Self-mutilation, suicide attempts, and suicides are far too common in prison. The prevalence of such self-harm is linked both to the prevalence of mental illness among prisoners and inadequate mental health treatment.
We were not able to find any national or state-wide statistics on the prevalence of self-mutilation in prison. Nevertheless, the extent of the mutilation and the determination exhibited by prisoners to engage in serious acts of self-harm is astonishing. Prisoners have swallowed pins, inserted pencils in their penises and paperclips in their abdomens, bitten chunks of flesh from their arms, slashed and gashed themselves. In many prisons around the country, Human Rights Watch has interviewed prisoners whose bodies are massively scarred from self-mutilation. Both correctional and mental health staff acknowledge that self-mutilation is a major problem.
Elaine Lord, superintendent at the Bedford Hills Correctional Facility in New York, catalogues the remarkable ways women have injured themselves: “cutting their own throat, legs, arms, or wrist; headbanging; inserting foreign objects under the skin or into wounds or surgical sites on the body; overdosing on medication; or swallowing an extraordinary variety of objects including, but not limited to, knitting needles, screws, straight pins, safety pins, pens, pencils, light bulbs, springs, nails, pieces of radiator, screens, uniform name tags, pieces of wall, and chips of paint.”598
The complaint in a lawsuit against the supermax prison in Tamms, Illinois, drawing on prisoner medical records and psychiatrist interviews, details the self-harm of several mentally ill prisoners.599 Among the examples cited:
Other examples of self-mutilation from around the country include the following:
Young men, persons with mental illness, alcohol and drug addicts, and people who are in custody, are amongst the most at-risk groups for suicide.605 Given the prevalence of all of these indicators concurrently among prisoners in the United States, it is not surprising that suicide attempts are a serious problem inside prison. A nationwide survey conducted by prison suicide expert Lindsey Hayes in 1995 found that suicide rates in state prison systems ranged from 18.6 per one hundred thousand all the way up to 53.7 per one hundred thousand.606 According to The 2001 Corrections Yearbook, the average suicide rate in prison was 0.26 per 1,000 prisoners, or twenty-six per 100,000, two-and-a-half times the rate of suicide in the U.S.population at large, which for 2000 was 10.6 per 100,000.607
Mental illness is a high risk factor for suicide; untreated or poorly treated mental illness even more so. NAMI reports research findings that about 90 percent of persons who completed suicides had a diagnosable mental or substance abuse disorder.608 The organization estimates that between 2 and 15 percent of persons diagnosed with major depression, 3 to 20 percent of persons diagnosed with bipolar disorder, and 6 to 15 percent of persons diagnosed with schizophrenia die by suicide. People with personality disorders are approximately three times as likely to die by suicide than those without.609
Human Rights Watch has not been able to find any national or system-wide statistics on the rate of mental illness among prisoners who committed suicide. Nevertheless, correctional and mental health staff and independent experts we interviewed agreed that attempted and completed suicides are more prevalent among prisoners with a diagnosed serious mental illness. A few studies of prison suicides support this view. For example, in Texas prisons, a study of twenty-five suicides committed between June 1996 and June 1997 found that 60 percent of the prisoners had been identified at intake screening with mental disorders, and 76 percent had psychiatric diagnoses at some point during their incarceration.610 A study in 2002 of New York prison suicide risk factors by New York’s Office of Mental Health, which provides mental health services to New York prisoners found that 70 percent of prisoners who committed suicide had a history of mental illness. Forty percent of them had received a mental health service within three days of the suicide; and 40 percent had prior stays in psychiatric hospitals.611 A review by Prison Legal Services of individual reports of New York prison suicides between 1995 and 2001 prepared by New York State’s Commission of Correctionindicates that many of the prisoners had been on the mental health case load and had discontinued their medication (without receiving adequate medication compliance counseling) or had been seriously mentally ill but had been repeatedly underdiagnosed.612 In Pennsylvania, prisoners on the mental health/mental retardation roster committed approximately 56 percent of the suicides in 1997 and 64 percent of those in 1998.613
Efforts at self-harm are particularly prevalent in segregated, high security settings. According to Raymond Bonner, suicide prevention expert and chief psychologist at the Federal Correctional Institution at Allenwood, Pennsylvania, “By and large, most self-harm behavior in prison is exhibited by individuals who are confined in conditions of segregation, social isolation, and/or psychosocial deprivation.”614
