U.S. Department of Justice
National Institute of Corrections

Prison Suicide: An Overview
and Guide to Prevention

National Institute of Corrections
Morris L. Thigpen, Director
Susan M. Hunter, Chief
Prisons Division
John E. Moore, Project Manager

Prison Suicide: An Overview and Guide to Prevention
By
Lindsay M. Hayes
Project Director
National Center on Institutions and Alternatives
Mansfield, Massachusetts
June 1995

This document was prepared under grant number 93P01GHU1 from the National Institute of
Corrections, U.S. Department of Justice. Points of view or opinions stated in this document are those
of the author(s) and do not necessarily represent the official position or policies of the U.S.
Department of Justice.

Copyright © 1995 by the National Center on Institutions and Alternatives
The National Institute of Corrections reserves the right to reproduce, publish, translate, or otherwise
use, and to authorize others to publish and use all or any part of the copyrighted material contained
in this publication.
ii

TABLE OF CONTENTS
FOREWORD .......................................................................................................................................v
PREFACE AND ACKNOWLEDGMENTS ..................................................................................vi
1. INTRODUCTION AND LITERATURE REVIEW ..............................................................1
2. NATIONAL AND STATE STANDARDS FOR PRISON
SUICIDE PREVENTION ...........................................................................................................8
Reviewing the National Standards ................................................................................................9
Reviewing State Standards ...........................................................................................................15
Conclusion ....................................................................................................................................26
3. PRISON SUICIDE RATES: A 10-YEAR REVIEW.............................................................27
NCIA Survey Findings..................................................................................................................27
Conclusion ....................................................................................................................................31
4. EFFECTIVE SUICIDE PREVENTION PROGRAMS IN STATE PRISONS.................33
Elayn Hunt Correctional Center..................................................................................................33
State Correctional Institution at Retreat.....................................................................................40
5. SUICIDE PREVENTION IN FEDERAL PRISONS: A SUCCESSFUL
FIVE-STEP PROGRAM............................................................................................................46
Program Description .....................................................................................................................47
Demographic Data........................................................................................................................51
Survey of Chief Psychologists — Overview.................................................................................56
Summary........................................................................................................................................56
6. THE COURTS’ ROLE IN SHAPING PRISON SUICIDE POLICY.................................58
Jail and Prison Suicide Lawsuits...................................................................................................58
Two Roads to the Courthouse .....................................................................................................59
Courts as Agents of Reform..........................................................................................................59
Suicide Claims and Section 1983 Actions ..................................................................................60
So Much for Theory — What About the Facts? ........................................................................63
Summary........................................................................................................................................67
7. SUMMARY AND CONCLUSIONS.......................................................................................68
REFERENCES ...................................................................................................................................70
APPENDICES
A.
B.
C.
D.

Sample Suicide Precaution Protocols ..........................................................................................78
Total Prison Suicides and Rates by State: 1984-1992 ................................................................80
Suicide Prevention Protocols of the Elayn Hunt Correctional Center......................................83
Selected Procedures of the Pennsylvania Department of Corrections ......................................95

iii

TABLES
Table 2-1.
Table 3-1.
Table 3-2.
Table 3-3.
Table 3-4.
Table 3-5.
Table 4-1.
Table 4-2.
Table 4-3.
Table 4-4.

Suicide Prevention Protocols Within Departments of Corrections ...........................18
Total Prison Suicides and Rates by State, 1993 ..........................................................29
Total Prison Suicides and Rates by State, 1984 through 1993...................................29
Total Prison Suicides and Rates in the Seven Smallest State Prison
Systems, 1984 through 1993.......................................................................................30
Total Prison Suicides and Rates, 1984 through 1993 .................................................30
States with Declining Prison Suicide Rates of 50% or More ......................................31
Total Annual Admissions versus Total Annual Suicides, 1983
through 1994 ...............................................................................................................34
Annual Prison Suicide Rates in Louisiana, 1984 through 1994.................................40
Annual Prison Suicide Rates in Pennsylvania, 1984 through 1993...........................42
Suicide Potential Checklist at SCI-Retreat .................................................................43

iv

FOREWORD
While suicide is recognized as a critical problem within the jail environment, the issue of
prison suicide has not received comparable attention. Until recently, it has been assumed that
suicide, although a problem for jail inmates as they face the initial crisis of incarceration, is not a
significant problem for inmates who advance to prison to serve out their sentences. This assumption,
however, has not been supported in the literature. Although the rate of suicide in prisons is far lower
than in jails, it remains disproportionately higher than in the general population. To date, little
research has been done or prevention resources offered in this critical area.
This monograph was produced by the National Center on Institutions and Alternatives in
an effort to fill a critical void in the knowledge base about prison suicide. In addition to a thorough
review of the literature and of national and state standards for prevention, the document offers the
most recent national data on the incidence and rate of prison suicide, effective prison suicide
prevention programs, and discussion of liability issues. The National Institute of Corrections hopes
that this document will encourage continued research, training, and development of comprehensive
prevention policies that are imperative to the continued reduction of prison suicides throughout the
country.

Morris L. Thigpen, Director
National Institute of Corrections
June 1995

v

PREFACE AND ACKNOWLEDGMENTS
In April 1993, I embarked on the task of developing a comprehensive monograph on prison
suicide. Having devoted more than 15 years to the study and prevention of jail suicide, I was not only
well aware of the problem of suicide in custody, but also had developed the strong bias that we should
be directing much more energy toward the issue. My feeling then and now is that while the number
of suicides in jails far exceeds the number in prison, that fact certainly should not lessen our
responsibility to identify and prevent as many of these prison deaths as we can. It is always difficult,
however, to preach prevention without first identifying the parameters of the problem. The intent
of this document is not only to detail what is now known about prison suicide, but also to describe
how far we have come in our prevention efforts and the work that still lies ahead. Only by continuing
to examine the problem of prison suicide and transmitting what is learned to those entrusted with
the custody and care of inmates will we be in the best possible position to reduce the likelihood of
prison suicide. It is my hope that this monograph provides the appropriate vehicle for disseminating
such information.
Many individuals are involved in a project of this scope. First, I would like to thank Susan M.
Hunter, chief, NIC Prisons Division, and John E. Moore, program monitor, for their positive response
to my initial concept proposal and support in the project, as well as Nancy Sabanosh for her diligence
in pushing the document through the publication process. Second, the assistance from each
department of correction throughout the country, resulting in a 100 percent survey response, is
greatly appreciated and thanks are also due to those jurisdictions that granted permission for various
suicide prevention protocols to be reprinted in the appendices. Third, I would like to especially thank
staff at both the Elayn Hunt Correctional Center (EHCC) in St. Gabriel, Louisiana, and State
Correctional Institution (SCI) at Retreat in Hunlock Creek, Pennsylvania, for allowing me to
conduct onsite case studies of the suicide prevention programs that are presented in Chapter 4. At
EHCC, Warden C.M. Lensing and Mental Health Coordinator Nancy Gautreau provided invaluable
assistance and insight during my visit. At SCI Retreat, Superintendent Dennis R. Erhard, Inmate
Program Manager John G. Mack, Psychologist James P. McGraw, Jr., and Chief of Psychological
Services for the Pennsylvania DOC Dr. Lance Couturier were equally as helpful to developing the
case studies.
Finally, this monograph could not have been written without the assistance and support of
several other individuals. Thanks go to Thomas W. White, Ph.D., and Dennis J. Schimmel, Ph.D.,
for writing the article on suicide prevention efforts within the Federal Bureau of Prisons that appears
as Chapter 5; and William C. Collins, Esq., for writing the article on prison suicide liability that
appears as Chapter 6. In addition, Ronald L. Bonner, Ph.D., James T. Sprowls, Ph.D., and Chris
Cormier Hayes reviewed earlier drafts and provided invaluable assistance, while Alice Boring brought
it all together.

Lindsay M. Hayes
June 1995

vi

Chapter 1
INTRODUCTION AND LITERATURE REVIEW
Writing about “difficult prisoners” in his autobiography Fifty Years of Prison Service,
Zebulon R. Brockway appeared perturbed by the prospect of managing suicidal inmates and by the
resulting publicity in the event of their deaths. As superintendent of Elmira Reformatory (often
described as the original model from which progressive penology evolved) from 1876 to 1900,
Warden Brockway described his experience with three prison suicides:
One, a prisoner on parole in New York City who violated his
obligations, was taken for kindly investigation to the secretary of the
Prison Association, at the rooms then situated in the third story of the
Bible House. While awaiting the secretary’s convenience the young
man suddenly dashed through an open window to his death on the
pavement below. The newspapers made a sensational account of it
and inquired why, if the reformatory was as it should be, a paroled
man should voluntarily go to his death rather than be returned to
treatment there. Another, a resident prisoner under a definite
sentence, hanged himself in his cell. The coroner’s jury absolved the
reformatory management from any blame, but the hungry newspapers
magnified the incident. Hughes, a prisoner from Albany, of feeble
intellect, hanged himself by his suspenders in his cell. The remains
were forwarded to his parents, working people in Albany. The
condition of the remains on arrival, by reason of the manner of the
death and the futile extraordinary efforts by our physician, Dr. Wey,
for his resuscitation, led to the mistaken opinion that he suffered ill
treatment at the reformatory — an opinion which, though contrary to
the coroner’s verdict, was entertained by his parents and was
mentioned sensationally in the newspapers of Albany (Brockway,
1969, pp. 191-92).
Of course, Warden Brockway had his own theory about suicidal behavior among his
prisoners: “I traced the abnormal activity to (a) instinctive imitation, (b) craving curiosity, (c)
mischievous desire to excite alarm, (d) intent to create sympathy and obtain favors, (e) a certain
subjective abnormality induced by secret pernicious practices.” His solution: “Suicide attempts were
completely stopped by notice in the institution newspaper that thereafter they would be followed in
each case with physical chastisement” (Brockway, 1969, p. 192).
Fortunately, our current understanding of both the causes and prevention of suicide within
the correctional environment has survived Warden Brockway’s questionable wisdom. But while
suicide is recognized as a critical problem within jails, the issue of prison suicide has not received
comparable attention — primarily because the number of jail suicides far exceeds the number of
prison suicides. Suicide continues to be the leading cause of death in jails, where over 400 inmates
take their lives each year; the suicide rate in detention facilities is approximately nine times greater
than that of the general population (Hayes and Rowan, 1988). On the other hand, suicide ranks third
as a cause of death in prisons (Bureau of Justice Statistics, 1993a), and, as will be shown in Chapter
1

3, the number and rate of suicides in prison are considerably lower than in jails. While two
comprehensive national studies of jail suicide have been completed (Hayes and Kajdan, 1981; Hayes
and Rowan, 1988), a comparable national examination of prison suicides has not occurred to date.
Historically, little is known about the risk of suicide in prison, a research topic that has been
characterized as a victim of relative neglect in criminology and corrections (Austin and Unkovic,
1977). Before 1973, most research on prison suicides was concentrated on attempted suicide (e.g.,
Reiger, 1971), self-mutilation (e.g., Johnson, 1973), or deaths in the European correctional system.*
More recent research offers limited insight through its exclusive focus on prison suicide rates (e.g.,
Batten, 1992; Lester, 1990); victim profiles (e.g., Austin and Unkovic, 1977); absence of discussion
regarding precipitating factors; and failure to differentiate prison and jail suicides (e.g., Salive,
Smith, and Brewer, 1989). Other observers are simply unimpressed with prison suicide rates and
are not convinced that the issue bears significant attention (e.g., Payson, 1975). These same
observers assume that, while the risk of suicide looms large in jail among inmates facing the initial
stages of confinement, such risk dissipates over time in prison as individuals become more
comfortable or tolerant of their predicament and develop coping skills to effectively handle life
behind bars. This assumption, of course, has not been empirically studied, is far too simplistic, and
ignores both the process and individual stressors of prison life.
The precipitating factors of suicidal behavior in jail are well established (Rowan and Hayes,
1995). It has been theorized that there are two primary causes for jail suicide — first, jail
environments are conducive to suicidal behavior and, second, the inmate is facing a crisis situation.
From the inmate’s perspective, certain features of the jail environment enhance suicidal behavior:
fear of the unknown, distrust of the authoritarian environment, lack of apparent control over the
future, isolation from family and significant others, shame of incarceration, and the dehumanizing
aspects of incarceration. In addition, certain factors often found in inmates facing a crisis situation
could predispose them to suicide: recent excessive drinking and/or use of drugs, recent loss of
stabilizing resources, severe guilt or shame over the alleged offense, and current mental illness
and/or prior history of suicidal behavior. These factors become exacerbated during the first 24 hours
of incarceration, when the majority of jail suicides occur. Inmates attempting suicide are often
under the influence of alcohol and/or drugs and placed in isolation. In addition, many jail suicide
victims are young and generally have been arrested for non-violent, alcohol-related offenses.
Although prison suicide victims share some of these characteristics, the precipitating factors in
suicidal behavior among prison inmates are somewhat different and fester over time.

*

Research on prison suicides in foreign countries was purposely excluded from this literature review, primarily because
correctional systems in other countries are operated quite differently from those in the United States. For example,
the word “prison” has different meanings throughout Europe, and many foreign prison systems hold both pretrial
(remand) and sentenced inmates. The most comprehensive and enlightening research on prison suicide from Europe
to date is Liebling, Suicides in Prison, London, England: Routledge Publishing, 1992.

2

An Englishman named J.M. Wooley was one of the first researchers to address these issues
over 80 years ago. Studying the topic of prison suicide when transportation was a common method
of excluding criminals from society, Wooley (1913) reviewed specifically the suicides of Indian
prisoners from 1902 through 1911 who were placed in solitary confinement before being transported
to settlement camps. The research indicated that 43 percent of the suicides occurred during the first
18 months of incarceration, 90 percent were by hanging, and inmates sentenced for murder
committed suicide five times more frequently than non-murderers. Wooley cautioned, however, that
the data became less significant unless certain institutional factors were addressed: prison discipline,
hard labor, solitary confinement, overcrowding, homosexual attacks, and staff brutality.
More recently, Anno (1985) examined 38 suicides in the Texas Department of Corrections
(TDC) between 1980 and 1985 and determined that the suicide rate was 18.6 per 100,000 inmates.
The research also revealed that the vast majority of victims (97%) were housed in single cells, 45
percent had a history of prior suicide attempts, 68 percent had a history of mental illness, and 58
percent had been convicted of a personal crime. The victims’ case files also contained various
behavioral and verbal cues:
In almost all of the TDC cases, there was some evidence available in
the records or, more often, in the subsequent reports of the
individuals’ deaths that could have alerted an aware staff member to
the fact that the inmate was suicidal. In some cases, the inmate told
someone he had been thinking of suicide. In others, it was noted that
the individual had just received some bad news (e.g., death of a
family member). In still other instances, there were notations in the
record of bizarre behavior or withdrawn, depressed behavior or
expressions of extreme shame and remorse regarding their crime
(Anno, 1985, p. 90).
A study of 19 suicides in Kentucky prisons between 1973 and 1986 found that, although
most victims’ characteristics paralleled those of the general inmate population, 79 percent of the
suicides occurred in special housing units and 53 percent of victims had a history of serious mental
illness and one or more prior suicide attempts (Jones, 1986). Most interesting was the finding that
several environmental and operational factors might have contributed to the suicides: 1)
inadequate or unavailable psychological services at initial intake and during incarceration, 2) poor
communication among staff, 3) perception of self-injurious behavior as a means of manipulation,
4) basic elements of the institutional environment that constrain personal efficacy and control, 5)
limited staff training and direction in suicide prevention, 6) limited staff direction in responding to
suicide incidents, and 7) investigations directed primarily toward establishing an appropriate
response by staff without the accompanying thorough investigation of the causes of the suicide.
Based on 37 prison suicides between 1979 and 1987, Salive et al. (1989) projected a suicide
rate in the Maryland prison system of almost three times that of the general population. Although
precipitating factors were not offered, the study found higher suicide rates among white inmates and
those aged 25 to 34, convicted of personal crimes, and housed in a maximum security facility. In
addition, while the length of actual time served by inmates who committed suicide varied widely,
only 22 percent of the victims had sentences under eight years, and almost 25 percent of all victims
were serving life sentences.
Two states with large prison populations — California and New York — recently collected
data on inmate suicides within their prison systems. In a review of 15 suicides that occurred in its
3

