When “Suicide Watch” Becomes a Death Sentence

When “Suicide Watch” Becomes a Death Sentence

When “Suicide Watch” Becomes a Death Sentence

Instead of the help they need, people in prisons and jails with mental health issues are often left alone to suffer—and sometimes die.


When Anthony Gay was booked into the Peoria County jail in Illinois in 2022, after a conviction for “possession of a firearm by a felon,” he was placed in a so-called rubber cell, a freezing solitary confinement space with a hole in the floor for a toilet. Being left alone in these conditions triggered feelings of abandonment, a result of his borderline personality disorder and the PTSD he suffers from spending decades in solitary confinement during a previous incarceration.

“It made me more agitated, more upset, feeling more rejected,” he recalled. “And I ended up stabbing a pencil into my arm.” After multiple incidents of self-harm, Gay was placed on suicide watch, where he remained for 40 days.

On suicide watch, he said, “they kept me in a holding cell where the light was on 24 hours…. It was freezing in there.” An officer positioned in an open doorway was supposed to make sure he didn’t harm himself, but was often distracted and not paying close attention. “I cut [myself] like five or six times.” In one incident, Gay cut open his scrotum, which he said saturated the cell with blood. He said officers cuffed him, kicked him, and put him in a painful restraint chair and a spit hood for three hours before he was able to see a mental health clinician and then taken to a hospital.

Gay was later transferred to a federal prison in Butner, N.C., to undergo a mental health assessment and treatment. There, too, he was placed on suicide watch multiple times, including once for 40 days, during which he said he was not allowed to shower or brush his teeth. “I smelled so bad it caused me nausea,” he recalled. He said incarcerated people, not staff members, were assigned to watch him at times, and security staff had the power to put him in restraints without the consultation of mental health staff. He continued to harm himself and said he was admitted to the hospital five or six times.

In both the county jail and the federal prison, the suicide watch conditions reminded Gay of the 22 years he spent in solitary confinement in Illinois prisons after an initial arrest for stealing a hat and a dollar bill in a 1994 altercation. In prison, Gay’s mental health deteriorated, he racked up punishments, and his prison sentence—and time in solitary—snowballed. (He was finally released in 2018 but was rearrested in 2020 for possession of a weapon, which he maintains was planted.)

Jails and prisons typically place people considered to be at risk of suicide or self-harm on suicide watch. In federal prisons like the one Gay went to, people can be kept on watch for as long as staff determine them to be suicidal. Federal courts have ruled that in mental health detention units, ​​”treatment must entail more than segregation and close supervision of the inmate patients.”

But in practice, suicide watch cells typically offer little or no furnishings, clothing, programming, activities, family visits, or human interaction—conditions that exacerbate trauma.

“In my opinion, most suicide observation cells are de facto solitary confinement, and not at all therapeutic,” Terry Kupers, a psychiatrist and expert on the mental health effects of solitary confinement, told The Nation in an e-mail. “There is a window or video monitoring, and a mental health clinician comes by (hopefully daily) to ask if the individual is still feeling suicidal. But rarely have I seen any actual psychotherapy or much talk at all occur. The individual is in the observation cell 24 hours per day without recreation and with nothing to do, and usually without clothes.”

Despite these stark conditions, some people on suicide watch find desperate and excruciating ways to harm themselves, such as diving headfirst onto the floor or swallowing items during the often 15-minute intervals between checks. In some facilities, staff have been found failing to conduct the required checks and falsifying logbooks. While there is little data available, a study of 696 jail suicides in 2005 and 2006 found that 8 percent occurred on suicide watch. (More than one-third occurred in various types of isolation units.)

How prisons and jails respond to suicide risks is more critical than ever. In 2019, the most recent year for which data is available, the Bureau of Justice Statistics recorded an 85 percent increase in state prison suicides since tracking began in 2001, even as state prison populations grew just 1 percent from 2001 to 2019. Over the same period, suicides rose 61 percent in federal prisons. In jails, where suicide rates have always been high—accounting for close to one-third of all jail deaths—suicides rose 13 percent.

“This might sound ironic, but I don’t like engaging in self-harm,” Gay said. “However, after years and years and years of being tortured [in solitary confinement] and becoming accustomed to it, it alleviates the psychological pain. It’s to the point where now I have a low tolerance for psychological pain but a high tolerance for physical pain…. I never had these types of problems before I went to prison and solitary.”

Suicide prevention services in the United States are often severely lacking or traumatizing. They are even worse behind bars, where someone expressing suicidal thoughts is unlikely to receive hospital care, a suicide treatment plan, or therapeutic intervention.

In Richland County, S.C., a lawsuit against the Alvin S. Glenn Detention Center brought by Disability Rights South Carolina in 2022 alleges that people with serious mental illness on suicide watch are “often placed naked into non-therapeutic, filthy cells where they are behind metal doors with small windows and often cannot be seen by security staff.”

The suit alleges that one plaintiff with serious mental illness and persistent suicidality is frequently confined for extended periods to a restraint chair, where he is forced to urinate on himself. Even while on suicide watch, he has accessed wires and shards of glass to mutilate himself. Another plaintiff was denied access to psychotherapy, counseling, recreation, and showers for two weeks while on suicide watch, where he was forbidden toilet paper and any hygienic supplies other than a bar of soap the size of his thumbnail.