The confinement of mentally ill prisoners in segregation also heightens the risk of their suicide, indeed, it heightens the risk of suicide for all prisoners. The World Health Organization has reported that “the majority of suicides in correctional settings occur when a prisoner is isolated from staff and fellow prisoners. Therefore, placement in segregation or isolation cells…can increase the risk of suicide.”615 U.S. statistics reflect the higher prevalence of suicide in segregated settings. One study found that “approximately 68 percent of the inmates who committed suicide were on special housing status (e.g., segregation, administrative detention, or in a psychiatric seclusion unit) and, with only one exception, all victims were in single cells at the time of their deaths.”616
It is a tragic irony that many of the mentally ill who attempt or commit suicide were originally placed in segregation because of acts of self-harm. Segregation is, however, perhaps the worst possible setting for suicidal prisoners. As Raymond Bonner notes, “Social and environmental isolation is never an appropriate consequence [of acts of self-harm or attempted suicide] as it undoubtedly worsens emotional state, hinders problem-solving and can increase the risk for life-threatening behavior.”617
The experiences of individual state prison systems bears this out.
According to a study of suicides in New York prisons between 1998 and 2000, 54 percent of the suicides took place in the Special Housing Units.619 Citing the result of suicide reviews by the New York Commission of Corrections, the complaint filed in 2002 by Disability Advocates Inc. against the New York Office of Mental Health and the New York Department of Correctional Services stated that: “for each year from 1998 through 2001, from 30% to 50% of the suicides for the entire prison population occurred within the 8% of the prison population confined in twenty-three hour isolated confinement housing…[D]eficient mental health treatment and the stresses of isolated twenty three hour confinement have been significant facts leading to suicide.”620
In June, shortly before Bell’s death, the same psychiatrist failed to read her chart and thus was unaware of the fact that she had been burning herself with cigarettes in recent days. A few days later, Bell ended her own life.625
Litigation has established suicide prevention as a required component of mental health services.627 Nevertheless, in 1995 when custodial suicide prevention expert Lindsey Hayes surveyed prison responses to suicidal prisoners, he found a pattern of neglect and an inadequate invention system. In his Department of Justice-funded report, he urged correctional systems to improve staff training, better identify prisoners at risk of suicide, improve communication between different offices within prisons, provide special housing for suicidal prisoners to be placed within, increase the supervision of these prisoners, and encourage interventions by staff to minimize the chances of a prisoner actually attempting to kill him or herself. Hayes found that only four of the fifty states had all of these elements within their suicide prevention policies. He found that while 79 percent of state departments of correction had suicide prevention policies, only 15 percent of the policies covered the majority of the elements in the American Correctional Association or National Commission on Correctional Health Care standards.628
Eight years later, Hayes believes that, nationally, many of the problems remain: “Inmates reporting that they are taken out of cells and thrown into another cell and stripped naked. That obviously shouldn’t happen. Nobody should be stripped naked and left without protective clothing — a paper gown, there are various smocks and safety garments.”629 In fact, prisoners across the country also told Human Rights Watch that all too often suicide attempts resulted in being placed naked for days in cold, barren observation cells. Interaction with mental health staff while in the observation cell is minimal. Some prisoners told Human Rights Watch they do not tell mental health staff of suicidal thoughts because they want to avoid at all costs being put in the observation cells.
Independent correctional experts condemn the practice of leaving suicidal prisoners naked, exposed, and without intensive mental health services. According to Lindsey Hayes, such treatment “further enhances the potential of them becoming suicidal or engaging in self-injurious behavior. It’s degrading, humiliating.”633 Dr. Terry Kupers told Human Rights Watch that placing suicidal prisoners in barren observation cells:
Dr. Janet Schaeffer told Human Rights Watch of a suicidal prisoner she had encountered in a Pennsylvania facility who was repeatedly stripped naked and put into an observation cell despite a history of having been sexually abused as a child that had left him terrified when he did not have his underwear on. “It contributed to his anxiety,” Schaeffer reported.