prison facilities during 1990, the California Department of Corrections (1991) found that 60 percent
of victims had been diagnosed with a serious mental disorder and that 53 percent had a history of
substance abuse. All but one of the victims were housed in a single cell, and 40 percent were
confined in administrative segregation units. A subsequent analysis by the California Department
of Corrections (1994) determined that the rate of suicide in its prison facilities decreased from 17
per 100,000 inmates in 1990 to 14 per 100,000 in 1992, but dramatically and inexplicably rose to
25 per 100,000 in 1993.
The New York State Department of Correctional Services (1994) analyzed 52 suicides in
its prison facilities between 1986 and mid-1994 and compared the data to the general inmate
population. White inmates represented 18 percent of the prison population but 42 percent of the
suicides, whereas black inmates represented 50 percent of the prison population but only 20 percent
of the suicides. Further, although inmates convicted of a violent felony represented 56 percent of
the prison population, they accounted for 80 percent of the suicides. Regarding length of
incarceration, 64 percent of all victims committed suicide within 2 years of entering the prison
system, and 66 percent of the victims had mandatory minimum sentences of at least 4 years, with
23 percent serving life sentences.
Finally, in a study provided in Chapter 5, White and Schimmel discuss one of the most
thorough reviews to date of suicides in federal prisons. In their analysis of 86 suicides that occurred
within the Federal Bureau of Prisons (FBOP) system between 1983 and 1992, the researchers found
that 49 percent of the victims had a documented history of diagnosed mental illness or treatment and
that approximately 46 percent of those who committed suicide had attempted it or made gestures
in the past. In addition, 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.
Of special interest was the fact that although pretrial inmates and Mariel Cuban detainees
represented only 6 percent and 4 percent of the total FBOP population, respectively, these two
groups combined accounted for 42 percent of all suicides. In addition, although inmates serving
sentences of over 20 years represented only 12 percent of the inmate population, they accounted for
28 percent of all suicides. Generally, long-term prisoners committed suicide after serving
approximately 5 years of their sentences. Finally, with access to FBOP-authorized psychological
autopsies on each suicide, White and Schimmel speculated about several precipitating factors: “new
legal problems” for the inmate in 28 percent of the suicides, “marital or relationship difficulties” in
23 percent, and “inmate-related conflicts” in 23 percent.
Despite the consistent findings in all of this recent research, its general use is somewhat
limited. Research to date in the area of custodial suicide has generally been retrospective and
descriptive. The descriptors have been gathered after the fact, and their etiological and/or
developmental role in the process of suicide is therefore unclear. Most important, this research has
perhaps unknowingly conceptualized suicide as a static, isolated event that is simply associated with
other static factors (e.g., demographics). Such an approach, however, cannot explain or account for
the process by which certain prison inmates decide to end their lives at a given time within a
particular condition (Bonner, 1992a).
This process can be better explained in the general literature on suicidology. Efforts to
correlate suicide to socio-demographic variables and psychiatric categories (e.g., depression) will
have a negligible impact unless the individual’s “psychache” (intolerable psychological pain) is
addressed (Shneidman, 1993). “Suicide is not a bizarre and incomprehensible act of selfdestruction. Rather, suicidal people use a particular logic, a style of thinking that brings them to the
conclusion that death is the only solution to their problems. This style can be readily seen, and there
4

are steps we can take to stop suicide, if we know where to look” (Shneidman, 1987, p. 56). In
applying this doctrine to prison suicide, Bonner (1992a) offers the “stress-vulnerability model,” the
theory that suicide must be viewed in the context of a process by which an inmate is (or becomes)
ill-equipped to handle the common stresses of confinement. As the inmate reaches an emotional
breaking point, the result can be varying degrees of suicidal intention, including ideation,
contemplation, attempt, or completion. Initially, these stressors mirror those of jail suicide victims,
such as fear of the unknown and isolation from family, but over time:
...incarceration may bring about added stressors, such as loss of
outside relationships, conflicts within the institution, victimization,
further legal frustration, physical and emotional breakdown, and a
wide variety of other problems in living. Coupled with such negative
life stress, individuals with psychosocial vulnerabilities (including
psychiatric illness, drug/alcohol intoxication, marital/ social isolation,
suicidal coping history, and deficiencies in problem-solving ability)
may be unable to cope effectively and in time may become hopeless
(Bonner, 1992a, p. 407).
In addition to hopelessness, the general literature on suicidology identifies other risk factors
for suicidal behavior: current degree of suicidal ideation and previous attempts, dysfunctional
assumptions, dichotomous (all-or-nothing) thinking, inability to solve problems and a view of
suicide as the desirable solution to one’s problems, psychiatric disorders, substance abuse, and
availability of something to use to commit suicide (Weishaar and Beck, 1992). Such factors, in
combination or interaction with the common stresses of confinement, could break down the ability
to cope and create the emotional avenue for suicidal behavior. With few exceptions, however (most
notably Bonner and Rich, 1992; Ivanoff and Jang, 1991; Ivanoff, Smyth, Grochowski, Jang, and
Klein, 1992), these factors have not been empirically tested in a correctional setting. Yet, although
research has not sufficiently addressed the psychosocial process of prison suicide, court decisions
and developing national standards have, to a degree, filled the void by advocating the view that
suicide is a process that typically displays observable signs of maladaptive coping and suicidal
intention. If identified in time, the process can be reversed or prevented in most cases (Bonner,
1992b).
A discussion of prison suicide would be incomplete without a few words about suicide and
the manipulative inmate. Few issues challenge prison officials and staff more than the management
of manipulative inmates. It is not unusual for inmates to call attention to themselves by threatening
suicide or feigning an attempt to avoid a court appearance, bolster an insanity defense, be relocated
to a different cell, be transferred to the prison infirmary or a local hospital, receive preferential staff
treatment, or seek compassion from a previously unsympathetic spouse or other family member.
Although the prevailing theory is that any inmate who would go to the extreme of
threatening suicide or engaging in self-injurious behavior is suffering from at least an emotional
imbalance that requires special attention, too often prison officials (with the support of mental health
staff) conclude that the inmate is not dangerous and simply attempting to manipulate his or her
environment. They often suggest such behavior be ignored and not reinforced through intervention.
In fact, it is not unusual for mental health professionals to resort to labeling, with inmates engaging
in “deliberate self-harm” termed “manipulative” or “attention seeking,” and “truly suicidal” inmates
seen as “serious” and “crying for help.” Clinicians routinely differentiate between behavior they

5

regard as genuine suicide attempts and other self-injurious behavior they label, variously, as selfmutilation, suicidal gestures, parasuicide, manipulation, or malingering (Haycock, 1989a).
A study of self-injury among prison inmates, for example, found that acts of self-mutilation
often signify increased tension in the inmates’ lives caused by situations they sense are beyond their
direct control (Thorburn, 1984). Use of violence for control is common in prison, and self-directed
violence as in self-mutilation can provide a distorted sense of control. A study of parasuicide
(intentional self-harm) among prison inmates found that psychiatric history and parasuicide records
of the inmates’ group of significant others (i.e., other prisoners) were the best predictors of
intentional self-harm (Ivanoff, 1992). In any event, at a minimum, all acts of self-injury can be said
to reflect personal breakdowns resulting from crises of self-doubt, poor coping and problem-solving
skills, hopelessness, and fear of abandonment (Toch, 1975). It has been argued that there are no
false suicidal acts:
Correctional, medical, and mental health staff should abandon the
effort to classify suicidal behavior according to expressed or
presumed intent, particularly since the tendency of persons to
minimize the seriousness of their suicidal intent after the fact is wellknown across community, hospital, and other settings. There are no
reliable bases upon which we can differentiate “manipulative” suicide
attempts posing no threat to the inmate’s life from those true “nonmanipulative” attempts which may end in a death. The term
“manipulative” is simply useless in understanding, and destructive in
attempting to manage, the suicidal behavior of inmates (or of
anybody else) (Haycock, 1992, pp. 9-10).
Other clinicians disagree and argue that self-injurious behavior displayed by “truly suicidal”
or “manipulative” inmates should result in different interventions. For suicidal inmates, intervention
that promotes close supervision, social support, and access to or development of psychosocial
resources is crucial. For manipulative inmates, intervention that combines close supervision with
behavior management is crucial in preventing or modifying such behavior. Historically, the
problem has been that manipulative behavior was ignored or resulted in punitive sanctions,
including isolation. Often, manipulative inmates escalate their behavior and die, either by accident
or miscalculation of the staff’s responsiveness. Therefore, these clinicians stress, the problem is not
in how we “label” the behavior, but how we react to it — and the reaction should not include
isolation.

6

Finally, the literature is replete with recommendations on how to reduce incidents of suicidal
behavior among prison inmates, a problem that many believe is the most preventable cause of death
in prisons (Anno, 1991; Salive et al., 1989). A primary recommendation, based chiefly on
overwhelmingly consistent research, is that isolation should be avoided whenever possible. Whether
its use is disciplinary or observational, isolation can pose a special threat to inmates who have
limited abilities to cope with frustration. Further, while some inmates are initially placed in
administrative segregation for reasons unrelated to risk of suicide, they can injure themselves as a
result of the isolation. As one inmate offered: “The Hole and Segregation cells are depressing
enough to drive many men to take their lives in order to escape. For some it would appear to be the
only way out. After years of living in the cramped confines of a segregation cell with no hope of
getting out, it is easy to see why a man would prefer death” (Cardozo-Freeman, 1984, p. 430).
Death row inmates are preoccupied with thoughts of suicide (Johnson, 1981) and exhibit an
unusually high rate of suicide (Lester, 1990). A psychiatrist who investigated the use of isolation
in several prison systems throughout the country attributed prolonged social isolation and lack of
stimulation in segregation to a “solitary confinement syndrome,” where inmates become “floridly
psychotic and subject to uncontrollable impulses, including random violence, self-mutilation, and
suicidal behavior” (Murphy, 1994, p. 4).
And while few prison officials today would support Warden Brockway’s suggestion of
“physical chastisement” as a tool for suicide prevention, the use of segregation for self-injurious
inmates can be said to be the modern equivalent, and it should be met with the same disapproval.
As observed by one federal court:
...The Court finds the treatment of seriously mentally ill inmates to
be appalling. Rather than providing treatment for serious mental
illnesses, ADOC punishes these inmates by locking them down in
small, bare segregation cells for their actions that are the result of
their mental illnesses. These inmates are left in segregation without
mental health care. Many times the inmates, such as H.B. are in a
highly psychotic state, terrified because of hallucinations, such as
monsters, gorillas or the devil in her cell....This use of lockdown as
an alternative to mental health care for inmates with serious mental
illnesses clearly rises to the level of deliberate indifference to the
serious mental health needs of the inmates and violates their
constitutional rights to be free from cruel and unusual punishment
(Casey v. Lewis, 1993, p. 1477).
Other recommendations found in the literature include suicide prevention training for both
correctional and mental health staff (Anno, 1985; Sperbeck and Parlour, 1986); preventive
intervention for long-term inmates (Salive et al., 1989); better communication between correctional,
medical, and mental health staff (Jones, 1986); and comprehensive suicide prevention policies that
include screening procedures, architectural considerations, monitoring/observation patterns, and
interaction techniques (Anno, 1991). The success of efforts to prevent suicide in prisons will
depend on our ability and willingness to identify the vulnerable inmate, provide the necessary
supervision, and offer alternative ways of coping and reducing emotional distress (Bonner, 1992b).

7

Chapter 2
NATIONAL AND STATE STANDARDS
FOR PRISON SUICIDE PREVENTION
Beginning in the early 1960s, various legislative bodies and agencies have examined prison
systems in an effort to fashion standards for the efficient operation of correctional facilities. From
these efforts, two basic types of standards emerged to measure the adequacy of prison conditions:
1) the minimum standards of constitutional decency devised and refined by federal courts in
decisions challenging the conditions of confinement, and 2) the growing body of self-regulatory
standards and accreditation procedures promulgated by professional and federal agencies to
stimulate improvement of the facilities through voluntary, administrative action (National Institute
of Justice, 1980).
The courts have taken an active role in measuring the adequacy of prison conditions. As of
January 1995, 39 states plus the District of Columbia, Puerto Rico, and the Virgin Islands were
under court order or a consent decree to limit the number of inmates and/or improve conditions of
confinement in either the entire state prison system or its major facilities (National Prison Project,
1995). Of these, 33 jurisdictions were under court order for overcrowding or conditions of
confinement in at least one of their major prison facilities, while 9 jurisdictions were under court
order for their entire system. Only 3 states (Minnesota, New Jersey, and North Dakota) have never
been involved in major litigation challenging prison overcrowding or conditions.
Although correctional standards are not legally binding and do not set constitutional
requirements (see Rhodes v. Chapman, 1981), the U.S. Supreme Court has stated that such standards
have the ability to serve as guidelines or benchmarks in assessing the “duty of care” or “reasonable
conduct” (see Bell v. Wolfish, 1979). Correctional standards are also seen by experts as: 1)
promoting humane conditions of confinement; 2) reducing liability in the event of a lawsuit; and
3) increasing organizational efficiency, including the desire to professionalize the field of
corrections. According to one federal court monitor, “The move toward professionalism in the field
has been going on for many years, but comprehensive standards were not forthcoming until the early
1960s. Standards then represent a quantum leap in the move toward professionalism, and cover such
topics as personnel, administration, and operations” (Lonergan, n.d.).
Correctional standards have become a yardstick for measuring conditions of confinement.
As noted several years ago, “The new judicial activism has added a sense of urgency to the
development of increasingly specific self-regulatory standards by executive and professional
organizations. In turn, the availability of these standards promises to introduce a new level of
objectivity to litigation challenging the conditions of confinement” (National Institute of Justice,
1980, p. 39). In 1990, the American Correctional Association (ACA) commissioned a study to
determine the impact of its correctional standards on court rulings and found that 1) courts often
consult ACA standards when attempting to determine appropriate expectations in a correctional
setting, 2) courts sometimes cite ACA standards as the basis for establishing a court standard or a
requirement in a decision, and 3) courts have sometimes used ACA standards and accreditation as
a component of a continuing order or consent decree (Miller, 1992). Not all courts use standards
(ACA or otherwise) to measure conditions of confinement, however, because in “many instances
a lower requirement is adopted consistent with the court’s view of the constitutional or statutory
requirement. In others, a higher standard might be established by the court given the circumstances

8

of the case. And often the court prefers to take a totality of conditions perspective instead of relying
on specific standards” (Miller, 1992, p. 60).
In attempting to manage a correctional facility, the prison administrator is faced with two
dilemmas: what constitutes sound correctional practices and what represents the “state of the art.”
Standards, whether national or state, can provide guidance for the administrator. When devising
a strategy to reduce liability, for example, the administrator can cite compliance with national and/or
state standards as part of a good faith defense. Because standards reflect the state of the art, they
provide reasonable and minimal guidelines on which the administrator can base policies and
procedures. By promoting professionalism, standards “provide administrators with the opportunity
to develop a planned program for upgrading facilities and procedures in accordance with a
nationally recognized and respected format. The standards can assist administrators in working
effectively with the courts and legislatures” (ACA, 1981, p. vii).

Reviewing the National Standards
Although initially created a decade earlier, correctional standards gained prominence in the
late 1970s. In 1966, ACA published its Manual of Correctional Standards, followed by Manual
of Standards for Adult Correctional Institutions in 1977. These standards were again revised and
published as Standards for Adult Correctional Institutions in 1981. The American Public Health
Association (APHA) published Standards for Health Care in Correctional Institutions in 1976,
revised and reissued 10 years later as Standards for Health Services in Correctional Institutions.
In 1979, the American Medical Association (AMA) published Standards for Health Services in
Prisons. During the 1980s, the U.S. Department of Justice published Federal Standards for Prisons
and Jails (1980); the National Commission on Correctional Health Care (NCCHC) revised the
AMA’s 1979 standards and published Standards for Health Services in Prisons (1987); and the
American Psychiatric Association (APA) published a task force report and guidelines manual
entitled Psychiatric Services in Jails and Prisons (1989). In 1990, ACA issued the third, revised
edition of Standards for Adult Correctional Institutions, and the Joint Commission on Accreditation
of Healthcare Organizations (JCAHO) published Ambulatory Health Care Standards. Finally,
NCCHC issued the third, revised edition of Standards for Health Services in Prisons in 1992.
The relationship between suicide prevention and correctional standards is a fairly recent
phenomenon. While the 1970s and 1980s witnessed a plethora of national correctional standards,
the standards greatly varied in their specificity regarding prevention of prison suicides. In fact,
several standards failed to even address the issue.*

*

Because neither the APA nor U.S. Department of Justice or JCAHO standards address basic suicide prevention
protocols, they will not be reviewed here. Appendix E of Anno (1991) contains an excellent comparative analysis of
national prison health care standards.

9

American Correctional Association Standards
ACA’s Standards for Adult Correctional Institutions are the most widely recognized national
prison standards, but, because their primary emphasis is on the operation and administration of
prisons, the early editions did not fully address health care. For example, with two minor
exceptions,* the 1981 ACA standards did not specifically address the issues of suicide prevention
and handling suicidal inmates, the components of the special health program, or the frequency or
type of supervision for suicidal inmates.
In August 1983, standard 2-4182-3 was created:
Written policy and procedure require that all special management
inmates are personally observed by a correctional officer at least
every 30 minutes, but on an irregular schedule. More frequent
observation is required for those inmates who are violent or mentally
disturbed or who demonstrate unusual or bizarre behavior; suicidal
inmates are under continuing observation.
The following year, the issue of suicide prevention was again addressed in standard 2-42851 with some of the strongest commentary to date:
Added August 1984. There is a written suicide prevention and
intervention program that is reviewed and approved by a qualified
medical or mental health professional. All staff with responsibility
for inmate supervision are trained in the implementation of the
program.
Discussion. Staff have a responsibility for preventing suicides
through intake screening, identification, and supervision of suicideprone inmates. They should receive special training in the
implementation of a suicide prevention program.
In January 1989, standard 2-4092 was revised to require that the topics “signs of suicide
risk” and “suicide precautions” be included in the training curriculum for new correctional officers.
The following year, ACA issued the third edition of Standards for Adult Correctional Institutions.
With one exception, it contained no further revisions to suicide prevention protocols. Standard 24092 was renumbered as 3-4081, standard 2-4182-3 was renumbered as 3-4245, standard 2-4289
was renumbered as 3-4343, standard 2-4304 was renumbered as 3-4355, and standard 2-4285-1 was
renumbered as 3-4364. While standard 2-4285-1 had contained ACA’s strongest commentary about
preventing suicide, emphasizing that “staff have a responsibility for preventing suicides,” that
language was removed from the third edition and the standard (renumbered as 3-4364) simply reads,
*

Standard 2-4289, requiring that all inmates except intrasystem transfers be medically screened, including inquiry into
“past and present treatment or hospitalization for mental disturbance or suicide”; and standard 2-4304, requiring a
special medical program for inmates needing close medical supervision because they could be suicidal.