The jail also has an unrelated open case with the state to develop a strategic plan for improving the general conditions at the facility following several deaths, including a 27-year-old man who was found dead of dehydration in his cell with rat bites on his body.

Around the country, lawsuits, reports, and investigations reveal similar conditions in suicide watch cells.

In Massachusetts state prisons, suicidal individuals are put on “mental health watch” and locked in restrictive cells, where they are “at substantial risk of serious harm,” according to an investigative report by the Department of Justice’s Civil Rights Division released in November 2020.

One man, identified as “GG” in the report, was repeatedly cycled on and off of prolonged mental health watches. Despite constant observation by a prison staff member, GG harmed himself more than a dozen times while he was on watch. Many of the incidents, which included inserting pieces of razors, paper clips, or spoons into his eyes and penis and swallowing about 15 pills, led to hospital stays. “The pain takes the voices away,” he told Department of Justice staff.

The report notes that GG flourished during a nearly 30-day stay outside the prison at Bridgewater State Hospital, where he had no incidents of self-harm, participated in mental health group sessions, journaled, played cards with others, and was compliant with his medications. But these types of hospital placements are rare and temporary.

Although Massachusetts policy limits mental health watch to four consecutive days, the Justice Department found that over a 13-month period, 106 people were held for more than 14 days, including some for longer than six months. Four of the eight people who died by suicide in Massachusetts prisons over the study period were on mental health watch or had been recently, and more than 56 percent of 1,200 “self-injurious behavior” incidents occurred in mental health watch cells.

In December 2022, the Massachusetts Department of Correction entered into an agreement with the Justice Department and will be overseen by a federally appointed independent monitor. The state also agreed to provide people experiencing mental health crises with support staff interaction, including three mental health contacts a day; to develop a new unit for intensive mental health treatment; to provide better documentation; and to give mental health staff a say in patients’ cell conditions and privileges.

In an ongoing lawsuit in Louisiana, four named plaintiffs at David Wade Correctional Center allege that people on suicide watch in the prison are given only paper gowns, are denied phone calls and visits, and receive no acute mental health care and no suicide risk assessment. They further allege that incarcerated people have their mattresses removed from their cells every day from 5 am to 9 pm when on Policy 34—an independent disciplinary sentence “deployed at staff discretion with no due process protections or hearings.” Those placed on an “extreme” version of suicide watch are restrained in a chair all day.

“Due to lack of human contact and uncontrolled mental illness, many will scream, laugh, and talk to themselves,” the plaintiffs allege in their complaint. “Others rock in place or deteriorate to more severe manifestations of their conditions, such as smearing blood or feces.” In September, a federal judge found that these conditions violated people’s constitutional rights and allowed a second hearing to proceed in January. The parties are currently waiting on the court’s order for a remedy.

In California, the family of Logan Masterson sued the Santa Rita Jail after he died by hanging himself in an isolation cell in 2018, two days after he was transferred from a suicide watch cell. Before that, Masterson had been held in a “safety cell.”

According to the lawsuit, which was settled in 2021, jail staff placed people in psychiatric distress into safety cells, “rather than individually determining the least restrictive environment in which a suicidal prisoner can be safely housed.” The complaint alleged that the safety cells had no furnishings, no toilets, and usually no outside windows. It stated, “The only features of the cell are the door, which has a slot through which food can be delivered, and a grate in the floor that serves as the toilet. Without toilet paper in these cells, and no way to wash, feces makes its way across the cell, on the floors and walls.”

The complaint also noted that people in these safety cells often have their clothes confiscated. “There is no mattress or pad, let alone a bed, in the safety cells for prisoners to sit or sleep on,” the complaint alleged. “Prisoners are thus forced to sit, sleep, and eat on the same cold, dirty floor on which the grate for the toilet is located.”

The demeaning, debilitating conditions in suicide watch units can deter people from being honest with medical professionals. “Many otherwise suicidal inmates may be reluctant to share their suicidal ideation for fear of being placed in an environment they perceive as punitive,” wrote Jeffrey L. Metzner and Lindsay M. Hayes, leading national experts on correctional suicide, in a 2020 textbook published by the American Psychiatric Association.

In a 2013 paper, Hayes painted a picture of how this scenario often plays out. “Take, for example, the inmate who is on suicide precautions for attempting suicide the previous day,” he wrote. “He is now naked in a cell with only a suicide smock, given finger foods, and on lockdown status. The mental health clinician approaches the cell and asks the inmate through the food slot (within hearing distance of others on the cellblock): ‘How are you feeling today? Still feeling suicidal?’… Will this inmate’s response be influenced by their current predicament? How would any of us respond?”

Repeated suicide attempts, especially when followed by claims of improvement, can cause people to cycle on and off suicide watch units. Kupers noted that in the hundreds of investigations he has conducted following prison suicides, the individual frequently cycled between suicide watch and solitary confinement, and ultimately died by suicide in a solitary confinement cell.