Instead of such isolation, Schaeffer maintains that suicidal prisoners should be talked to by staff, encouraged to interact with their surroundings and with other people; they should, she told Human Rights Watch, be helped to “[re-]establish social relations, not placed in a situation where such interactions are further broken off.”
Recognition of their legal obligations, a genuine commitment to avoid suicide (which is one of the most traumatic experiences for correctional staff and surviving prisoners), and the development of national standards for suicide prevention636 have prompted corrections authorities to begin establishing more effective suicide prevention protocols. Some states have implemented significant measures to limit suicides within their prisons. For example, the Secretary of Corrections of Pennsylvania appointed a Suicide Prevention Task Force to analyze suicide risk factors, department and prison responses to suicide attempts and completed suicides, and to propose recommendations for changes in department policies, procedures and training. Based on the report and findings of the task force in 1999, the department implemented a series of new procedures and policies and expanded the use of others.
Among other things, Pennsylvania prison authorities revised the suicide prevention policy to improve suicide watch procedures, mandate that watches be conducted outside of administrative segregation areas, require that prisoners be provided anti-suicide smocks, and mandate use of a suicide risk indicators checklist. The prison superintendent’s prerogative in determining which incidents were suicide attempts and which were merely “gestures” was reduced. The department also undertook to expand the range of mental health treatment services by, for example, increasing the number of psychiatric observation cells, streamlining procedures for committing prisoners in psychiatric crises into inpatient treatment, and increasing the number of Special Needs Units — specialized housing areas where prisoners with handicaps can receive additional services and protection. Recognizing that mentally ill prisoners placed in segregation are at particularly high risk of suicide, the department modified administrative segregation policies to increase the diversion of prisoners with mental illness from these housing areas. Disciplinary proceedings include an assessment of the role of mental illness in the commission of an infraction and the possible impact of segregation on the prisoner’s illness. Prison officials are encouraged to reduce disciplinary time for mentally ill prisoners who commit infractions, and to provide enhanced mental health services and tracking for prisoners with mental illness who must be placed in segregation. The department also now uses a suicide risk indicators checklist for prisoners being placed in segregation to ensure that clinical staff visit any at risk prisoners.637 The aggressive and comprehensive effort is paying off: the number of suicides within the Pennsylvania system declined from fourteen in 1995 to five in 2000, despite an increase of over eight thousand in the size of the state’s prison population.638
In California, the largest prison system in the country, thirty-two prison suicides occurred from October 1998 to December 1999.639 Underneath these numbers, however, were large discrepancies between prisons. While many California prisons had no suicides, the supermax prisons at Sacramento and Pelican Bay each had three suicides, and Corcoran had five.640 That is, the three supermax prisons accounted for one-third of the state prison suicides. The authors of a report on California prison suicides wrote that “review of data submitted on individual suicides indicated a delivery of care that was inconsistent with established program guides and/or suicide policies” in twelve California prisons, including the above-mentioned three.641 While California’s prison system, as a whole, had a suicide rate only marginally higher than that found in the American population at large, the suicide ratein prisons such as Corcoran were far higher than the national average. “The five suicides that occurred at Corcoran during the period reviewed reflect the difficulties that facility had in providing adequate mental health treatment to seriously mentally disordered inmates generally, and to inmates at risk for suicide in particular,” the report noted.642 The report authors recommended better training for clinicians and correctional officers alike in recognizing and responding to indicators that a prisoner might be a suicide risk.
California appears to have taken these criticisms to heart and to have expanded its suicide prevention activities. In the year 2000, there were only fifteen suicides throughout the California system. The following year, that number rose again to twenty-seven, suggesting the decline in 2000 might have been a statistical blip.643 Generally, though, California appears to have dedicated considerable resources to monitoring suicide risks, one of the reform measures it has adopted following a federal court decision that mental health care in California prisons was unconstitutionally deficient.644
Self-harm is not always a symptom of a serious mental illness. Nevertheless, the desire to harm oneself warrants careful attention by mental health staff. Similarly, all attempts at suicide must be dealt with as a mental health emergency. Yet in prison self-harm or attempted self-harm is frequently dismissed as malingering — without consideration of whether the effort to attract attention is being made by someone with serious psychiatric needs. Dr. Terry Kupers has testified:
“Inmates display a variety of self-harm behaviors for different reasons in response to varying problems in living behind bars,” Raymond Bonner has written.646 “Motives may range from actually wanting to die to wanting specific solutions to problems or emotional relief. The term manipulation serves little useful purpose in understanding self-harm behavior and often hinders objective problems-solving and risk assessment….”