10

“The program should include specific procedures for intake screening, identification, and
supervision of suicide-prone inmates.”
American Medical Association Standards
AMA’s Standards for Health Services in Prisons contained the first national standards
developed exclusively for prison facilities that specifically addressed health care. First published
in 1979, the AMA standards included several suicide prevention protocols. For example, standard
144 addressed the need for an “interim health appraisal,” requiring that:
Psychiatric problems identified either at receiving screening or after
admission must be followed up by medical staff. The urgency of the
problems determines the responses. Suicidal and psychotic patients
are emergencies and require prompt attention.
Inmates awaiting emergency evaluation should be housed in a
specially designated area with constant supervision by trained staff....
In addition, standard 147 required a medical evaluation of all inmates housed in segregation
at least three times weekly by qualified health care personnel:
Due to the possibility of injury and/or depression during such periods
of isolation, health evaluations should include notation of bruises or
other trauma markings, and comments regarding attitude and outlook.
Carrying out this policy may help to prevent suicide or an illness
from becoming serious.
Finally, AMA’s standards required a “special medical program” for inmates with “a broad
range of health problems, e.g., seizure disorders, diabetes, potential suicide, chemical dependency,
psychosis.”
American Public Health Association Standards
Although APHA’s Standards for Health Services in Correctional Institutions did not
distinguish the sometimes subtle differences in health care for jail and prison inmates, the 1986
regulations were definitive about the issue of suicide prevention:
Suicide is the major cause of death among detainees and prisoners.
Health providers must be trained to recognize warning signs and
must devise appropriate plans to safeguard life. Inmates are
especially at risk for suicide when first admitted to a jail. Whereas
correctional authorities have responsibility for safe custody, health
staff possess the training and expertise to recognize signs of
depression and aberrant behavior, which may include suicidal intent.

11

A. Every correctional facility must institute a suicide prevention
program which addresses the profile of inmates at greatest risk
for suicide and details particular plans for intervention.
B. Jail health providers must screen inmates for suicidal intent or
ideation as part of the admission medical evaluation, since 50%
of jail suicides occur in the first 24 hours and 27% occur during
the first 3 hours.
C. Prison health staff shall screen inmates for suicidal intent on
admission to the institution or transfer to another facility.
D. When an inmate at risk is identified by medical staff, the inmate
must be referred to the Mental Health Unit for immediate
evaluation. Upon psychiatric evaluation, any inmate considered
to be an actual suicide risk shall be hospitalized on an emergency
basis. All others shall be placed in a mental observation area
with a suicide watch pending further evaluation by a psychiatrist.
E. Isolation may increase the chance that an inmate will commit
suicide and must not be used as a substitute for staff supervision,
especially in jails, especially for intoxicated individuals. A drugand/or alcohol-intoxicated prisoner shall not be locked in an
unobserved cell or holding unit. Observation of intoxicated
inmates must be constant. If observation is carried out via TV
monitor, staff must be able to gain access to the prisoner within
three minutes.
National Commission on Correctional Health Care Standards
NCCHC’s Standards for Health Services in Prisons, published in January 1987, was a
substantially revised version of AMA’s 1979 standards. For example, unlike the AMA regulations,
the NCCHC standards highlighted the relationship between “receiving screening” (standard P-30)
and the identification of suicidal inmates:
It is extremely important for screeners to explore fully the inmate’s
suicide and withdrawal potential. Reviewing with an inmate any
history of suicidal behavior, and visually observing the inmate’s
behavior (delusions, hallucinations, communication difficulties,
speech and posture, impaired level of consciousness, disorganization,
memory defects, depression or evidence of self-mutilation) are
recommended. This approach, coupled with the training of the staff
in all aspects of mental health and chemical dependency, should
enable facilities to intervene early to treat withdrawal and to prevent
most suicides.

12

More important, the NCCHC standards offered the most comprehensive and practical suicide
prevention regulations to date because they not only required that prisons develop a written plan but
also listed the essential components of a suicide prevention program:
P-58: Suicide Prevention
The prison has a written plan for identifying and responding to suicidal individuals.
Discussion. While inmates may become suicidal at any point during
their stay, high-risk periods include the time immediately upon
admission to a facility; after adjudication, when the inmate is
returned to a facility from court; following the receipt of bad news
regarding self or family (such as serious illness or the loss of a loved
one); and after suffering some type of humiliation or rejection.
Individuals who are in the early stages of recovery from severe
depression may be at risk as well. The facility’s plan for suicide
prevention should include the following elements:
a. Identification. The receiving screening form should
contain observation and interview items related to the
inmate’s potential suicide risk.
b. Training. All staff members who work with inmates
should be trained to recognize verbal and behavioral cues
that indicate potential suicide.
c. Assessment. This should be conducted by a qualified
mental health professional, who designates the inmate’s
level of suicide risk.
d. Monitoring. The plan should specify the facility’s
procedures for monitoring an inmate who has been
identified as potentially suicidal. Regular, documented
supervision should be maintained.
e. Housing. A suicidal inmate should not be placed in
isolation unless constant supervision can be maintained.
If a sufficiently large staff is not available that constant
supervision can be provided when needed, the inmate
should not be isolated. Rather, s/he should be housed with
another resident or in a dormitory and checked every 1015 minutes. The room should be as nearly suicide-proof
as possible (that is, without protrusions of any kind that
would enable the inmate to hang him/herself).
f. Referral. The plan should specify the procedures for
referring potentially suicidal inmates and attempted
suicides to mental health care providers or facilities.
13

g. Communication. Procedures for communication between
health care and correctional personnel regarding the status
of the inmate should exist, to provide clear and current
information.
h. Intervention. The plan should address how to handle a
suicide in progress, including how to cut down a hanging
victim and other first-aid measures.
i. Notification.
Procedures for notifying prison
administrators, outside authorities, and family members of
potential, attempted, or completed suicides should be in
place.
j. Reporting. Procedures for documenting the identification
and monitoring of potential or attempted suicides should
be detailed, as should procedures for reporting a
completed suicide.
k. Review. The plan should specify the procedures for
medical and administrative review if a suicide does occur.
In 1992, the NCCHC standards were again revised and although standard P-58 was
renumbered as P-54, it remained intact. In addition, the revised NCCHC standards offered a fourlevel suicide prevention protocol for the assessment, housing, and observation of suicidal inmates.*
Briefly, Level 1 is reserved for the inmate who recently attempted suicide. The inmate should be
housed in either a “safe room” or the health clinic, with health care staff providing one-on-one
constant observation of the inmate while he or she is awake, and visual checks every 5 to 10 minutes
while the inmate is asleep. Level 2 is reserved for the inmate who is considered a high suicide risk.
The inmate should be housed in either a “safe room” or the health clinic, with health care staff
providing visual observation of the inmate every 5 minutes while awake and every 10 minutes while
asleep. Level 3 is reserved for the inmate who is assessed as a moderate suicide risk, who might
previously have been on either Level 1 or 2. The inmate should be observed every 10 minutes while
awake and every 30 minutes while asleep. Level 4 is reserved for the inmate who, perhaps based
on past history, could be at risk of becoming severely depressed and/or suicidal. The inmate should
be observed every 30 minutes while awake and asleep.

*

Titled “Sample Suicide Precaution Protocols,” this section of NCCHC’s 1992 Standards for Health Services in
Prisons is reprinted in Appendix A.

14

Conclusion
Historically, national correctional standards have been viewed with some skepticism,
referred to as too general or vague, lacking in enforcement power, and often politically influenced.
“Courts and correctional administrators seeking specific guidelines as to what constituted
‘adequate’ provisions for health care were not likely to derive much satisfaction from the early
standards” (Anno, 1991, p. 18). And formal adoption of current national correctional standards by
a prison system does not necessarily ensure that individual facilities have put those procedures into
operation. There are numerous examples of accredited prison facilities that are under court order
for inadequate conditions of confinement.
Most of the national standards were developed as recommended procedures rather than
regulations that measured outcome. For example, current ACA standards require a “written suicide
prevention and intervention program” but offer no guidance as to what components should be
included in such a program. The potential result is that two prison systems could be in compliance
with this standard yet have dramatically different procedures. It must be noted, however, that
management of prisons and conditions of confinement have improved since correctional standards
were first promulgated in the early 1960s. “Most state departments of correction have ... a system
of health care in place: some because they were mandated to do so by federal courts, others because
they chose to follow the recommendations of the health professional associations” (Anno, 1991, p.
1).
Once a footnote in medical care standards, suicide prevention is now addressed separately
and distinctly in most national correctional standards. Several national organizations and other
influential bodies recognized that, because suicide remains a leading cause of death in prisons,
standards were needed to specifically address suicide prevention. Perhaps best exemplified by the
NCCHC standards, national guidelines for suicide prevention have provided the opportunity and
framework for departments of correction to create and build upon their policies and procedures for
the prevention of suicides.

Reviewing State Standards
Most states adopted prison standards in the 1970s. The call for standards came from many
fronts, including the federal courts. In what has been described as the first federal court decision
devoted entirely to the adequacy of a state’s prison health care services, a federal appeals court
upheld a lower court ruling in Newman v. Alabama (1974) that the state’s correctional system was
unconstitutional for its failure to provide sufficient and adequate medical care to its inmates. The
court ordered the state to develop immediate remedies for the deficient health care, including
comprehensive policies and procedures for the delivery of medical services to inmates. This case
precipitated other courts becoming more involved in conditions of confinement, resulting in the
landmark Estelle v. Gamble (1976), in which the U.S. Supreme Court ruled that:
Deliberate indifference to the serious medical needs of prisoners
constitutes the unnecessary and wanton infliction of pain...proscribed
by the Eighth Amendment. This is true whether the indifference is
manifested by prison doctors in their response to the prisoner’s needs
or by prison guards in intentionally denying or delaying access to
medical care or intentionally interfering with treatment once
15

prescribed. Regardless of how evidenced, deliberate indifference to
[a] prisoner’s serious illness or injury states a cause of action (Estelle
v. Gamble, 1976, pp. 104-105).
Estelle’s result was the coining of a legal yardstick — “deliberate indifference” — that led to the
filing of numerous class-action lawsuits challenging the adequacy of medical care in prisons.
The call for improved conditions of confinement and prison standards did not come from
the courts alone, however, but also from professional groups like AMA and ACA and with the
financial and technical assistance of the federal government. Through the U.S. Justice Department’s
Law Enforcement Assistance Administration (LEAA), the development, promulgation, and
enforcement of standards became a significant part of a state’s responsibility for maintaining and
improving the conditions of its prisons during the 1970s. Ensuring adequate prison health care was
of growing concern outside the legal arena (Anno, 1991). Both state and national correctional and
medical officials were searching for solutions — either through implementation of specific programs
designed to improve health care in certain facilities or by the development of standards for prison
health care. Twenty years later, prison health care has improved notably:
While both litigation and the assistance offered by the health care
professional associations have resulted in significant improvements
in the status of prison health care in the various states, some problems
remain. Nonetheless, it is refreshing to note that the pressing
problems of today are not the same as those of the 1970s. That, in
and of itself, represents growth....The challenges for the 1990s
include how to fine-tune those systems so that the quality of care
offered will mirror that of the community...how to cope with
population increases that put pressure on existing delivery systems,
and how to control burgeoning health care costs (Anno, 1991, p. 21).

16

Suicide Prevention Programs
One example of fine-tuning in health services is the development of written policies and
procedures for suicide prevention in state departments of correction. To determine the degree to
which prison standards address suicide prevention, the National Center on Institutions and
Alternatives (NCIA) recently surveyed all 50 state departments of correction (DOCs), the District
of Columbia, and the Federal Bureau of Prisons. Each was asked whether its agency and/or
individual facilities had developed any policies and procedures regarding prison suicide and, if so,
to forward a copy of the procedures.* Determining what constituted a suicide prevention policy
during the review of responses was predicated on two conditions: 1) that the policy followed the
spirit of standard 3-4364 (ACA, 1990) — “a written suicide prevention and intervention program
that is reviewed and approved by a qualified medical or mental health professional” and 2) that the
policy was a separate directive within a DOC’s operational procedures or was contained in a
separate section of another DOC administrative directive (e.g., medical or mental health).
As shown in Table 2-1, 41 DOCs (79%) had a suicide prevention policy, 8 DOCs (15%) had
no suicide prevention policy but had varying numbers of protocols contained in other agency
directives, and 3 DOCs (6%) did not address the issue of suicide prevention in any written policy
or directive.
ACA (1990) standard 3-4364 and NCCHC (1992) standard P-54 were used as yardsticks
to measure the comprehensiveness of a DOC’s suicide prevention policy. For this analysis, NCIA
combined the requirements of both standards and identified the six most critical components of a
suicide prevention plan: staff training, intake screening/assessment, housing, levels of supervision,
intervention, and administrative review (see Hayes, 1994a).
NCIA’s analysis found that only three departments of correction (California, Delaware, and
Louisiana) had suicide prevention policies that addressed all six critical components and that an
additional five departments of correction (Connecticut, Hawaii, Nevada, Ohio, and Pennsylvania)
had policies that addressed all but one critical component. Thus, only 15 percent of all departments
of correction had policies that contained either all or all but one critical component of suicide
prevention. In contrast, 14 departments of correction (27%) had either no suicide prevention
policies or limited policies — 3 with none, and 11 with policies that addressed only one or two
critical components. The majority (58%) of DOCs had policies that contained three or four of the
critical components.
Staff Training

*

Responses were received from all jurisdictions.

17

The key to any suicide prevention program is properly trained correctional staff, who form
the backbone of any prison facility. Very few suicides are actually prevented by mental health,
medical, or other professional staff because suicides usually are attempted in inmate housing units
and often during late evening and on weekends when inmates are outside the purview of program
staff. These incidents must therefore be thwarted by correctional staff who have been trained in
suicide prevention and have developed an intuitive sense about the inmates under their care.
Correctional officers are often the only staff available 24 hours a day; thus, they form the front line
of defense in preventing suicides.
Both ACA and NCCHC standards stressed the importance of training as a critical component
of the suicide prevention plan. ACA standard 3-4081 required that all new correctional staff receive
training in the “signs of suicide risk” and “suicide precautions,” while
TABLE 2-1
SUICIDE PREVENTION PROTOCOLS WITHIN DEPARTMENTS OF CORRECTION
DOC
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Col.
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia

Prevention
Screening/
Policy
Training Assessment

Housing
x

x
x
x
x
x
x
x
x
x
x
x
x
x
x

x
x
x
x

x

x
x
x
x
x
x
x
x
x

x
x
x

x
x

x

x
x
x

x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x

x
x
x

x
x
x
x
x
x
x
x
x

Admin.
Review

Last
Revision
5/93
2/93
8/89

x

constant/unspecified
30, 60
constant, 15
15
15, 30, 60
constant, 15, 30

x

constant, 15

x

10, 15

no date
9/93
7/92
7/93
6/93
10/93
1/91
2/93
11/93
5/91

x

15, 30
10-15

3/90
3/93

x

x
x

x
x

5-15
constant, 15

x

x

x

x
x
x

x
x
x

x

x

x

x
x
x

x

10
15, 30
5
15
15
constant, 15
15, 30, periodic
15
constant
constant, 5, 15
constant, 15
15, 30
5, 15
15
10-15
constant, 15, 30
15

x
x
x
x
x
x
x
x
x

x
x

x
x

x
x
x
x

x
x

x
x
x
x

Intervention

15
15, 30, 60
10

x

x
x
x
x
x
x
x

x

Suicide Watch Levels
(in minutes)

x

x
x

x

15
x
x
x
x
x

15
15
constant, 10-15
constant, 15

18

x
x
x

x

9/93
Draft/94
2/92
5/93
12/91
5/92
11/93
6/92
5/93
12/93
8/93
8/93
7/92
1/92
9/92
7/93
9/93
12/92
5/92
no date
4/94
4/88
3/86
6/91
11/92
10/93
2/94
4/82
2/92

Washington
West Virginia
Wisconsin
Wyoming
Federal Bureau
of Prisons

x
x

x
x

x

x
x

x
x

x
x

x
x
x
x
x

constant, 15
15
15
constant, 15

x
x

6/84
5/87
4/90
10/92
4/90

standard 3-4364 required that staff be trained in the implementation of the suicide prevention
program. NCCHC standard P-54 stressed that “all staff members who work with inmates should
be trained to recognize verbal and behavioral cues that indicate potential suicide.”
NCIA’s analysis found that only 27 departments of correction (52%) addressed the issue of
training in their suicide prevention policy or other administrative directive. Further, few DOCs were
specific about the length, frequency, and areas of training. For example, one DOC procedure stated,
“Wardens should ensure that appropriate staff are trained with the skills and knowledge to recognize
and initially manage suicidal behavior.” Another procedure simply stated that the “training director
shall ensure that appropriate training is provided.” Some DOCs were notable exceptions, however,
including the Nevada Department of Prisons, whose suicide prevention training procedure stated:
1. Pre-Service Training (PST) — All new employees are required
to complete classes in the identification, recognition, and mental
health referral of suicidal and mentally disordered or
developmentally disabled inmates.
2. In-Service Training (IST) — At least yearly, the mental health
staff should conduct an advanced class at each institution on
suicide prevention. Areas covered include signs [and] symptoms
to predisposing factors of potentially suicidal inmates; risk factors
in the evaluation of suicidal potential; [management] of
potentially suicidal inmates; levels of suicide prevention; and AR
concerning mental health issues. This will be for custody,
programs, and medical staff.
Intake Screening/Assessment
Screening and assessment when inmates enter a facility are critical to a correctional facility’s
suicide prevention program. Although the psychiatric and medical communities disagree about
which factors can be used to predict suicide in general, research on jail and prison suicides has
identified a number of characteristics that are strongly related to suicide, including intoxication,
emotional state, family history of suicide, recent significant loss, limited prior incarceration, lack
of a social support system, psychiatric history, and various stressors of confinement. Most
important, prior research has consistently reported that at least two-thirds of all suicide victims
communicate their intent some time before death and that any individual with a history of one or
more suicide attempts is at a much greater risk for suicide than those who have never made an
attempt (Clark and Horton-Deutsch, 1992). The key to identifying potentially suicidal behavior in
prison inmates is through inquiry during intake screening/assessment and other high-risk periods
of incarceration. An inmate can attempt suicide at any point during incarceration.
Both ACA and NCCHC standards addressed the issue, with the latter stating that the
screening form should contain observations about an inmate’s potential suicide risk and that a
qualified mental health professional should conduct the screening and designate the inmate’s risk
19

of suicide. As shown in Table 2-1, only 29 departments of correction (56%) address the issue of
intake screening and assessment in their suicide prevention policy or other administrative directive.
Procedures at the Connecticut Department of Corrections perhaps best exemplified this critical
component:
All newly admitted inmates will be screened by Health Services staff
within 24 hours of admission to the facility for both obvious and
subtle signs of potential for suicide.
•

Designated Health Services staff administer an Intake
Screening Form to all newly admitted inmates.

