one of us: Norwegian Wisdom for American
Penal Practice. Emory Int'l L. Rev., 31, 329.
Lanes, E. (2009). The association of administrative segregation placement and
other risk factors with the self-injury-free time of male prisoners. Journal of
Offender Rehabilitation, 48(6), 529–546. https://doi.org/10.1080/10509670903
081342.
Leigh-Hunt, N., Bagguley, D., Bash, K., Turner, V., Turnbull, S., Valtorta, N., & Caan,
W. (2017). An overview of systematic reviews on the public health
consequences of social isolation and loneliness. Public Health, 152, 157–171.
https://doi.org/10.1016/j.puhe.2017.07.035.
Lobel, J., & Smith, P. S. (2019). Solitary confinement: Effects, practices, and pathways
toward reform. Oxford University Press. https://doi.org/10.1093/oso/97801
90947927.001.0001.
Lovell, D., Johnson, L. C., & Cain, K. C. (2007). Recidivism of supermax prisoners in
Washington state. Crime & Delinquency, 53(4), 633–656. https://doi.org/10.11
77/0011128706296466.
Luigi, M., Dellazizzo, L., Giguère, C. É., Goulet, M. H., Potvin, S., & Dumais, A. (2020).
Solitary confinement of inmates associated with relapse into any recidivism
including violent crime: A systematic review and meta-analysis. Trauma,
Violence, & Abuse. 2020:1524838020957983. https://doi.org/10.1177/152483
8020957983.
Mears, D. P., & Bales, W. D. (2009). Supermax incarceration and recidivism.
Criminology, 47(4), 1131–1166. https://doi.org/10.1111/j.1745-9125.2009.00171.x.
Mears, D. P., Hughes, V., Pesta, G. B., Bales, W. D., Brown, J. M., Cochran, J. C., &
Wooldredge, J. (2019). The new solitary confinement? A conceptual