Prisoners who injure themselves or attempt suicide are often disciplined, and usually placed in segregation, if they were not there already. The treatment of self-harm as a disciplinary matter is rooted in the corrections paradigm. Self-harm violates the rules, and rule-breaking must be punished. As Fred Cohen explains, corrections officials are also concerned about deterring malingering: “The mind-set in corrections is that there has to be a ‘price’ for self-mutilation or suicide attempts; otherwise, inmates would begin to believe that they can ensure a transfer to better housing conditions simply by a simple cut or threat of suicide.”647
The response to self-harm and attempted suicide as a disciplinary rather than mental health matter is also rooted in the way prisons distinguish between what they consider serious mental illness, which they consider to be solely Axis 1, and personality disorders. Self-harm is often a consequence of certain personality disorders. As discussed above in chapter VIII, prisonmental health staff tend to discount the importance of personality disorders because they lack the resources to address the high number of prisoners with such disorders, because they get frustrated trying to deal with the notoriously difficult to treat personality disorders, and because they often themselves become “institutionalized,” adopting the correctional staff attitude that these prisoners are simply “bad,” not “mad.” They discount the mental health significance of acting out behavior, including self-harm, by prisoners diagnosed with personality disorders, and see malingering which warrants punishment, rather than illness that needs treatment.
For example, Dr. Thomas Conklin evaluated aspects of mental health care in certain Texas prisons in 1998. Following a review of the charts of thirteen suicide attempts and gestures among prisoners in the Estelle Unit, he found that “all suicide gestures by inmates are seen as manipulating the correctional system with the conscious intent of secondary gain. In not one case was the inmate’s behavior seen as reflecting mental pathology that could be treated.”648 Similarly, Dr. Jeffrey Metzner, after reviewing the medical charts and post-mortem psychological evaluation report, made the following assessment about the treatment of a Texas prisoner who committed suicide in 1997:
The reports of punitive responses to self-harm are legion:
597 State of Illinois Department of Corrections Adjustment Committee Final Summary Report. Hearing: August 22, 1998, 8.40 p.m. Hearing was before George C. Welborn, chief administrative officers, Tamms Correctional Center, Illinois.
598 Lord, “Prison Careers of Mentally Ill Women,” p. 376.
599 Boyd v. Snyder, Amended Complaint, No. 99 C 0056 (N.D. Illinois, February 25, 1999).
600 Human Rights Watch interview with T.C., Tamms Correctional Facility, Illinois, November 7, 2001.
601 Letter to Human Rights Watch from prisoner V.Y., dated September 2, 2002.
602 Human Rights Watch interview with E.X., McNeil Island Prison, Washington, August 22, 2002.
603 Human Rights Watch interviews, Graterford Prison, Pennsylvania, August 12, 2002. Staff let X.G. out of his cell for an interview in the unit’s yard.
604 Fluellen v. Wetherington, Civil Case No. 1:02-CV-479(JEC) (N.D., Georgia, March 15, 2002).
605 Preventing Suicide: A Resource for Prison Officers. Department of Mental Health, World Health Organization (Geneva, 2000) p. 5.
606 Lindsey Hayes, Prison Suicide: An Overview and Guide to Prevention (Mansfield, MA, National Center for Institutions and Alternatives, 1995), p. 4.
607 Centers for Disease Control and Prevention, National Center for Health Statistics, Health, United States, 2000, available at http://www.cdc.gov/nchs/data/hus/tables/2002/02hus047.pdf, accessed on August 26, 2003.
608 See Jane Pearson, Ph.D., Suicide in the United States, NAMI (formerly known as the National Alliance for the Mentally Ill), available online at: http://www.nami.org/update/suicide.html, accessed on August 26, 2003.