•

Indication of potential suicide will result in an immediate
referral to [mental health staff] and a screening by
administration of the Mental Health Suicide Intake
Screening Form. Following completion of this form,
appropriate disposition regarding housing, coordination,
and referrals will be recommended by the mental health
staff or medical supervisor.

•

Staff should never take lightly any suicidal threats,
attempts, or hints from other inmates about a potentially
suicidal inmate.

•

To assist in the identification of potential suicidal
inmates, a Guideline for Suicidal Risk is provided to
staff. These questions are designed to elicit and
formulate information as part of the assessment process.

Housing
In determining the most appropriate housing location for a suicidal inmate, prison officials
often tend to physically isolate and restrain the individual. These responses might be more
convenient for staff, but they are detrimental to the inmate, as the use of isolation escalates the
inmate’s sense of alienation and further removes the individual from proper staff supervision.
National correctional standards stress that, to every extent possible, suicidal inmates should be
housed in the general population, mental health unit, or medical infirmary, located close to staff.
Further, removal of an inmate’s clothing (except belts and shoelaces) and the use of physical
restraints (e.g., leather straps, straitjackets) should be avoided whenever possible and used only as
a last resort when the inmate is physically engaging in self-destructive behavior. Handcuffs should
never be used to restrain suicidal inmates. Housing assignments should be based on the ability to
maximize staff interaction with the inmate, not on decisions that heighten the depersonalizing
aspects of incarceration.
Most DOC policies reflected the importance of housing to a suicide prevention program.
NCIA’s analysis found that 39 departments of correction (75%) addressed the issue of housing in
their suicide prevention policy or other administrative directive. But while most procedures
addressed the issues of inmate clothing and the use of restraints as a last resort, few specifically
20

prohibited the use of isolation or seclusion and many did not address the removal of obvious
protrusions in cells. In addition, few procedures were tailored to the level of an inmate’s suicide
risk. One notable exception was the Virginia Department of Corrections’ housing procedure for
inmates at “imminent” risk of suicide:
Inmates on Suicide Precautions Status with One-to-One Supervision
(“Constant Watch”) may be housed in a stripped cell, i.e., an empty
cell furnished only with a mattress. Inmates will receive
undergarments to wear, and a blanket in cool weather. Clothing or
blankets may be removed upon the order of a QMHP (Qualified
Mental Health Professional) if warranted by the inmate’s condition.
Stripping the inmate of all clothing should be avoided if possible and
used only as a last resort. If available, a paper gown should be
provided to the inmate on the recommendation of the QMHP. In the
event that the stripping of an inmate of all clothing is viewed as
necessary and continues to be necessary for more than forty-eight
(48) hours, transfer to an acute care mental health unit should be
considered.
Levels of Supervision
Prompt, effective emergency medical service can save lives. Research indicates that the
overwhelming majority of suicide attempts in custody are by hanging. Medical experts warn that
brain damage from strangulation can occur within 4 minutes, death often within 5 to 6 minutes. In
prisons, the promptness of the response to attempted suicide is often driven by the level of
supervision afforded the inmate. While both ACA and NCCHC standards addressed levels of
supervision, the degree of specificity varied. ACA standard 3-4245 required only that suicidal
inmates be under continuing observation, while NCCHC standard P-54 required observation ranging
from constant supervision to physical checks every 10 to 15 minutes by correctional staff.
Consistent with national standards, two levels of supervision are generally recommended for suicidal
inmates: close observation and constant observation. Close observation is reserved for the inmate
who is not actively suicidal but expresses suicidal ideation and/or has a recent prior history of selfdestructive behavior. Staff should observe such an inmate at staggered intervals not to exceed every
15 minutes. Constant observation is reserved for the inmate who is actively suicidal, either
threatening to or engaging in the act of suicide. Staff should observe such an inmate on a
continuous, uninterrupted basis.
Other aids (e.g., closed-circuit television, inmate
companions/watchers) can be used as a supplement to, but never a substitute for, such observation
(see Hayes, 1994a).
As shown in Table 2-1, although 41 departments of correction (79%) addressed the issue of
supervision levels in their suicide prevention policy or other administrative directive, the highest
level of observation afforded suicidal inmates within these prison systems varied considerably. For
example, of the 41 DOCs, only 14 (34%) had procedures for constant supervision; 18 DOCs (44%)
used 15-minute watches as the highest level; 8 DOCs (20%) had only 5- to 10-minute watches; and
1 DOC (2%) had only 30-minute watches. In addition, many of the policies from the remaining 11
DOCs that did not specifically address the issue of supervision levels were vague. For example, the
only reference to observation of suicidal inmates in one policy was:
21

Arrangements shall be made for an inmate identified as a potential
suicide to be maintained under frequent observation. Other
maintenance methods may include reassignment of housing,
increased contact with those staff members with whom the inmate
has developed a positive relationship, or the provision of treatment
services. Prognosis is good if immediate prevention measures are
taken. The acute suicide period is usually of short duration; if the
person can be talked through the crisis, the likelihood of an actual
suicide is significantly reduced.
Several departments of correction had policies that allowed either closed-circuit television
or inmate companions/watchers to be used as a substitute for staff in the supervision of suicidal
inmates requiring constant observation. In NCIA’s analysis, these policies were not grouped with
those from other DOCs that exclusively used staff for constant observation of suicidal inmates
because such a directive was contrary to national correctional standards and practices.* In contrast,
the suicide prevention policy from the Connecticut Department of Corrections provided a precise
definition of supervision levels for suicidal inmates:
SUICIDE WATCH: A suicide watch is defined as supervisory precautions taken for
suicidal inmates that require frequent observation. Suicide watch has two levels of
observation.
(a) 15-Minute Watch — for those not actively suicidal, but have
expressed thoughts of suicidal ideation and/or have a prior history
of suicidal behavior. Such inmates are to be physically observed
by an officer at staggered intervals not to exceed 15 minutes.
This involves observing living, breathing flesh and entering the
cell to do so if necessary. A TV monitoring system is not to be
utilized as a substitute for an active 15-minute watch.

*

Departments of correction in Kansas, Minnesota, New Jersey, and Tennessee allowed for the use of closed-circuit
television as a substitute for staff supervision; West Virginia and the Federal Bureau of Prisons allowed for inmate
companions/watchers as a substitute for staff supervision.

22

(b) Continuous Observation 1:1 — for those actively suicidal, either
by threatening or engaging in the act of suicide. Such inmates
shall be physically observed on a continuous and uninterrupted
basis. The officer shall maintain a clear [un]obstructed view of
the inmate at all times. A TV monitoring system shall not be
utilized [as a substitute for] constant supervision. TV monitoring
is a supplement, not a substitute. The officer shall document the
suicide watch for each inmate utilizing the “Observation,
Seclusion, Restraint Checklist Form.”
Intervention
Following a suicide attempt, the degree and promptness of the staff’s intervention often
foretell whether the victim will survive. National correctional standards generally acknowledge that
a facility’s policy regarding intervention should be threefold. First, all staff who come in contact
with inmates should be trained in standard first aid procedures and cardiopulmonary resuscitation
(CPR). Second, any staff member who discovers an inmate attempting suicide should immediately
survey the scene to ensure the emergency is genuine, alert other staff to call for medical personnel,
and begin standard first aid and/or CPR. Third, staff should never presume that the inmate is dead
but rather should initiate and continue appropriate life-saving measures until relieved by arriving
medical personnel.
The federal courts have addressed the issue of intervention in attempted inmate suicide. In
March 1992, a federal appeals court upheld a lower court’s finding in Heflin v. Stewart County
(1992) that the proximate cause of an inmate’s death was both an inadequate, contradictory policy
and the correctional staff’s inaction in attempting to save his life:
...The defendants assert that there was no evidence that the county
had a policy or custom requiring officers on the scene of a suicide
attempt at a jail to leave an inmate found hanging while pictures were
taken and until the medical examiner arrived. Furthermore, the
county had sent Deputy Crutcher for training at the Tennessee
Corrections Institute. If he failed to follow required procedures as
instructed at the Institute — or forgot his instructions — the county
cannot be held liable for his derelictions.
This argument overlooks the fact that Sheriff Hicks was the sole
policymaker for the conduct of jail officials. Deputy Crutcher
testified that he followed jail policy in not cutting Heflin down and
attempting to revive him....
Both Crutcher and Hicks were trained in CPR. Furthermore, after the
sheriff arrived at the jail he did nothing other than follow the same
policy or custom described by Crutcher. In fact, after Dr. Lee arrived
and directed that Heflin be cut down, Sheriff Hicks delayed that
procedure until photographs could be taken of the hanging body....

23

There clearly was evidence from which the jury could find that
Heflin died as a proximate result of the failure of Sheriff Hicks and
Deputy Crutcher to take steps to save his life (Heflin v. Stewart
County, 1992, pp. 714, 720).
Although both ACA and NCCHC standards addressed the issue of intervention, neither
offered specific protocols. For example, ACA standard 3-4351 required that “personnel are trained
to respond to health-related situations within a four-minute response time. The training program
... includes the following: recognition of signs and symptoms, and knowledge of action required in
potential emergency situations; administration of first aid and cardiopulmonary resuscitation
(CPR).” NCCHC standard P-54 stated, “Intervention: The plan should address how to handle a
suicide in progress, including appropriate first-aid measures.”
NCIA’s analysis found that only 12 departments of correction (23%) addressed the issue of
intervention in their suicide prevention policy or other administrative directive. Of these DOCs,
perhaps the Louisiana Department of Public Safety and Corrections’ procedures best exemplified
this critical component:
Suicide Attempt/Postsuicide Procedures:
Duties
a. First officer on scene
• Notify other staff (call for help, activate beeper, etc.);
• Get the victim down if hanging (using C-spine stabilization)
(IMMEDIATE ACTION IS REQUIRED! SECONDS MAY
SAVE A LIFE!);
• Initiate first aid (control bleeding, begin CPR, etc.);
• Policy permits single-officer cell entry to save life.
b. Second officer on scene
• Request ambulance or medical assistance;
• Assist with first aid as necessary;
• Maintain security and preserve scene as much as possible.
c. Supervisor
• Ensure that ambulance or medical response team has been called
and is enroute;
• Supervise and assist with first aid/CPR, as necessary, until
medical assistance arrives;
• Ensure that scene is preserved as much as possible;
• Notify duty warden, institution’s investigator, and mental health
treatment staff so that the supervisor then can focus his full
attention on the suicide incident. The duty warden is then to be
responsible for notifying other appropriate institutional
personnel;

24

•

d.

Ensure that staff cooperate with medical team’s speedy entry of
area and evacuation of victim.

EMTs, paramedics, or medical response team
• Initiate advanced life support care, resuscitation, or other
necessary life recovery treatment, commensurate with their
training level;
• Transport victim to the appropriate medical facility;
• If death occurs, request that an autopsy be performed.

Equipment
Each single-cell lockdown cellblock housing unit shall have the following
equipment immediately available to the officers on duty to be used in
responding to suicide events:
a.
b.
c.
d.
e.
f.
g.

An airway protection service
Surgical gloves
Blood stopper compression bandage
Large paramedic shears
Hoffman design 911 rescue tool
Pocket mask
Bite block.

Administrative Review
An administrative review is the final critical component of a comprehensive suicide
prevention program. National correctional standards recommend that such reviews include 1) a
critical review of the circumstances surrounding the incident; 2) a critical review of prison
procedures relevant to the incident; 3) a synopsis of all relevant training received by involved staff;
4) a review of pertinent medical and mental health services involving the victim; and 5) any
recommendations for changes in policy, training, physical plant, medical or mental health, and
operational procedures.
The issue of administrative review was covered in two NCCHC standards. NCCHC
standard P-54 stated that a suicide prevention policy should specify the procedures for medical and
administrative review if a suicide does occur; standard P-09 stated:
A mortality review, involving physicians, nurses, and others, seeks
to determine if there was a pattern of symptoms [that] might have
resulted in earlier diagnosis and intervention. Additionally, the
review examines events immediately surrounding a death to
determine if appropriate interventions were undertaken. Each inmate
death should be compared with other inmate deaths to determine if
it is part of an emerging pattern.
As shown in Table 2-1, NCIA’s analysis found that only 14 departments of correction (27%)
addressed the issue of administrative review in their suicide prevention policy or other
25

administrative directive. The Pennsylvania Department of Corrections’ policy on clinical review
provided an excellent example:
It is the policy of the Department of Corrections that the
superintendent of a department facility shall cause a clinical review,
of all successful suicides, to be conducted by appropriate staff. In
cases of attempted suicide, it will be up to the discretion of the
superintendent as to whether or not a critical review shall be
conducted....The focus of the review should be twofold: what
happened in the case under review and what can be learned to help
prevent future incidents....
The clinical review shall be a learning experience and, as such, shall
be conducted in an open and honest manner with contributions
encouraged from all staff in order to sharpen staff detection skills and
help prevent unnecessary loss of life due to suicide. All information
gathered as a result of the clinical review shall be confidential.
...Appropriate information, not the confidential report, will be shared
with the institutional training coordinator, who in turn will present an
annual in-service training seminar for all staff on recognition and
prevention of suicide based on information gathered by the clinical
review team.

Conclusion
With a few notable exceptions, most prison systems have not developed comprehensive
suicide prevention programs as promulgated in either ACA or NCCHC standards. Although many
DOCs had a suicide prevention policy, most were not comprehensive because they failed to
adequately address the six critical suicide prevention protocols. Why the necessity for such
scrutiny? Because, as one observer noted, while inmates do not always exhibit clearly visible signs
and symptoms of suicidal behavior, comprehensive suicide prevention programming “will reduce
the opportunity for suicide and should reduce the prison’s potential liability as well” (Anno, 1991,
p. 151).

26

Chapter 3
PRISON SUICIDE RATES: A 10-YEAR REVIEW
Suicide ranks third, behind natural causes and AIDS, as the leading cause of death in prisons
(Bureau of Justice Statistics, 1993a). To measure the severity of the problem, researchers calculate
the rate of suicide within individual prison systems, but to date few national studies of prison suicide
rates have been conducted. The knowledge base is therefore limited to research on individual state
prison systems. The state systems report widely disparate findings — 18.6 per 100,000 inmates in
the Texas prison system (Anno, 1985); 39.6 for male prison inmates in Maryland (Salive et al.,
1989); and 53.7 in the Oregon prison system from 1963 through 1987 (Batten, 1992). In addition,
rates of suicide within the same prison system can vary widely from year to year — from 17 per
100,000 inmates in 1990 to 14 in 1992 to 25 in 1993 in California, for example (California
Department of Corrections, 1994).
The limited research that is available on national prison suicide rates is both dated and
plagued by inconsistent reporting. Previous calculations of national prison suicide rates for 1978
to 1979 and 1980 to 1983 found the rate for male inmates was 24.6 and 24.3, respectively (Lester,
1982, 1987). The calculations, however, were based on Bureau of Justice Statistics (BJS) data that
was under-reported. For example, the most recent data available from BJS (1993a) reported a total
of 89 prison suicides throughout the United States during 1991. That total, however, does not
include data from “non-reporting” jurisdictions (the Federal Bureau of Prisons, Connecticut, the
District of Columbia, Louisiana, Texas, and New Mexico) or reflect that an unknown number of
suicides could be contained within the 17 percent of deaths reported to BJS as “unspecified causes.”
Excluding non-reporting jurisdictions, the national prison suicide rate, based on BJS data of
639,281 inmates in custody as of December 31, 1991, would be 13.9 suicides per 100,000 inmates.
This rate is low, however, compared to other data. For example, an analysis of annual survey data
from the Criminal Justice Institute (1992) and CEGA Publishing (1992), followed up by telephone
calls to several jurisdictions, verified 127 prison suicides for all state and federal prisons during
1991. Thus, a more accurate national prison suicide rate for 1991 would be 16.4 per 100,000
inmates, based on 774,198 inmates in custody.*

NCIA Survey Findings
In its survey of DOCs in all 50 states, the District of Columbia, and the Federal Bureau of
Prisons, NCIA asked each to supply the total number of suicides in its prison facilities and the total
number of inmates in the prison facilities (in each case excluding state inmates held in county jails
or other non-state facilities) as of December 31, 1993.