Page 24 of 25

framework for guiding and assessing research and policy on “restrictive
housing”. Criminal Justice and Behavior, 46(10), 1427–1444. https://doi.org/1
0.1177/0093854819852770.
Méndez, J. E. (2019). Torture, solitary confinement, and international law. Solitary
confinement: Effects, practices, and pathways toward reform, 117.
Morgan, J. N. (2017). Caged in: The devastating harms of solitary confinement on
prisoners with physical disabilities. Buff. Hum. Rts. L. Rev., 24, 81. https://doi.
org/10.2139/ssrn.2952112.
Morgan, R. D., Gendreau, P., Smith, P., Gray, A. L., Labrecque, R. M., MacLean, N.,
… Mills, J. F. (2016). Quantitative syntheses of the effects of administrative
segregation on inmates’ well-being. Psychology, Public Policy, and Law, 22(4),
439–461. https://doi.org/10.1037/law0000089.
Morse, T. et al., (2011). Talking about health: correction employees' assessments
of obstacles to healthy living. Journal of Occupational and Environmental
Medicine, 53(9), 1037-1045.
Norwegian Parlimentary Ombudsman. Special report on solitary confinement
and lack of human contact in Norwegian prisons. Document 4:3 2018–2019).
Retrieved from https://www.sivilombudsmannen.no/wp-content/uploads/201
9/08/SOM_S%C3%A6rskilt-melding_ENG_WEB.pdf
Petersilia, J. (2008). Influencing public policy: An embedded criminologist reflects
on California prison reform. Journal of Experimental Criminology, 4(4), 335–
356. https://doi.org/10.1007/s11292-008-9060-6.
Pizarro, J. M., Zgoba, K. M., & Haugebrook, S. (2014). Supermax and recidivism: An
examination of the recidivism covariates among a sample of supermax exinmates. The Prison Journal, 94(2), 180–197. https://doi.org/10.1177/0032
885514524697.
Regehr, C., Carey, M., Wagner, S., Alden, L. E., Buys, N., Corneil, W., & White, N.
(2019). Prevalence of PTSD, depression and anxiety disorders in correctional
officers: A systematic review. Corrections, 6(3), 1–13. https://doi.org/10.1
080/23774657.2019.1641765.
Reiter, K., & Blair, T. (2015). Punishing mental illness: Trans-institutionalization and
solitary confinement in the United States. In extreme punishment (pp. 177-196):
Springer.
Reiter, K., Ventura, J., Lovell, D., Augustine, D., Barragan, M., Blair, T., … Pifer, N.
(2020). Psychological distress in solitary confinement: Symptoms, severity,
and prevalence in the United States, 2017–2018. American Journal of Public
Health, 110(S1), S56–S62. https://doi.org/10.2105/AJPH.2019.305375.
Rhodes, L. A. (2004). Total confinement: Madness and reason in the maximum
security prison, (vol. 7). Univ of California Press.
Rubin, A. T., & Reiter, K. (2018). Continuity in the face of penal innovation:
Revisiting the history of American solitary confinement. Law & Social Inquiry,
43(4), 1604–1632. https://doi.org/10.1111/lsi.12330.
Ryan, A. T., & DeVylder, J. (2020). Previously incarcerated individuals with
psychotic symptoms are more likely to report a history of solitary
confinement. Psychiatry Research, 290, 113064. https://doi.org/10.1016/j.
psychres.2020.113064.
Sakoda, R. T., & Simes, J. T. (2021). Solitary confinement and the US prison boom.
Criminal Justice Policy Review, 32(1), 66–102. https://doi.org/10.1177/08874
03419895315.
Schlanger, M. (2012). Prison segregation: Symposium introduction and
preliminary data on racial disparities. Mich. J. Race & L., 18, 241.
Schlanger, M. (2020). Incrementalist vs. maximalist reform: Solitary confinement
case studies. Nw. UL Rev., 115, 273.
Scholz, R. W., & Tietje, O. (2002). Embedded case study methods: Integrating
quantitative and qualitative knowledge. https://doi.org/10.4135/9781412984027.
Smith, P. S. (2006). The effects of solitary confinement on prison inmates: A brief
history and review of the literature. Crime and Justice, 34(1), 441–528. https://
doi.org/10.1086/500626.
Spinaris, C. G., Denhof, M. D., & Kellaway, J. A. (2012). Posttraumatic stress disorder
in United States corrections professionals: Prevalence and impact on health
and functioning. Desert Waters Correctional Outreach, 1–32.
Strong, J. D., Reiter, K., Gonzalez, G., Tublitz, R., Augustine, D., Barragan, M., …
Blair, T. R. (2020). The body in isolation: The physical health impacts of
incarceration in solitary confinement. PloS One, 15(10), e0238510. https://doi.
org/10.1371/journal.pone.0238510.
The American Medical Association. (2016) “Solitary confinement of juveniles in
legal custody H-60.922”.
The American Psychiatric Association (2017). Position Statement on Segregation
of Prisoners with Mental Illness
The American Public Health Association (2013). “Solitary confinement as a public
health issue” Policy Number: 201310.

Cloud et al. Health and Justice

(2021) 9:28

Page 25 of 25

The National Commission on Correctional Healthcare. (2016). Position Statement
on Solitary Confinement (Isolation).
The World Medical Association. (2019) “WMA Statement on Solitary Confinement.”
Wildeman, C., & Andersen, L. H. (2020). Solitary confinement placement and postrelease mortality risk among formerly incarcerated individuals: A populationbased study. The Lancet Public Health, 5(2), e107–e113. https://doi.org/10.101
6/S2468-2667(19)30271-3.
Williams, B., & Ahalt, C. (2019). First Do No Harm: Applying the Harms-to-Benefits
Patient Safety Framework to Solitary Confinement. In In Solitary Confinement,
(pp. 153–172). Oxford University Press.

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