609 Some experts believe the higher range of suicide rates is most accurate. For example, Dr. Jeffrey Metzner told Human Rights Watch that 15 percent of people with schizophrenia commit suicide, and 5 to 15 percent of people with clinical depression. Human Rights Watch telephone interview with Dr. Jeffrey Metzner, July 16, 2003. See also, Douglas Jacobs, ed., Harvard Medical School’s Guide to Suicide Assessment and Intervention (San Francisco: Jossie Bass, 1999), p. 7.
610 Xiao-Yan He, A.R. Felthous, C. E. Holzer, P. Nathan, & S. Veasey, “Factors in Prison Suicide: One Year Study in Texas,” Jail Suicide/Mental Health Update, vol. 10, no. 1 (2001).
611 Correctional Association of New York, “Mental Health in the House of Corrections,” forthcoming publication.
612 Prison Legal Services, Review of New York State Commission of Correction reports on prisoner suicides (undated); on file at Human Rights Watch.
613 Lance Couturier, Ph.D. and Frederick R. Maue, M.D., “Suicide Prevention Initiatives,” 2000, p. 2
614 Raymond Bonner, “Rethinking Suicide Prevention and Manipulative Behavior in Corrections,” Jail Suicide/Mental Health Update, vol. 10, no. 4 (Fall 2001), pp. 7-8.
615 Preventing Suicide: A Resource for Prison Officers. Mental and Behavioral Disorders, Department of Mental Health, World Health Organization (Geneva, 2000) p.10.
616 Lindsay Hayes, Prison Suicide: An Overview and Guide to Prevention (the National Center on Institutions and Alternatives, Mansfield, Massachusetts, June 1995), p. 4.
617 Raymond Bonner, “Rethinking Suicide Prevention and Manipulative Behavior in Corrections,” Jail Suicide/Mental Health Update, vol. 10, no. 4 (Fall 2001), pp. 7-8.
618 Written communication to Human Rights Watch from Max Mobley, director of mental health, Arkansas Department of Corrections.
619 “Suicides High in Prison ‘Box,’” Poughkeepsie Journal, December 16, 2001.
620 Disability Advocates Inc., v. New York State Office of Mental Health, Complaint,No. 02 CV 4002 (S.D.N.Y., May 28, 2002), pp. 14-15.
621 “Mentally Retarded Man Dies in Mecklenburg Jail the Norfolk Killer, Serving 53 Years, Apparently Hanged Himself in his Cell,” Virginian Pilot and The Ledger-Star, August 26, 1997.
622 Information contained in An Investigation Into the Suicide of A Prison Inmate, Department for the Rights of Virginians with Disabilities, Case Number 98-0035, June 1999.
623 Carol Ann Bell was serving a fifteen- to fifty-year sentence for stabbing and robbing a cabdriver when she was sixteen.
624 Zertuche v. Timmerman-Cooper, Complaint (S.D. Ohio, August 22, 2001).
625 Under the terms of the settlement of the lawsuit, approved by a probate court in July 2002, the Ohio Department of Rehabilitation and Correction – in addition to paying damages to Bell’s family – agreed to expand mental services at the prison for individuals experiencing mental health crises and to increase mental health training for correctional staff. Bell’s suicide also contributed to ongoing discussions within the Ohio Department of Rehabilitation and Correction regarding the confinement of mentally ill offenders in segregation. Human Rights Watch interview with Monique Hoeflinger, attorney, Prison Reform Advocacy Center, which represented Bell’s family, September 9, 2003.
626 Information contained in court opinion in Martha Sanville v. McCaughtry, 266 F.3d 724 (7th Cir., September 21, 2001).
627 Fred Cohen, The Mentally Disordered Inmate and The Law (New Jersey: Civic Research Institute, 2000), p. 14-4. Fred Cohen wrote, while “there are constitutional duties to preserve life and to provide medical or mental health care, these duties do not translate into some guarantee of safety, health, the quality of life.”
628 Lindsay Hayes, Prison Suicide: An Overview and Guide to Prevention (the National Center on Institutions and Alternatives, Mansfield, Massachusetts, June 1995), p. 4; Human Rights Watch telephone interview with Lindsey Hayes, June 18, 2002.