*

The 1991 survey conducted by the Criminal Justice Institute received responses from all jurisdictions except Louisiana,
resulting in the reporting of 120 prison suicides for that year. NCIA verified 7 additional suicides in Louisiana,
Nebraska, Ohio, Vermont, and Virginia.

27

As shown in Table 3-1, NCIA was able to verify 158 suicides in state and federal prisons
during 1993, excluding suicides that occurred outside the prison (i.e., while on work release or
escape status, for example). Based on a total prison population of 889,836 inmates, the national
suicide rate for 1993 was 17.8 per 100,000 inmates. Thus, the rate of suicide in U.S. prisons during
1993 was almost 50 percent greater than in the general population, calculated as 12.2 by the
National Center for Health Statistics (1993). Reflecting its large prison population, California led
all states with 29 suicides. Six jurisdictions (California, Michigan, New York, Ohio, Texas, and the
Federal Bureau of Prisons) accounted for over 50 percent of all suicides and had a combined suicide
rate of 19.9. Twelve states reported no prison suicides during 1993. Although 19 states had prison
suicide rates above the national average of 17.8 (including extremely high rates in Alaska, Rhode
Island, Vermont, and Wyoming), caution should be used in interpreting rates based solely on data
from one year.
In an effort to review historical trends in the rate of prison suicides throughout the country,
NCIA analyzed data from 1984 through 1992 (see Appendix B for a list of total prison suicides and
rates by jurisdiction for that time period).*
Table 3-2 presents the aggregate 9-year total of prison suicides and rates combined with
NCIA’s 1993 data. As indicated, 1,339 suicides occurred in state and federal prisons throughout
the country from 1984 through 1993, resulting in a 10-year suicide rate of 20.6. California led all
states with 176 prison suicides, while New Mexico reported only 2 suicides during the 10-year
period. New Mexico also had the lowest suicide rate (7.1), while North Dakota had the highest
(101.7) — a misleading statistic since this prison system has not experienced an inmate suicide since
1988. In addition, 10 large jurisdictions (Arizona, California, Florida, Illinois, Michigan, New
York, Ohio, Pennsylvania, Texas, and the Federal Bureau of Prisons) accounted for almost 50
percent of all suicides, yet had a combined suicide rate below the national rate (17.8 vs. 20.6).
Table 3-2 also indicates that 31 jurisdictions had suicide rates above the national rate
(including extremely high rates in Alaska, Minnesota, Montana, and North Dakota). At first glance
it would appear that the seven jurisdictions operating dual systems of confining both pretrial and
sentenced inmates had suicide rates that far exceeded the national average. From a low of 15.6 in
the District of Columbia to a high of 87.3 in Alaska, these seven dual-system jurisdictions had a
combined suicide rate of 34.4. Given the fact that pretrial inmates appear more vulnerable to suicide
and the suicide rate in local jails is estimated to be more than nine times greater than in the
community, the rate of suicide within dual prison systems is not surprising. It also appears,
*

NCIA used the Criminal Justice Institute’s Corrections Yearbook for each year from 1985 through 1993 and CEGA
Publishing’s Corrections Compendium for November 1992, June 1991, July/August 1989, September 1987, and
February 1986. These two data sources were inconsistent. For example, the Corrections Yearbook for 1990
reported 145 prison suicides for 1989, while Corrections Compendium (June 1991) reported 120 suicides and BJS
reported 113 prison suicides for that year. When it found inconsistencies, NCIA contacted the jurisdictions in
dispute and was thus able to verify 146 prison suicides for 1989.

28

however, that the distinctiveness of jurisdictions with dual systems is not the sole cause of high
suicide rates in prison systems throughout the country. As shown in Table 3-3, the seven smallest
prison systems (excluding dual systems) had a combined suicide rate of 53.8 — more than two and
one-half times greater than the national average.†
Washington
West Virginia
Wisconsin
Wyoming
Federal Bureau of Prisons*

TABLE 3-1
TOTAL PRISON SUICIDES AND RATES
BY STATE,
1993
State
Alabama
Alaska*
Arizona
Arkansas
California
Colorado
Connecticut*
Delaware*
District of Columbia*
Florida
Georgia
Hawaii*
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island*
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont*
Virginia
†

Suicides
1
2
6
1
29
2
1
2
4
5
3
0
0
4
2
0
0
1
2
0
3
1
7
0
2
1
0
1
1
0
3
0
8
3
0
8
3
3
3
2
1
1
2
17
1
1
4

Total Inmate
Population
16,363
2,703
17,674
7,928
112,370
7,877
13,384
3,669
10,787
53,048
27,722
2,792
2,266
34,495
14,470
4,898
5,664
8,622
16,067
1,545
20,177
9,652
36,743
4,059
8,574
15,409
1,254
2,453
6,153
1,846
20,500
3,510
64,575
22,233
501
40,253
11,190
6,545
26,060
2,700
17,263
1,507
11,474
66,664
2,621
875
18,247

Rate

TOTAL

0
0
3
3
11

9,528
1,964
8,783
1,048
81,131

—
—
34.2
286.3
13.6

158

889,836

17.8

*Dual system of both pretrial and sentenced inmates.

6.1
74.0
33.9
12.6
25.8
25.4
7.5
54.5
37.1
9.4
10.8
—
—
11.6
13.8
—
—
11.6
12.4
—
14.9
10.4
19.1
—
23.3
6.5
—
40.8
16.3
—
14.6
—
12.4
13.5
—
19.9
26.8
45.8
11.5
74.1
5.8
66.4
17.4
25.5
38.2
114.3
21.9

West Virginia is included among the seven smallest states only because the smaller dual system of Vermont was
excluded from the table. If Vermont replaced West Virginia in Table 3-3, the combined suicide rate of the seven
smallest states would be 59.7.

29

New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island*
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont*
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Federal Bureau of Prisons*

TABLE 3-2
TOTAL PRISON SUICIDES AND RATES
BY STATE,
1984 THROUGH 1993
State
Alabama
Alaska*
Arizona
Arkansas
California
Colorado
Connecticut*
Delaware*
District of Columbia*
Florida
Georgia
Hawaii*
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey

Suicides
17
20
38
13
176
17
32
7
13
43
34
7
7
38
20
6
12
14
28
9
30
26
43
27
17
25
10
10
21
3
26

Total Inmate
Population
122,117
22,921
125,059
59,459
779,724
54,005
85,857
30,625
83,309
385,035
205,828
22,416
16,763
242,998
117,613
37,667
53,604
66,357
128,667
13,325
154,341
79,177
258,742
30,584
70,443
129,297
12,076
22,024
49,989
11,612
150,391

Rate
13.9
87.2
30.4
21.9
22.6
31.5
37.3
22.9
15.6
11.2
16.5
31.2
41.8
15.6
17.0
15.9
22.4
21.1
21.8
67.5
19.4
32.8
16.6
88.3
24.1
19.3
82.8
45.4
42.0
25.8
17.3

TOTAL

2
53
25
5
49
32
13
49
12
21
6
23
89
13
3
28
22
3
10
6
86

28,134
482,915
184,832
4,917
286,364
93,380
51,497
189,297
20,410
130,515
12,078
83,624
451,677
21,834
7,468
136,814
72,394
15,175
66,509
8,821
528,541

7.1
11.0
13.5
101.7
17.1
34.3
25.2
25.9
58.8
16.1
49.7
27.5
19.7
59.5
40.2
20.5
30.4
19.8
15.0
68.0
16.3

1,339

6,499,221

20.6

*Dual system of both pretrial and sentenced inmates.

30

TABLE 3-3
TOTAL PRISON SUICIDES AND RATES IN THE
SEVEN SMALLEST STATE PRISON SYSTEMS,
1984 THROUGH 1993
State

Suicides

Total Inmate
Population

Rate

Maine
Montana
New Hampshire
North Dakota
South Dakota
West Virginia
Wyoming

9
10
3
5
6
3
6

13,325
12,076
11,612
4,917
12,078
15,175
8,821

67.5
82.8
25.8
101.7
49.7
19.8
68.0

TOTAL

42

78,004

53.8

Although it might be assumed that prison systems with high suicide rates would mirror the
suicide rate in their respective communities, current data does not support this proposition.
According to National Center for Health Statistics (1993) data, with the exceptions of Montana and
Wyoming, all of the seven smallest and dual-system jurisdictions with high prison suicide rates had
general population suicide rates comparable to the national average of 12.2.* Perhaps a better
explanation for the high prison suicide rates in these states is that, although all prison systems are
plagued by limited resources, the strain is more acute in smaller jurisdictions.
The most encouraging finding from NCIA’s survey is the gradual decrease in the rate of
prison suicides throughout the country during the past 10 years. As shown in Table 3-4, after a high
of 27.2 in 1985, the prison suicide rate in subsequent years declined steadily, to a low of

TABLE 3-4
TOTAL PRISON SUICIDES AND RATES,
1984 THROUGH 1993
Year
1984
1985
1986
1987
1988
1989
1990
1991
1992

Suicides
121
132
126
139
139
146
118
127
133

Total Inmate
Population
446,212
485,301
522,780
554,654
598,239
672,193
730,486
774,198
825,322

Rate
27.1
27.2
24.1
25.1
23.2
21.7
16.2
16.4
16.1

*

The following distribution indicates suicide rates in the general population in small and dual-system jurisdictions:
Alaska (12.8), Connecticut (10.0), Delaware (11.6), District of Columbia (5.6), Hawaii (9.4), Maine (14.3), New
Hampshire (11.7), North Dakota (11.6), Rhode Island (8.2), South Dakota (13.5), Vermont (16.2), West Virginia
(13.3), Wyoming (18.9). In addition, Minnesota’s 10-year suicide rate was 88.3, yet its suicide rate for the general
population was only 11.5.

31

1993
TOTAL

158

889,836

17.8

1,339

6,499,221

20.6

16.1 in 1992. Although the rate of prison suicides rose nationally to 17.8 in 1993, the increase could
indicate an upward trend or merely an aberration. In addition, the declining prison suicide rate
nationwide during the past 10 years is punctuated by a dramatic drop from 21.7 in 1989 to 16.2 in
1990. In fact, from 1984 through 1989, the rate of prison suicides throughout the country was 24.5,
but from 1990 through 1993, the rate dropped to 16.6.
Although the reason behind this reduction is unknown, several jurisdictions were primarily
responsible for the decline. As shown in Table 3-5, suicide rates in 14 state prison systems
decreased 50 percent or more from 1984 to 1989 compared to 1990 to 1993. During 1990 to 1993,
these 14 states had a combined suicide rate of 13.5 — a decline of more than 60 percent from the
1984 to 1989 rate of 34.6. Only three states (Delaware, Vermont, and Wyoming) experienced
increases of more than 50 percent during these periods.
It is noteworthy that three other states experienced substantial reductions in prison suicide
rates from 1984 to 1991 compared to 1992 and 1993: an 82 percent reduction in Connecticut (48.9
versus 8.9), 58 percent in Missouri (22.5 to 9.5), and 54 percent in Pennsylvania (30.2 to 13.9).
TABLE 3-5
STATES WITH DECLINING PRISON SUICIDE
RATES OF 50% OR MORE
State
Georgia
Hawaii
Idaho
Indiana
Kansas
Maryland
Minnesota
Montana
New Hampshire
New Jersey
North Dakota
Rhode Island
Washington
West Virginia
TOTAL AVERAGE

1984-1989

1990-1993

23.3
41.2
57.7
23.4
29.4
26.3
118.3
123.7
59.9
24.7
177.4
81.9
42.7
35.4

9.1
19.6
23.8
9.4
13.0
12.1
55.1
35.7
—
9.5
—
37.6
17.2
—

34.6

13.5

Conclusion
What is the significance of these findings? While the current data does not allow for a
comparative analysis of prison suicide rates and prevention programs, the data does provide several
interesting findings. First, the rate of suicide in prisons throughout the country during the past 10
years was 20.6 deaths per 100,000 inmates — a rate more than 50 percent greater than that of the
general population yet far below the rate of jail suicides. Second, states with small prison
populations appear to have exceedingly high rates of suicide — often more than two and one-half
times greater than the national average. Third, apart from 1993, the rate of prison suicides has
gradually and steadily declined throughout the country since 1985, punctuated by a dramatic decline
after 1989. In fact, rates have decreased 50 percent or more in 14 state prison systems since 1989.
32

Finally, the prison suicide rate for 1993 — 17.8 — could indicate an upward trend or merely
an aberration. Significant, however, is that 15 states experienced higher rates of prison suicide
during 1993 compared to their 9-year averages (1984 to 1992).* Haycock (1991) has written that
several recent developing characteristics of prisons suggest higher suicide rates in the future:
mandatory sentencing laws, dramatic increases in death penalty and life sentences, overcrowded
prison systems, increased cases of AIDS, and the graying of the inmate population could instill
despair and hopelessness in inmates. Only time will determine whether 1993 was an aberration or
a sign of an upward trend.

*

For example, from 1984 through 1992, California paralleled the rest of the country with a gradually declining prison
suicide rate — from a high of 43.1 in 1984 to a low of 14.4 in 1992. In 1993, however, 29 suicides occurred,
resulting in a rate of 25.8. The other 14 jurisdictions experiencing varying rates of increase during 1993 were
Arizona, Delaware, District of Columbia, Michigan, New York, Ohio, Oregon, Rhode Island, South Dakota, Texas,
Vermont, Virginia, Wisconsin, and Wyoming.

33

Chapter 4
EFFECTIVE SUICIDE PREVENTION PROGRAMS
IN STATE PRISONS
While most state prison systems have developed basic suicide prevention policies, few are
comprehensive. A handful of effective programs operating in state prisons throughout the country,
however, have reduced incidents of inmate suicide. In its survey, NCIA asked whether DOCs could
identify any model suicide prevention programs and, if so, send information about them. Through
this solicitation, NCIA received affirmative responses from 10 DOCs and subsequently began a
preliminary evaluation of the nominated programs.
The determination of what constituted a model suicide prevention program was predicated
on two conditions: 1) the prison facility adhered to each of the six critical components of a written
suicide prevention policy (staff training, intake screening/assessment, housing, levels of supervision,
intervention, and administrative review), and 2) the facility had an extended suicide-free period.
Although responses from many of the nominated programs reflected adequate suicide prevention
procedures, the programs were ultimately removed from final consideration because they lacked
more than one of the six critical suicide prevention components and/or had experienced a recent
suicide. And although none of the 10 prisons could be said to operate model programs, two
facilities — Elayn Hunt Correctional Center in St. Gabriel, Louisiana, and the State Correctional
Institution-Retreat in Hunlock Creek, Pennsylvania — were selected as best exemplifying highly
effective prison suicide prevention programs. An onsite visit was made to both facilities to develop
case studies.