Kupers finds this pattern alarming. “In my opinion, anyone at high enough risk to be sent to observation should never be sent back to a solitary confinement cell and should be monitored for suicide risk, at a tapering-off level of monitoring, for quite a while after the stay in observation,” he wrote to The Nation.

Admire Harvard, a trans woman incarcerated in a men’s prison in Florida, has experienced this type of cycling in the extreme. Harvard, who has been diagnosed with schizoaffective disorder and gender dysphoria, was the lead named plaintiff in a solitary confinement lawsuit brought against the state Department of Corrections by the Southern Poverty Law Center in 2019. At age 18, Harvard was sent to solitary confinement for 60 days for allegedly lying to prison staff to get a high-calorie meal. Her stint in solitary ballooned to almost 10 years as she racked up more than 125 infractions, most of which were for nonviolent behaviors related to her mental health, such as kicking the cell door or disrespecting staff.

As her mental health deteriorated, Harvard was hospitalized for psychiatric reasons around 20 times and cycled on and off suicide watch more than 50 times. The plaintiffs and their attorneys sought class-action status on behalf of all people held in solitary confinement in Florida prisons, but that status was denied in 2022 by a Donald Trump–appointed judge. After losing on class certification, Harvard and the other named plaintiffs voluntarily dismissed the case.

Correctional staff often believe that suicides in jails and prisons are impossible to predict and prevent, an attitude that can impede meaningful prevention efforts, write Metzner and Hayes.

Hayes wrote that instead of taking a more comprehensive approach, prison officials “appear preoccupied” with using suicide watch technology such as closed-circuit television monitoring and so-called suicide-resistant jail cells and safety smocks. There is an entire industry dedicated to manufacturing and selling products like anti-suicide smocks and blankets for prisons and jails.

Hayes believes that correctional officials are also often overly focused on whether someone is suicidal at intake. Incarcerated people are constantly at risk of poor mental health outcomes from the dismal living conditions, exposure to violence, and reliving of past trauma behind bars. Receiving bad news from home, a negative trial decision, or a denied parole application can also set back their mental health.

“Screening for suicide risk during the initial booking and intake process should be viewed as something similar to taking one’s temperature—it can identify a current fever, but not a future cold,” Hayes wrote. “Suicides are prevented and suicide rates reduced when correctional facilities provide a comprehensive array of programming that identifies suicidal inmates who are otherwise difficult to identify, ensures their safety on suicide precautions, and provides a continuity of care throughout confinement.”

Professional health organizations recommend that prisons and jails establish clear written policies; allow only qualified mental health professionals to make decisions about suicide watch placement; hold better and more frequent staff trainings on suicide prevention and first aid; assess incarcerated people’s mental health periodically and after major events like court hearings; and avoid punishing suicide attempts or labeling suicidal ideation as manipulative. They also recommend placing people in the “least restrictive environment” possible.

Hayes and Metzner further advise that people on suicide watch should be housed with the general population, if possible, and that interactions with staff should be encouraged. Physical restraints should be avoided, and people should retain access to routine privileges like showers, visits, phone calls, out-of-cell exercise, and their own clothing. People expressing suicidal ideation should be observed at intervals of no more than 10 to 15 minutes. Those who are actively suicidal should be observed continuously and should meet privately with mental health staff daily.

Of course, the most effective way to limit correctional suicides would be to stop incarcerating people with serious mental health risks. Yet this is devastatingly common: In the last comprehensive national survey of people in jails, conducted between February 2011 and May 2012, 44 percent of respondents reported having been previously diagnosed with a mental disorder, and more than 26 percent had experienced “serious psychological distress” in the 30 days prior to taking the survey.

Kupers supports shifting mental health care from the criminal justice system to a community-based one. In a 2021 statement, the American Public Health Association similarly argued that mental health treatment should occur in the community, not in jails and prisons, no matter how “humane and trauma-informed” they claim to be. Instead, the APHA makes clear that “community-based care, support, and accountability best promote health, well-being, and justice.”

Some cities, including Atlanta and Los Angeles, are in the midst of early-stage efforts to replace jails with hospital beds, supportive housing, and other non-cor-rectional facilities. And since the trauma of incarceration can produce suicidality in people without a history of mental illness, broader diversion programs and community initiatives, such as Offices of Neighborhood Safety, can help reduce incarceration—and therefore suicides—behind bars.

Of course, these initiatives require the public and political will to divert funds from the criminal justice system to communities.

In the meantime, Gay says he continues to fight to abolish solitary confinement and punitive suicide watch cells.

“People [self-harm] for different reasons,” he explained. “There’s people that want to kill themselves. But then there’s people who, like me, want to alleviate the psychological pain. So instead of being indifferent and creating an invalidating environment, they should help validate the person and say to the person, ‘We’re here to help you. And this is how we can do it.’”

People on suicide watch “should have a mattress,” Gay continued. “They should have a blanket. They should have mental health [staff] see them daily. They should be able to have recreation with an activity therapist. They should have more contact, as opposed to less. They shouldn’t be just left in the cell, like someone left on dry sand on a deserted island.”

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