629 Human Rights Watch telephone interview with Lindsey Hayes, March 26, 2003.
630 Human Rights Watch interview with Y.P., Seattle, Washington, August 20, 2002.
631 Kathryn Burns, M.D. and Jane Haddad, Psy.D., “Mental Health Care in the Alabama Department of Corrections,” Bradley v. Hightower, Civ. No. 92-A-70-N (N.D. Ala., June 30, 2000) ), p. 28.
632 Boyd v. Snyder, Amended Complaint, No. 99 C 0056 (N.D. Illinois, February 25, 1999). The court denied plaintiff’s motion for class certification. Rasho v. Snyder, 2003 U.S. Dist. Lexis 2833 (S.D. Illinois, February 28, 2003).
633 Human Rights Watch telephone interview with Lindsey Hayes, March 26, 2003.
634 Email correspondence from Dr. Terry Kupers to Human Rights Watch, April 14, 2003.
635 Human Rights Watch telephone interview with Janet Schaeffer, psychologist, April 28, 2003.
636 In 1981, the American Correctional Association developed widely recognized suicide prevention standards, revised in 1990. The National Commission on Correctional Health Care also first issued suicide standards in 1987, most recently revised in 2003. The ACA and NCCHC standards are adopted voluntarily and are not legally binding.
637 Lance Couturier, Ph.D. and Frederick R. Maue, M.D., “Suicide Prevention Initiatives in a large Statewide Department of Corrections,” Jail Suicide/Mental Health Update, vol. 9, no. 4, Summer 2000. We have only touched upon a few of the thirteen new policies and procedures adopted to prevent suicides discussed in the article.
638 Numbers detailed by Lance Couturier, “Suicide Prevention In a Large State Department of Corrections,” Corrections Today, August 2001.
639 Information contained in the Coleman Suicide Report, written by Raymond Patterson, M.D., and Kerry Hughes, M.D., July 14, 2000. The researchers found that 81.2 percent (twenty-six out of thirty-two) of suicides were by hanging.
640 Ibid., p. 4.
641 Ibid., p. 5.
643 Numbers contained in Report on Suicides Completed in the California Department of Corrections in Calendar Year 2000.
644 Coleman v. Wilson, 912 F. Supp. 1282 (E.D. California, 1995). The court accepted a magistrate findings of numerous deficiencies in California’s prison mental health services, including the failure to implement its suicide protocols because of severe understaffing.
645 Testimony of Dr. Terry Kupers, Jones ‘El v. Berge, Civil Case 00-C-0421-C (W.D. Wisconsin, 2001), pp. 124-25.
646 Raymond Bonner, “Rethinking Suicide Prevention and Manipulative Behavior in Corrections,” Jail Suicide/Mental Health Update, vol. 10, no. 4 (Fall 2001), pp. 7-8.
647 Written communication to Human Rights Watch, June 7, 2003.
648 Conklin’s conclusions are quoted in a letter regarding the Texas Department of Criminal Justice from Dr. Jeffrey L Metzner to attorney Donna Brorby, December 31, 1998, p. 9. Dr. Metzner was retained by Broby to conduct assessments regarding mental health care services provided to TDCJ inmates in connection with the Ruiz litigation.
649 Letter from Dr. Jeffrey L. Metzner to attorney Donna Brorby, December 31, 1998, p. 31.
650 Terry Kupers, Prison Madness, 1999, p. 186.
651 Human Rights Watch telephone interview with Todd Winstrom, June 5, 2002.
652 D.M. v. Fauver, First Amended Class Action Complaint, Civil 96-1840 (D.N.J.). The case ultimately settled. D.M. v. Terhune, 67 F. Supp. 2d 401 (D.N.J., 1999).
653 Human Rights Watch telephone interview with Dr. Janet Schaeffer, May 29, 2002.
654 Testimony of Dr. Terry Kupers, Jones ‘El v. Berge, Civil Case 00-C-0421-C (W.D. Wisconsin, 2001).
655 Disability Advocates Inc., v. New York State Office of Mental Health, Complaint,No. 02 CV 4002 (S.D.N.Y., May 28, 2002), pp. 14-15.