Elayn Hunt Correctional Center
Opened in 1979, the Elayn Hunt Correctional Center (EHCC) is a multi-security-level adult
institution in St. Gabriel, Louisiana. As the second largest prison in the state with a capacity for
1,875 inmates, EHCC has two main functions: 1) to serve as the intake point for male offenders
committed to the Louisiana Department of Public Safety and Corrections, and 2) to provide housing
for approximately 1,475 sentenced prisoners. All newly sentenced male inmates committed to the
Louisiana Department of Public Safety and Corrections are initially processed into the system
through EHCC’s 400-bed Adult Reception and Diagnostic Center (ARDC). During a 14-day period,
inmates receive a complete medical examination, thorough psychological assessment, and in-depth
classification review. Inmates are then assigned and transferred to one of 11 prison facilities in the
state.
EHCC receives and holds a variety of inmates, including those assigned to the general prison
population, disciplinary transfers from other facilities, prisoners with mental health problems and
those at medical risk, participants in boot camp, those serving life sentences, and trustees assigned
to work crews. In addition to offering normal institutional programming (education, employment,
boot camp, for example), EHCC serves as the department’s central mental health facility and
medical center for all seriously or chronically ill minimum- and medium-security inmates. The
institution is staffed with 4 full-time physicians and 2 part-time specialists, 2 physician assistants,
26 nurses, 1 full-time psychologist, 2 part-time psychiatrists, 6 psychological associates, 9 clinical
social workers, and 1 substance abuse counselor. These personnel also assist with intake procedures
for the Louisiana Correctional Institution for Women, located nearby. In addition to providing a
34

full array of medical services, EHCC offers a comprehensive mental health program, including a
variety of individual and group counseling sessions covering transitional adjustment for newly
incarcerated inmates, HIV/AIDS, substance abuse, problem-solving, and crisis intervention
programs (including suicide prevention).
The Louisiana prison system has not always been known for comprehensive programming
and constitutionally adequate conditions of confinement. Since the 1970s, the entire prison system
has been under litigation for overcrowding and a variety of other unconstitutional conditions. In
1975, one federal judge found that conditions at Louisiana State Penitentiary in Angola (the largest
prison in the state and the primary focus of litigation) “shocked the conscience.” In June 1989,
another federal judge declared a state of emergency at Angola, citing a rash of stabbings, escapes,
murders, and other deaths, including five inmate suicides in one year. In February 1991, conditions
in the Angola prison improved and the state of emergency was lifted (see Williams v. McKeithen,
1991). In January 1992, Richard L. Stalder was appointed secretary of the Louisiana Department
of Public Safety and Corrections. As a career professional who rose from the ranks of correctional
officer to warden, he set as first priorities improvement of confinement conditions within the prisons
and obtaining ACA accreditation, thereby working toward removing the 11 facilities from the
federal courts’ jurisdiction. To date, most of the state prisons have been accredited by ACA, and
8 of the 11 facilities have been released from federal court oversight.
Formal adoption of correctional standards through accreditation does not always ensure that
a prison has put those standards into operation. Under the leadership of Warden C.M. Lensing,
however, the Elayn Hunt Correctional Center not only has been accredited by ACA, but also
operates a highly successful suicide prevention program. EHCC’s suicide prevention program is
detailed in Institutional Policy No. 400-B1, Suicide Prevention and Intervention, which addresses
the six critical components of such a program. As indicated in Table 4-1, 57,091 inmates were
processed through the ARDC from January 1983 through October 1994 (including 11,034 prisoners
assigned to EHCC for housing). During this approximate 12-year period, only one inmate
committed suicide at EHCC (in 1983).
TABLE 4-1
TOTAL ANNUAL ADMISSIONS VERSUS TOTAL ANNUAL SUICIDES,
1983 THROUGH 1994

Year

ARDC/EHCC Admissions

Total
Suicides

1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994 (through October)

3,719/including 854 at EHCC
3,702/809
3,874/870
3,672/976
4,616/1,304
4,337/1,164
4,826/1,125
5,147/1,019
5,523/846
6,946/850
6,188/767
4,541/450

1
0
0
0
0
0
0
0
0
0
0
0

TOTAL

57,091/11,034

1

35

Staff Training
All EHCC staff providing direct care (including administrative, managerial, correctional,
mental health, and medical personnel) receive two hours of training in potential-suicide recognition
and intervention each year. The training sessions, held each Friday morning throughout the year,
include instruction on how to identify suicidal behavior and the components of the facility’s suicide
prevention policy. In addition, all staff receive four hours of instruction in first aid and four hours
of training in CPR annually.
Intake Screening/Assessment
Upon admission to the ARDC, all inmates receive Preliminary Health Screening by the
medical staff, which includes questions about current and prior suicide risk.* They also are screened
for assessment and intervention by mental health staff during processing, providing more
information about risk of suicide. Although medical and mental health staff can often identify
suicide risk during the 14-day process, other direct-care staff (including supervisory and correctional
line officers) are also in a position to identify an inmate’s suicidal behavior and report the potential
risk through the Mental Health Behavior Checklist. This form lists various factors that are
commonly displayed by suicidal inmates: self-destructive acts, suicidal/homicidal ideation, critical
changes in one’s life, depression, mood changes, agitation, hostility, insomnia/hypersomnia, bizarre
behavior, for example. The Mental Health Behavior Checklist is used not only to identify suicidal
behavior, but also to communicate the concerns of the direct-care staff to mental health and medical
staff for initiation of suicide prevention procedures.
When an inmate is identified as potentially suicidal, mental health staff assess the situation
and, if warranted, authorize the inmate to be placed on standard or extreme suicide watch. (In the
absence of mental health staff, medical staff can authorize a suicide watch.) The Mental Health
Management Order designates the location of housing, restrictions in personal property, and level
of supervision. Mental health staff reassess all inmates placed on suicide watch every 24 hours.
Only mental health staff (or an attending physician) may upgrade, downgrade, or discontinue a
suicide watch.
Housing
Although more than 15 years old, the EHCC physical plant is in impeccable condition. The
facility houses suicidal inmates in two locations: D-1 Cellblock, and the infirmary’s 24-Hour Unit.
The D-1 Cellblock contains six cells designated for inmates placed on standard suicide watch. Two
of the cells allow high visibility of inmates on extreme watch. Each cell contains closed-circuit
television (CCTV), which provides supplemental observation of the inmate. Whenever possible,
two inmates are assigned to a cell to avoid isolation. If an inmate must be placed alone in a cell,
security officers are encouraged to attempt frequent conversations with the inmate. The infirmary’s
24-Hour Unit contains 30 beds, three of which are reserved for inmates placed on extreme suicide
watch who might require four-point restraints and have accompanying medical problems. Mental
health or medical staff decide what clothing and bedding to issue each inmate on suicide watch.

*

Reformatted copies of all suicide prevention protocol forms used at EHCC are shown in Appendix C.

36

Levels of Supervision
Standard suicide watch is used for inmates who are not actively suicidal but have expressed
thoughts of suicide and/or have a prior history of suicidal behavior. Extreme suicide watch is used
for inmates who present a clear and/or continual risk of self-destructive behavior — banging their
heads against a wall or cell bars, threatening to do so, or tying linen to themselves and the cell bars.
The frequency of observation for both watch levels varies from 15-minute intervals to continual
observation, with each observation (particularly for extreme watch) normally averaging every 5
minutes. Correctional staff document each observation on the inmate’s Suicide Watch Log Sheet.
Further, within the prescribed interval, additional observations are made occasionally and randomly
to thwart the planning of self-destructive acts.
One correctional officer is assigned to the six cells reserved for suicidal inmates in the D-1
Cellblock. The 24-Hour Unit, in addition to supervision by correctional staff, is staffed around the
clock by medical personnel who observe inmates on suicide watch. Medical staff monitor all
inmates placed in restraints every two hours. In addition, within 12 hours of starting extreme watch,
mental health staff confer with both the psychiatrist and physician about the continued suitability
of the watch level and the treatment plan for the inmate.
The following recent case history of inmate John Doe illustrates the suicide prevention
assessment, housing, and supervision protocols at EHCC.
John Doe arrived at the facility’s ARDC on Thursday, July 7, 1994.
Medical staff performed a preliminary health screening, and a
psychological associate administered an assessment and intervention
screening. The assessment revealed that Doe had a recent history of
mental health problems and had been admitted to a psychiatric
hospital in 1993. It also determined that he currently was taking
psychotropic medication and participated in out-patient therapy for
depression. Doe admitted to a significant history of substance abuse
with cocaine addiction and reported a history of numerous suicidal
gestures, the most recent of which had occurred in November 1993.
During the interview, Doe showed significant depression and anxiety
and reported some thoughts of suicide in the recent past, although he
denied any current thoughts.

37

Based on the assessment, Doe was placed on standard suicide watch
with supervision at 5-minute intervals. He was assigned to the D-1
Cellblock and placed in a cell with closed-circuit TV. He was issued
a paper gown and mattress but deprived of all other property. Mental
health staff saw Doe the following day and reported “passing suicidal
thoughts with some depression.” The suicide watch was continued.
Doe was seen again on July 9, when he claimed he was “feeling
better” and denied having thoughts or plans of suicide. Staff noted,
however, that he still exhibited depression with anxiety and kept him
on suicide watch. The following day, he continued to deny suicidal
thoughts but continued to display depression and mental anguish; as
a precaution, he remained on suicide watch an additional day. On
July 11, Doe’s mood was found to be more appropriate, with no
significant depression. He continued to deny having suicidal
thoughts and did not display any distress. Based on his improved
condition, Doe was removed from standard suicide watch and placed
on mental health observation; his clothes were returned and
supervision was downgraded to 15-minute intervals. The following
day, Doe told the social worker he was feeling safe and in good
spirits. The psychiatrist saw him on July 13 and subsequently
removed him from mental health observation.
Doe was transferred to a general population housing unit at EHCC,
scheduled to see a psychiatrist during the following month, and
provided with routine services and psychiatric counseling as needed
until discharge from prison.
Intervention
EHCC follows excellent intervention procedures in the event of a suicide attempt. In
addition to staff trained in first aid and CPR, each of the three housing compounds at the facility is
assigned at least two correctional officers certified as “first responders” (i.e., with advanced first aid
training). The facility also has a fully operational ambulance for transporting patients to the local
hospital in Baton Rouge, and the control desk in each housing unit is equipped with oxygen tanks
and a fully stocked “suicide prevention kit.” Shaped like a carpenter’s tool box, the kit contains first
aid items (e.g., paramedic shears, large and regular gauze bandages, ace bandages, an elastic roll,
cloth tape), a disposable pocket mask, latex gloves, a bite block, and a tool designed to cut a variety
of materials that could be used in attempted hangings. Correctional officers in the Louisiana
Department of Public Safety and Corrections are trained to respond promptly to emergencies, call
for assistance, initiate first aid and CPR if necessary, and transport the victim to a medical facility.
Administrative Review
Following a suicide, EHCC policy requires that a formal post-suicide investigation be
conducted by a four-member team comprised of a mental health worker, a correctional investigator,
a security supervisor (from the housing unit where the incident occurred), and a medical staff

38

member (physician, registered nurse, or paramedic).* The team interviews staff and inmates,
reviews pertinent documents, and prepares and forwards a report to the warden and the secretary of
the Department.
Following his appointment in 1992, Secretary Stalder established a departmental Suicide
Review Committee to better coordinate comprehensive suicide prevention practices across all 11
prison facilities and to supplement internal investigations. The committee is comprised of
correctional, mental health, and medical personnel from each facility. Chaired by the EHCC mental
health director, the committee meets at least twice yearly as well as following an incident to review
the circumstances surrounding all serious suicide attempts or suicides and, when appropriate,
recommend revisions to operational procedures. Since 1992, the committee has recommended more
than 72 changes to procedures at individual facilities, based on 6 suicides and 17 serious attempts
throughout the state prison system. The following excerpts are from 10 of those recommendations.
•

Intensified staff training in suicide prevention, training in the use
of emergency life support techniques and procedures, and
enhanced efforts to increase security observation rounds in highrisk areas for suicide attempts are considered crucial elements in
recognizing and preventing suicide.

•

Enhance efforts TO KEEP AN INMATE UNDER CONSTANT
SURVEILLANCE following a suicide threat until the inmate is
under a suicide watch.

•

Initiate institutional systems to ensure that all concerned
personnel (security, classification, clergy, mental health, and
medical staff) are immediately alerted if an inmate indicates he
is thinking about suicide. An exchange of pertinent information
in this regard can aid in the prevention of suicide.

•

Security staff should thoroughly shake down suicide observation
cells to ensure the total removal of potential suicide apparatus.

•

Periodically check vent plates in cells used for suicide watches to
guard against using the vent plate as apparatus in attempted
hangings.

•

Security, medical, and mental health staff should make a
concerted effort to intensify and expand the frequency of [their]
time spent in high-risk areas (cell blocks, administrative
lockdown, isolation, protective custody, etc.) to identify and
prevent suicide attempts.

*

A less formal review is also made by the team for all serious suicide attempts.

39

•

Detailed information should be included in the inmate’s record as
to the reason(s) the suicide watch was initiated, continued, and
discontinued.

•

When indicated, mental health staff should continue follow-up of
an inmate who has experienced the recent death of a family
member.

•

In view of the trauma experienced from capture and rearrest,
prison escapees should be closely and frequently monitored.

•

Staff should make a more comprehensive effort to transfer all of
a prisoner’s pertinent mental health data to and from all facilities
with a transfer (including transfer of information via telephone
from mental health staff at the sending facility to mental health
staff at the receiving facility).

According to the committee chairperson, Nancy Gautreau, “One of the most tragic,
debilitating events that can happen to a prison is an inmate suicide. It will shake your structure. The
initial response is always — ‘What happened? Who was making the rounds? Did the inmate need
mental health services?’ We try to instill the attitude that there must have been something we could
have done to prevent that suicide.”*
The actions adopted systemically by the Louisiana Department of Public Safety and
Corrections (symbolized through the efforts of the Suicide Review Committee) have resulted in a
comprehensive suicide prevention policy and a recent reduction in the number of prison suicides
throughout the state. As indicated in Table 4-2, during the 9 years from 1984 through 1992, the
department experienced 26 prison suicides, reflecting a rate of 23.1 suicides per 100,000 inmates;
during several of those years, the state’s prison suicide rate was almost twice the national average.
During 1993, however, the rate dropped to 12.4 suicides per 100,000 inmates — a reduction of
almost 50 percent from the 9-year rate. And as of October, the entire state prison system had not
experienced an inmate suicide during 1994.

*

Interview with author, June 2, 1994.

40

TABLE 4-2
ANNUAL PRISON SUICIDE RATES IN LOUISIANA
1984 THROUGH 1994
Year

Total
Suicides

Total Inmate
Population

Rate

1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994 (through October)

1
2
5
—
4
5
3
2
4
2
—

10,575
10,637
10,684
11,206
11,895
12,896
13,849
14,508
16,350
16,067
15,594

9.5
18.8
46.8
—
33.6
38.8
21.7
13.8
24.5
12.4
—

TOTAL

28

144,261

19.4

Conclusion
The suicide prevention program at the Elayn Hunt Correctional Center is not perfect, and
observers could argue that the policy should be revised to include additional hours for pre-service
training in suicide prevention, clearer procedures for constant observation of extreme watch inmates,
and that automatic restraints for inmates on extreme watch are not necessary. Few observers,
however, could argue with the program’s overall success: 1 suicide in almost 12 years and 57,091
admissions. Warden Lensing summarizes his approach to suicide prevention at EHCC: “We fail
when we have fatalities based on unnatural causes....I don’t wait and react. I don’t like crisis
management. You need to stay one step ahead of the game. When you put suicide prevention kits
in each housing unit, place social workers in the cellblocks to assess suicidal inmates every day, and
schedule suicide prevention training every Friday, you symbolize to all staff the commitment we
have to suicide prevention.”*

State Correctional Institution at Retreat
The State Correctional Institution (SCI) at Retreat is located in Hunlock Creek,
Pennsylvania. In 1878, an almshouse was established at the site to provide care for indigents. In
the 1880s, a hospital for the insane was added to treat those with mental illness. During the first part
of this century, the facility was known as the Retreat Hospital for the Insane and Almshouse. It was
converted to the Retreat State Mental Hospital in the late 1940s, closed in 1981, and reopened as
SCI-Retreat in January 1988.
SCI-Retreat is a medium-security institution with the capacity for 480 male inmates
(although it now houses more than 820 inmates). In contrast to Louisiana’s EHCC, it does not
provide comprehensive reception and diagnostic services, and it is not designed for long-term
mental health care. SCI-Retreat’s professional staff include a full-time psychologist, social worker,
part-time psychiatrist, part-time physician, and 15 nurses providing 24-hour onsite medical care.

*

Interview with author, June 2, 1994.

41

According to Lance Couturier, Ph.D., chief of psychological services for the Pennsylvania
Department of Corrections, “1989 was a bad year: SCI-Camp Hill was hit with a riot and burned
down, SCI-Graterford was locked down, and a disturbance occurred at SCI-Huntingdon. And by
the end of the year, the department ranked fourth in the country in the number of inmate suicides.”*
In November 1990, a class-action lawsuit alleging overcrowded conditions, poor health care,
violence, and inadequate programming (Austin v. Pennsylvania Department of Corrections, et al.,
1990) was filed against 13 of 22 DOC facilities.
In January 1990, Joseph D. Lehman was appointed commissioner of the Pennsylvania DOC.
He immediately began to focus on relieving overcrowding, improving conditions of confinement,
and addressing the other issues raised in Austin.† The DOC began analyzing incidents of suicidal
behavior and found high concentrations of self-destructive conduct and mental illness in inmates
confined to administrative segregation, referred to as “restrictive housing units” (RHUs). As alleged
in the Austin lawsuit, many inmates were confined in the RHUs for prolonged periods without
ongoing mental health services.
In an effort to provide more comprehensive mental health services, the DOC’s Psychological
Services Division created a psychiatric review team (PRT) in each prison. Each PRT, comprised
of the facility’s chief psychologist, a psychiatrist, the inmate program manager, and selected unit
managers, meets regularly to review case files of inmates who have difficulty adjusting or whose
behavior is related to emotional problems and require more in-depth evaluation, closer monitoring,
and support. One of the PRT’s goals is to reduce a mentally ill inmate’s confinement in an RHU
through prompt intervention, continuing care, and, when appropriate, transfer to one of four DOC
mental health units or state Department of Public Welfare (DPW) forensic units. For example,
according to Dr. Couturier, “If a suicidal inmate needs to be under constant watch for more than 24
hours, he probably will require commitment to a mental health unit.”‡
As a result of chronic overcrowding throughout most of the prison system and to protect
against inmates who need mental health services from slipping through the cracks, each PRT keeps
an active roster of inmates with mental illness and/or mental retardation and tracks their movements
to and from DOC mental health units, DPW forensic units, and SCIs. Inmates tracked through the
PRT roster include those having a serious psychiatric problem, found guilty but mentally ill,
receiving psychotropic medication, having a history of psychiatric hospitalization, suffering from
mental retardation, and exhibiting suicidal behavior within the past two years.

*

Behind California, New York, and the Federal Bureau of Prisons. Interview with author, June 28, 1994.

†

On August 1, 1994, both parties in Austin signed an 87-page “proposed settlement agreement” to end further litigation
of the suit.

‡

Interview with author, June 28, 1994.

42

In March 1991, the DOC introduced unit management to all state correctional institutions,
with decisions regarding inmate control, programming, and overall operation of housing units
decentralized and delegated to a unit team. The goal of unit management is to instill teamwork and
facilitate communication and interaction between staff and inmates. A side benefit is that, through
frequent interaction with inmates, the unit’s staff are in a better position to identify potentially selfdestructive behavior and thwart suicide attempts.
As indicated in Table 4-3, the number of inmate suicides in the Pennsylvania DOC has
declined markedly since 1991, coinciding with the introduction of unit management and a
comprehensive suicide prevention policy. During the 7 years from 1984 through 1990, 39 suicides
occurred, reflecting a rate of 33.6 suicides per 100,000 inmates. (The 8 suicides during 1989
represented a rate of 41.6 suicides per 100,000 inmates.) During the 3 years from 1991 through
1993, however, only 10 suicides occurred, with a rate of 13.7 suicides per 100,000 inmates — a
reduction of more than three times the previous 7-year rate and well below the national average.
TABLE 4-3
ANNUAL PRISON SUICIDE RATES IN PENNSYLVANIA
1984 THROUGH 1994
Year

Total
Suicides

Total Inmate
Population

Rate

1984
1985
1986
1987
1988
1989
1990
1991
1992
1993

5
2
7
3
7
8
7
3
4
3

13,126
14,260
14,824
15,877
17,494
19,236
21,399
22,794
24,227
26,060

38.1
14.0
47.2
18.9
40.0
41.6
32.7
13.2
16.5
11.5

TOTAL

49

189,297

25.9

Dr. Couturier cites several reasons for the reduction in inmate suicides: the commissioner’s
leadership, the introduction of unit management, and a generally increased awareness of suicide
prevention. According to Dr. Couturier, “SCI-Retreat is a good example of what we have tried to
accomplish with our suicide prevention policy. Both the administrative and unit staff at Retreat
know all the inmates under their custody, they try to provide a continuum of care so that behavior
does not escalate into a crisis, and they don’t particularly like to use the restrictive housing unit —
all key factors in suicide prevention.”* SCI-Retreat’s suicide prevention program is based on
Chapter 9 of the DOC’s Mental Health Procedures Manual, “Procedures for Dealing with
Potentially Suicidal Inmates and Inmates Who Attempt Suicide.Ӡ The policy addresses all six
critical components of a suicide prevention program.
*

Interview with author, June 28, 1994.

†

A reformatted copy of Chapter 9 is shown in Appendix D.

43

44

Staff Training
All staff who have contact with inmates are trained annually on the signs and symptoms of
suicidal behavior and on DOC procedures for preventing suicide. New employees receive 1.5 hours
of suicide prevention training and 1.5 hours of mental health training at the DOC Training
Academy. Thereafter, 2-hour training sessions in suicide prevention/mental health and in first aid
and CPR are held annually at the facility.
Intake Screening/Assessment
Before admission to SCI-Retreat, inmates are processed at one of three DOC Diagnostic and
Classification Centers, where they receive a full medical and psychological examination and are
assessed for suicide risk. Upon entering SCI-Retreat, all inmates are administered a Receiving
Screening Form by medical and mental health staff, which includes queries about current and prior
suicide risk. The initial reception committee (comprised of the inmate program manager and
psychologist) also assesses inmates to determine housing and work assignments and identify any
special needs, including the potential for suicide.
In addition, if a correctional officer observes an inmate displaying any signs of suicidal
behavior, such as threats, depression, or self-mutilation, the unit manager is notified and the inmate
is immediately referred to the mental health staff. The psychologist meets with the inmate and
evaluates the level of suicide risk using the Suicide Potential Checklist (see Table 4-4). If

TABLE 4-4
SUICIDE POTENTIAL CHECKLIST AT SCI-RETREAT
q
q

Has the inmate sustained a recent loss (loved
one, friend, home, job) or a series of losses?
Is the inmate depressed?

q

Does he have a religious and/or philosophical
background that supports suicide?

q

Does he believe that suicide is an acceptable
release (from prison, life)?

q

Is he socially isolated from other inmates and
staff (without friends and other social support
systems)?

q

Is this the first time in prison?

q

Does he seem overly embarrassed, ashamed, or
guilty about the crime committed?

q

Has inmate been previously treated for mental
illness, emotional disturbance?

q

Does inmate have a history of self-destructive
acts?

q

Has a member of his family attempted suicide?

q

Does he think about suicide at this time?

q

Is he psychotic?

q

Is he hearing voices telling him to kill himself?

45

q
q

Has inmate expressed wish to die or failed to
perform life-saving acts?
Does inmate have terminal medical condition?

q

Does inmate talk or think about giving
possessions away or writing a will?

q

Does inmate talk about a particular
method/plan for killing himself?

q

Is that method/plan available?

warranted, the inmate is placed under suicide watch. In the absence of mental health staff, the
medical staff or shift commander may initially authorize a suicide watch, with the psychologist
conducting a formal evaluation the following day. All inmates placed on suicide watch are
reassessed by mental health staff every 24 hours. Only mental health staff, including the
psychiatrist, may upgrade, downgrade, or discontinue a suicide watch. In addition, if the psychiatric
review team determines, during its review of an inmate placed on suicide watch, that the inmate
needs extensive mental health services, the PRT attempts to commit the inmate to a DPW forensic
unit or transfer the individual to another SCI with a mental health unit.
Housing
Pursuant to DOC policy, the restrictive housing unit is not used for suicide watch at SCIRetreat. All inmates placed on suicide watch are housed in the medical infirmary. The unit has four
cells — two four-bed wards, one medical isolation cell, and one suicide observation cell directly
next to the officers’ station. Mental health and medical staff decide case by case whether to issue
clothing and bedding and, if so, which articles. Restraints are used only as a last resort when the
inmate is engaging in self-destructive behavior.
Levels of Supervision
Close watch is used for inmates who are not actively suicidal but have the potential for selfinjury (e.g., an inmate who cannot give a firm commitment not to harm himself). The officer
assigned to the infirmary visually checks inmates on a staggered 15-minute basis. Constant watch
is reserved for actively suicidal inmates who threaten or engage in self-injury. The infirmary
officer observes such inmates continuously and without interruption. Regular watch, the third level
of supervision, requires observation at 30-minute intervals and is used to de-escalate inmates from
higher watch levels. Observations during close and regular watch are documented on the inmate’s
Suicide Watch Checklist as the checks occur; observations during constant watch are documented
at 15-minute intervals. In addition, nursing staff also observe all suicide watch inmates at 15-minute
intervals, and the psychologist (or psychiatrist) monitors inmates daily.
Intervention
Each of the four general population housing units, the restrictive housing unit, and the
infirmary contain a first aid kit, disposable pocket masks, and a tool for cutting materials used in
attempted hangings. In addition to annual staff training in first aid and CPR, correctional officers
46

are trained to respond promptly to emergencies, call for assistance, and initiate first aid and CPR
if appropriate. When necessary, inmates who have attempted suicide are transported to WilkesBarre General Hospital by privately contracted ambulance personnel.
Administrative Review
Following a suicide or serious attempt, all SCI-Retreat staff who came into contact with the
inmate before the incident are required to submit a factual statement of the circumstances leading
to the event. In addition, a “clinical review of suicide” is conducted within five days of the
incident.* At SCI-Retreat, a Clinical Review Team (CRT) comprised of mental health, medical, and
correctional personnel interviews staff and inmates and reviews written records of the incident to
determine what factors precipitated the suicide or attempt and what action, if any, is necessary to
reduce the likelihood of future incidents. According to DOC policy, the clinical review is to be a
learning experience and is to be conducted openly and honestly. Contributions are encouraged from
all staff to sharpen their detection skills and to help prevent unnecessary loss of life. All information
gathered during a clinical review is confidential.
At the conclusion of the clinical review, the CRT chair (the SCI-Retreat psychologist) writes
a report to the superintendent covering the team’s findings and recommendations. A copy of the
report is forwarded to the DOC regional office and then to the central office. The report may
subsequently be used to correct action within the facility, revise DOC policy, and/or as a tool for
annual training.
Conclusion
Although it lacks written intervention procedures and staff would benefit from additional
hours of suicide prevention training, the suicide prevention program at SCI- Retreat exemplifies a
highly effective approach to the problem of suicide among prison inmates. From its opening in
1988 to 1994, the facility had not experienced an inmate suicide, despite 3,477 admissions.

*

A reformatted copy of DOC Policy Statement 7.3.5, “Clinical Review of Suicide,” is included in Appendix D. Although
clinical reviews are required for all completed suicides, prison superintendents can decide whether a clinical review
is warranted in cases of attempted suicide. At SCI-Retreat, the superintendent authorizes clinical reviews for all
serious suicide attempts.

47

Chapter 5
SUICIDE PREVENTION IN FEDERAL PRISONS:
A SUCCESSFUL FIVE-STEP PROGRAM
by
Thomas W. White, Ph.D., and Dennis J. Schimmel, Ph.D.*
Although suicide is a relatively infrequent occurrence, it is a leading cause of death in jails
(Bureau of Justice Statistics, 1993b) and prisons (Salive et al., 1989). While the rate of suicide for
incarcerated offenders varies among local, state, and federal jurisdictions and among types of
institutions, it is now generally accepted that suicide occurs more frequently in prisons and jails than
in the general population (Hayes and Rowan, 1988). Given the high risk for offenders, courts have
frequently held correctional administrators and practitioners to a high standard of accountability for
the management of suicidal and potentially suicidal offenders. Consequently, national organizations
like ACA and NCCHC have developed standards for evaluating suicide prevention programs in
correctional and detention facilities. The standards, however, are often inconsistent and, without
an accepted mechanism for enforcement, implementation must rely on voluntary compliance.
Nevertheless, correctional administrators would be wise to establish suicide prevention programs
in all detention and correctional facilities (O’Leary, 1989). Before it can be done efficiently and
cost effectively, however, the long-term effectiveness of existing suicide prevention programs must
be evaluated to determine which policies offer the most successful strategies for dealing with the
problem. To this end, the study discussed in this chapter was undertaken to review the overall
effectiveness of one such program — the Federal Bureau of Prisons’ (FBOP) suicide prevention
program.
In 1982, FBOP issued its first formal policy covering suicide prevention. The policy,
implemented in all federal institutions, outlines a full range of procedures to be followed pertaining
to the assessment, management, and treatment of suicidal inmates. The suicide prevention program
includes five basic components: 1) initial screening of all inmates; 2) treatment and housing criteria
for suicidal inmates; 3) development of standardized record keeping, follow-up procedures, and
systematic data collection; 4) staff training; and 5) periodic reviews and audits. After the first 5
years of the program’s implementation, FBOP’s Psychology Services Division — which is directly
responsible for program management — established a work group to review the program and, if
necessary, recommend procedural changes. The work group used both psychological autopsies and
staff interviews to analyze inmate suicides within FBOP between 1983 and 1987. The findings were
subsequently summarized in Schimmel, Sullivan, and Mrad (1989), hereafter referred to as the
“Schimmel study.”

*

Dr. White is the regional psychological administrator of the North Central Region of the Federal Bureau of Prisons. Dr.
Schimmel is the regional drug program coordinator for the North Central Region. The views expressed in this
article are the views of the authors and do not represent the official view of the Federal Bureau of Prisons or the
U.S. Department of Justice.

48

The term “psychological autopsy” refers to the process of reconstructing an individual’s life
during the time immediately before his or her death. Through the use of face-to-face interviews
with other inmates, correctional staff, mental health staff, and others having contact with the victim,
an interviewer attempts to understand the feelings, thoughts, motives, and behaviors leading to the
death. While psychological autopsies have been used for many years in the community (see, e.g.,
Robins, Gassner, Kayes, Wilkinson, and Murphy, 1959; Shneidman, 1969), the technique has been
used to a limited extent in jail settings (Salive et al., 1989; Spellman and Heyne, 1989) and rarely
in prisons. In fact, a review of the literature reveals that, while suicides in jails have attracted
increasing attention from researchers, very little research has been directed at virtually any aspect
of prison suicide, regardless of the technique used. The surprisingly small number of studies has
produced a rather narrow range of data regarding the most basic information concerning suicides
in prison, and the findings that have been reported consequently cannot be generalized for various
types of prisons.
The Schimmel study, with its use of psychological autopsies, has been cited as the most
comprehensive analysis of prison suicides reported to date (Bonner, 1992a); it has yielded a wealth
of new information about suicide in prison. The findings demonstrate a clear difference in the type
of inmates at risk in jails and prisons.
The current study was able to build on that earlier Schimmel study by reviewing data from
FBOP psychological autopsies for the 5-year period from 1988 through 1992. By analyzing data
for both 5-year periods, the present review was able to compare trends, and, by combining the data,
substantiate a comprehensive, 10-year analysis of FBOP’s program.

Program Description
As of January 1995, 86,378 inmates were incarcerated in over 110 federal institutions
throughout the country. Each institution is required to have a suicide prevention program
conforming to the requirements set forth in policy. Each institution’s program and policy
compliance are reviewed periodically, noting and correcting deviations from policy. Psychology
Services administers FBOP’s suicide prevention program, with the chief psychologist of each
facility acting as program coordinator for that facility. The chief psychologist is thus responsible
for implementing all policy requirements, including initial screening, treatment, and housing,
standardized record keeping, follow-up, and systematic data collection, staff training, and periodic
reviews and audits.
Initial Screening
FBOP’s suicide prevention program begins with an initial processing of inmates as they
arrive at a facility, performed by physician assistants as part of the basic medical assessment. Any
inmate showing the potential for suicide at that time is immediately referred to a psychologist for
a more in-depth evaluation. New inmates not referred by the physician assistant or other staff (who
could also detect suicide potential) are interviewed by a psychologist within 14 days of their arrival
at an institution. (Inmates transferred from other federal institutions are seen within 30 days of their
arrival.) This interview not only assesses suicide potential, but also provides a general psychological
screening to evaluate the inmate’s stability, program needs, and potential adjustment to the
institution. For example, as a result of this assessment, the inmate might be identified as needing
treatment for drug abuse, individual counseling, or referral for psychotropic medication.

49

Treatment and Housing
At any point during incarceration, an inmate can be referred to Psychology Services for
assessment of suicide risk. If the inmate is determined not to be imminently suicidal, appropriate
interventions, such as individual counseling sessions or referral for psychiatric medication, are
initiated, along with supervised follow-up as needed. On the other hand, if the program coordinator
deems the inmate to be imminently suicidal, he or she is immediately removed from the general
population and placed on suicide watch. The conditions of this watch are specific, clearly delineated
in policy, and exceed the frequently used technique of 15-minute visual checks. Generally, the
inmate is housed in a designated “suicide-proof” hospital room and constantly observed by trained
inmate companions or staff. Although any staff member may initiate a suicide watch in an
emergency, the program coordinator is the only person with authority to terminate the watch. The
coordinator is also responsible for determining the necessary follow-up interventions for an inmate
after a suicide watch ends and for ensuring that those interventions are implemented expeditiously.
The overall structure of the program clearly places most decisions about the suicidal
inmate’s management directly with the program coordinator. Focusing responsibility for the
treatment of the inmate on this one qualified individual eliminates the diffusion of responsibility that
can occur when several people have equal or overlapping authority. In those cases, the lack of a
singular and specific authority can also be a source of confusing or contradictory treatment.
Identifying the coordinator as the central decisionmaker provides consistent program
implementation and allows staff a specific source of expertise and referral.
Standardized Record Keeping, Follow-Up, and Systematic Data Collection
Comprehensive documentation is critical to any effective suicide prevention program.
Psychology Services staff are required to use a series of standardized forms when initiating and
terminating suicide watches, documenting and maintaining treatment procedures and referral
decisions in a computerized data system, and compiling yearly statistics on all suicide evaluations
and watches. The statistics compiled are then incorporated into a yearly report detailing the national
outcome of the suicide prevention program. During 1992, for example, FBOP documented 2,200
formal evaluations of suicide risk. Those evaluations resulted in 912 suicide watches, with the
average watch lasting approximately 86 hours. Of the 75,363 hours of suicide watch, 28 percent
were performed by staff and 72 percent by inmate companions. The standardized record-keeping
system forms the basis for effective clinical treatment and follow-up, and the availability of such
statistical data is a valuable source of information to be used in training and policy development.
Staff Training
A cornerstone of any effective suicide prevention program is well-trained staff, and the
program coordinator is responsible for providing training in a number of areas. The coordinator
must ensure, first, that all staff are trained in recognizing suicidal behavior, the proper procedures
to follow in referring an inmate for treatment, and their responsibilities if asked to perform a formal
suicide watch. Because it is often line staff who are in a position to see the signs of potential
suicide, this training is given a high priority and presented to every new employee, as well as to all
staff during required annual training. A second broad area of training is supplemental training for
staff who have frequent contact with inmates. Specifically, FBOP policy states that additional
training should be provided semiannually to physician assistants and correctional counselors, who
50

often deal with inmates in crisis situations (e.g., initial screenings, sick call, or special housing
units). Accurate and timely training of line staff is the most practical, cost-effective way to ensure
that inmates exhibiting suicide potential are identified and referred for evaluation and treatment.
One of the most innovative and perhaps most controversial aspects of FBOP’s program is
the use of inmate companions. At the warden’s discretion, inmate companions rather than staff may
be assigned to perform formal suicide watches. Coordinators select inmates for the program based
on a wide range of factors, and companions are not placed in a clinical or therapeutic role. Sixtyfive percent of federal institutions use this option, and, as previously noted, 72 percent of all watch
hours during 1992 were performed by inmate companions.
The facility’s program coordinator is responsible for developing a formal selection
procedure and training schedule for each inmate companion. Training typically focuses on ensuring
that inmates understand the procedures necessary to summon staff assistance should the inmate at
risk attempt suicide. Given their interaction with the suicidal inmate, however, inmate companions
are also given basic training in understanding suicidal behavior, empathic listening, and other
techniques for building communication. The companion thus has a basic understanding of the skills
necessary to communicate more effectively and provide the suicidal inmate with a ready source of
peer support.
Periodic Reviews and Audits
All suicide prevention programs are evaluated periodically. Those departments with
deficient programs are required to correct any deviations and bring their program into full
compliance. For example, if the necessary staff training was not provided, the suicide watch room
was inadequate, or inmates were not screened initially, the program coordinator would be required
to correct deficiencies and forward documentation of those actions to the appropriate reviewing
authority for approval.
In addition to a formal program review, institutions where a suicide occurs are required to
be reviewed by an outside official, typically a Psychology Services regional administrator or chief
psychologist from another FBOP facility. The review consists of a structured psychological autopsy
examining a number of historical, environmental, demographic, and psychological variables related
to the death. Through an analysis of the program review and psychological autopsy, the overall
effectiveness of the suicide prevention program is evaluated and changed if necessary. In fact, data
collected from these sources was invaluable in developing FBOP’s most recent Program Statement
on Suicide Prevention (effective April 1990). Such reviews have provided extremely relevant
information for presentation in staff training that can also be used in future policy development.
Annual Suicide Rates
Because the express purpose of a suicide prevention program is to reduce suicides, the
following analysis begins with an examination of FBOP’s annual suicide rate. Unfortunately, as the
Schimmel study demonstrated, the calculation of suicide rates is not always standardized, and the
inconsistency can lead to considerable variation between studies examining the same data. To avoid
problems of this nature in comparing FBOP suicide rates, the present investigation used the same
methods employed by the Schimmel study to ensure a standard basis for comparison. Specifically,
the annual suicide rate was determined by dividing the number of suicides by FBOP’s estimated
average daily inmate population for the year. Coincidentally, 43 suicides occurred in each of the
5-year periods being reviewed. Because the population of federal prisons has increased
51

substantially, the average daily population was higher during 1988 to 1992 than during 1983 to
1987. Consequently, with the absolute number of suicides remaining the same and the base
population increasing, the suicide rate logically decreased.
The Schimmel study found that when suicide rates for the first 5 years of FBOP’s program
were compared with pre-program data reported by Schmidt (1978) and Gaes (1981), the average
suicide rate decreased from approximately 35 suicides per 100,000 inmates for 1970 through 1982
to 24 per 100,000 for 1983 through 1987. The present review found that, for the period from 1988
to 1992, the average annual suicide rate was slightly less than 16 per 100,000, with the most recent
year reporting a rate of only 10 per 100,000. Given that FBOP’s overall population is 93 percent
male and that the suicide rate for males in the community is approximately 18 per 100,000, FBOP’s
overall rate is clearly promising. In fact, given the higher suicide rates found in other prison studies
(Dooley, 1990; Salive et al., 1989), a rate comparable to that of the general population is
encouraging.
Combining data from the present study (1988 to 1992) with that of the Schimmel study
(1983 to 1987) shows FBOP’s suicide rate during the first 10 years of its formal suicide prevention
program was approximately 20 per 100,000, a 43 percent decrease when compared to the preprogram suicide rate. Because the data is correlational rather than experimental, interpretation
inferring causal links is inappropriate. However, the reduction in suicide rates over the last 10 years
does suggest that FBOP’s suicide prevention program has had a positive effect in reducing suicides.

52

Demographic Data
Prison suicide rates have been associated with a number of common demographic variables
(Bonner, 1992a). The present review examined the variables of gender, age, race, and psychiatric
and suicidal history. In addition, it presents data on several non-personal variables associated with
the suicides, such as method used, housing, length of sentence and type of institution, and time of
day and time of year the suicides occurred. Finally, it examines precipitating factors and establishes
a profile of the typical inmate who committed suicide in federal custody.
Gender
Of the 43 federal inmates who committed suicide between 1988 and 1992, all were male.
The Schimmel study also found that all of the suicide victims in its research were male. In fact,
although the number of female inmates has increased to over 7 percent of the total federal prison
population, no female has committed suicide in FBOP since 1970.
Age
Data related to age indicates that suicide appears to be more frequent (35%) among inmates
between 31 and 40 years of age. These frequencies generally reflect the overall age distribution of
offenders in the system, however, and the largest number of suicides would therefore be expected
to come from that age group. In fact, these findings are similar to the distributions reported in the
Schimmel study and show little in the way of obvious age-related factors that might predict suicide.

53

Race
An examination of the prevalence of suicide by race shows that approximately 65 percent
of the inmates who committed suicide were white, 28 percent were black, and 7 percent were of
other racial groups. A comparison of these figures with the racial distribution of federal inmates
indicates that the only group showing any appreciable deviation from what might be expected is the
latter group, represented by one American Indian and two Asian victims. Given the small numbers
in this group, these figures do not appear significant. Overall, the victims’ racial background does
not appear to be a predominant factor in predicting those at risk for suicide. Although the Schimmel
study did not report racial distributions for the general population, the analysis found that 72 percent
of suicide victims were white and 28 percent were black, with other racial groups not represented
— reflecting a relatively similar racial breakdown between the two studies.
Psychiatric/Suicidal History
Of the 43 suicides between 1988 and 1992, 23 victims (53%) had a documented mental
health problem. Of these 23 cases, 11 inmates were diagnosed with severe psychotic disturbances,
while 6 were diagnosed as having some type of mood or affective disorder, such as depression. The
other victims’ diagnoses included paranoid ideation (4), organic syndrome (1), and post-traumatic
stress disorder (1). In addition to the presence of a psychiatric diagnosis, 17 victims (40%) had
made at least one previously documented suicide attempt or gesture.
The Schimmel study found that 37 percent of the victims had received a psychiatric
diagnosis reflecting a psychotic condition and 9 percent had been treated for depression — a total
of 46 percent with a documented history of mental health disorder. Forty-nine percent of these
victims also had a history of previous attempts or gestures. Therefore, approximately 50 percent of
the 86 suicides between 1983 and 1992 had a documented history of mental health diagnosis or
treatment, and approximately 44 percent of those inmates who committed suicide had made attempts
or gestures in the past.

54

Method Used
Consistent with past studies of suicides in custody, the most frequently used method of death
was strangulation. Of the 43 inmates who committed suicide between 1988 and 1992, 34 (79%) did
so by hanging. Of the other victims, three jumped from tiers or buildings, two took an overdose of
medication, two shot themselves in an unsuccessful escape attempt, and two cut their arms and
wrists. Coincidentally, the Schimmel study also found that 79 percent of the victims committed
suicide by hanging. Thus, 79 percent of all inmates who committed suicide over a 10-year period
did so by hanging or similar method of strangulation.
Housing
The most common location for suicide was in a special locked unit. Twenty-seven (63%)
of the suicides between 1988 and 1992 occurred in segregation, administrative detention, or a
psychiatric seclusion unit. Of the 16 suicides in the general population, 9 inmates (21%) committed
suicide in their cell, and 7 (16%) in common areas such as showers or stairwells. This current data
is similar to that reported in the Schimmel study. For example, the Schimmel study found that 63
percent of the victims committed suicide in locked units, 29 percent in their housing unit, and the
remaining 8 percent in other areas. Therefore, during the 10-year period from 1983 through 1992,
approximately two-thirds of all inmates who committed suicide did so while confined in some type
of locked special housing; with one exception, all victims were in single cells at the time of their
deaths. This finding is consistent with the data reported by Bonner (1992a) in his review of jail and
prison suicides and supports recommendations that inmates identified as suicidal not be placed in
isolation without sufficient monitoring.
Length of Sentence/Type of Institution
Similar to the findings reported in the Schimmel study, the current review identified three
groups of federal inmates who appear to be at risk for suicide. Two of the high-risk groups —
pretrial inmates and Mariel Cuban detainees — were unsentenced prisoners. Although they
represented only 6 and 4 percent of the total FBOP population, respectively, these two groups
combined accounted for 42 percent of the suicides. The third high-risk group was sentenced inmates
serving over 20 years. This group accounted for 28 percent of the suicides but only 12 percent of
the total number of sentenced inmates.
When suicides are viewed in relation to the type and security level of institutions where they
occur, it appears that administrative and high-security facilities have higher suicide rates than other
institutions. Merging the data on length of sentence with type of institution provides insight into
this finding. For example, metropolitan correctional centers, which house the majority of pretrial
inmates, had 11 suicides between 1988 and 1992, representing 26 percent of the total. Twelve
suicides (28%) occurred in penitentiaries that house a disproportionately high number of inmates
with longer sentences and Mariel Cubans; 14 suicides (32%) occurred in medium-security federal
correctional institutions. Of the remaining suicides, 5 (12%) occurred at federal medical centers and
only 1 (2%) at a minimum-security camp. Thus, data from the current review shows that institutions
housing a greater number of high-security-risk inmates have, as might be expected, higher rates of
suicide.
Time of Day

55

Unlike the findings reported in the Schimmel study, in which nearly 50 percent of suicides
occurred between 12:00 midnight and 6:00 a.m., the current review found no readily apparent
pattern associated with the time of day the suicides occurred. If the day is divided into four quarters
beginning at 12:00 midnight to 6:00 a.m., the suicides were relatively evenly distributed throughout
the day, with a small decrease between 6:00 a.m. and 12:00 noon and a slight increase between
12:00 noon and 6:00 p.m. While it is possible to rearrange the time frames (e.g., immediately
before and after count, early evening to early morning) to create some variation between different
times of day, doing so could yield more artificial than meaningful information.
Time of Year
Like time of day, time of year counted little in determining when suicides occurred. The
highest number occurred in January and October (seven suicides each), with the remainder relatively
evenly distributed throughout the year, ranging between two and five suicides for most months.

Precipitating Factors
Although speculative, psychological autopsy data was reviewed to determine the
precipitating factors that might have led to the suicides. The present findings were very consistent
with data reported in the Schimmel study in that the most frequently cited factors were related to
new legal problems (28%), marital or relationship difficulties (23%), and inmate-related conflicts
(23%).

56

Legal problems were most important for pretrial inmates. These problems covered a wide
range of concerns primarily related to receiving new charges or additional sentences, being
overwhelmed with the prospect of conviction, or facing a lengthy sentence. Marital or relationship
difficulties were also common in the pretrial group but could also be found in victims at various
stages of their incarceration. These cases most frequently focused on issues pertaining to loss of
family ties, marital problems (including separation and divorce), and the death of a family member.
In almost all cases, inmate-related conflicts most affected inmates with sentences of 20 years or
more. These conflicts, which often emerged after years of incarceration, focused on the inmate’s
perceived need for protection and subsequent inability to enter the general population (e.g., they
might have been labeled, or thought they were labeled, a “snitch”). In some cases, reports suggested
that these inmates appeared to develop what might be considered paranoid preoccupation with their
safety before their suicide. The cases were often difficult to manage, commonly seen in mediumand high-security institutions. Because of their situations, either real or imagined, these inmates
were unable to be released from special housing, but their continued placement in special housing
exacerbated emotional fears. Their preoccupation, although often noted, did not represent the
degree of psychological instability that would warrant transfer to an in-patient psychiatric facility.
Ten suicides appeared to be related to a variety of issues, such as poor health, parole
violations, and psychological difficulties. Mariel Cuban detainees evidenced little in the way of a
consistently identified precipitant, but observers often inferred general hopelessness regarding the
future. Six of the 43 victims left a suicide note. Typically, the notes did not point directly to
precipitating factors but more generally expressed a desire to remove themselves from the long-term
confinement they were facing. (Five victims had nothing in their immediate past that provided any
information regarding the reasons for their suicides.) In virtually all of the 43 cases, the victims had
not demonstrated any significant change in mood or behavior to signal the need for referral to
Psychology Services or to warn of their intentions. Even in retrospect, the actions of most
individuals before their suicide were not remarkable and did not indicate their intentions.
Inmate Profile
In addition to this demographic information, researchers reviewed several other
characteristics relating to personality, education, and social factors. Although none of these
additional factors was directly related to attempted suicide, it was possible to combine several pieces
of information to produce a profile of the typical inmate who committed suicide in the FBOP system
between 1988 and 1992. When this profile was compared with data from previous years, it was
remarkably similar.
The victim was a relatively young (35 years old) male, Caucasian (or
possibly Cuban), with few friends or family ties in the community.
He was a quiet, aloof individual who stayed to himself, was poorly
educated, and had little religious affiliation. He frequently had a
history of mental health problems and referrals, including past
suicide attempts, but was not viewed as suicidal or actively psychotic
immediately before his death. The victim was probably housed in an
administrative facility and facing new legal complications or was in
a high-security institution and experiencing significant marital or
family problems. Regardless of the institution’s level of security, the
victim was almost certain to be in a single cell, often in a special
57

housing unit, and confined for protective custody. He was serving
either less than a 10-year sentence or more than 20 years (except in
the case of Mariel Cuban detainees). As an inmate in protective
custody, the victim frequently voiced exaggerated fears for and
preoccupation with his safety but other than those concerns did not
demonstrate any unusual behavior or give any overt warning of his
intention before the suicide. The incident would occur in the early
afternoon or evening, and the victim would hang himself with a sheet
attached to a light fixture or grate over an air vent. He would leave
no suicide note.

Survey of Chief Psychologists — Overview
Because a significant aspect of FBOP’s suicide prevention program involves inmate
companions and staff training, both the Schimmel study and the current review solicited information
about these two issues from chief psychologists at each facility. Approximately 65 percent of
respondents in the current study used inmate companions and believed it was a worthwhile and
highly beneficial program. This figure was down slightly from the 70 percent reported in the
Schimmel study. Despite the slight decrease, most respondents in both surveys reported that inmate
companions were conscientious and did an excellent job, and they believed that the program should
be continued. In both surveys, most chief psychologists in FBOP institutions that chose not to use
inmate companions cited philosophical or ethical problems, liability concerns, or security
considerations.
Over 97 percent of respondents in the current survey and 100 percent in the Schimmel study
said they provided annual training in suicide prevention to correctional officers. Most chief
psychologists recognized the value and importance of this training and found it highly beneficial.
In the current study, 68 percent of respondents said they provided supplemental training to selected
staff, such as counselors and physician assistants. Finally, respondents in both studies agreed that
the suicide prevention program was working well. Only 15 percent of the chief psychologists
surveyed in the current study believed the existing policy should be revised. Of those who
suggested revisions, almost all recommended more definitive guidelines or training standards for
inmate companions. Overall, most chief psychologists believed that the existing policy was an
adequate and workable document as it was although it could perhaps benefit from some fine-tuning.

Summary
The results of the present study, while requiring cautious interpretation, support the longterm effectiveness of FBOP’s suicide prevention program. Although the correlational nature of the
data could not provide a direct causal link between the program’s implementation and a reduction
in suicides, the overall decline of 43 percent in suicide rates between 1983 and 1992 appears to be
more than coincidental. In addition, FBOP’s average suicide rate of 16 per 100,000 between 1988
and 1992 is not only below the rate reported in the Schimmel study, but also slightly lower than the
18 per 100,000 reported for males in the community. Despite the positive findings, however, these
results are only a beginning and highlight the need for additional studies using a controlled
experimental methodology to better define the cause and effect of the reported relationships.
Nevertheless, by any measure, the findings are very promising and suggest that implementation of
58

a comprehensive, well managed suicide prevention program can have a positive impact on reducing
the rate of prison suicides.
The data presented in this study came from a review of psychological autopsies performed
on each suicide. This methodological approach, while common in the community, has seen only
limited application in the long-term assessment of prison suicides, but it could be an invaluable
research and management tool. The data thus acquired could serve as the basis for additional
training and focused intervention with specific inmate populations.
The data obtained during this study has important implications for future program
management, policy review, and training efforts in FBOP. The information can also be applied to
other correctional facilities and systems particularly in developing institution-based suicide
prevention programs. The existence of written policy providing unambiguous procedures and clear
guidelines has made it possible to implement the suicide prevention program uniformly across a
wide range of federal institutions. Perhaps the most important aspect of the program relates to the
development of an ongoing administrative structure that obtains yearly data on the use of the
program and permits program managers to review long-term trends and needed procedural
adjustments. Included in this process is a comprehensive audit and the use of psychological
autopsies. While all aspects of FBOP’s program might not be applicable in a particular setting, its
basic structure provides the essential components of a responsive, professionally managed suicide
prevention program that merits consideration by other correctional facilities and systems.

59

Chapter 6
THE COURTS’ ROLE IN SHAPING PRISON SUICIDE POLICY
by
William C. Collins, Esq.*
A prison official has a duty to protect an inmate from any harm the prisoner might inflict
upon himself when such harm is reasonably foreseeable. This duty includes preventing the inmate
from committing suicide.† Breach of this fundamental principle of American common law will
subject the negligent party to liability for damages in a tort lawsuit, absent some state law against
such liability. A prison official who is deliberately indifferent to the mental health and protection
of an inmate whom the official knows to be suicidal violates the constitutional rights of that inmate.
Breach of this constitutional duty could expose the official to damages under 42 USC Section 1983,
as well as to remedial court injunctions issued under the same statute.
Both of these principles are well established. Recent reported cases, especially Section 1983
cases, however, indicate that it is becoming increasingly difficult to successfully sue an institution
or individual officials as a result of an inmate’s suicide.

Jail and Prison Suicide Lawsuits
In a review of the case law regarding prison suicide, one is immediately struck by the
comparative lack of suicide litigation from prisons when compared to that from jails. One obvious
reason for the difference is the dramatic contrast in the numbers of jail and prison suicides. Hayes
and Rowan (1988) reported 401 jail suicides in 1986, whereas NCIA reported 158 prison suicides
in 1993 (see Chapter 3).
Another reason for the comparatively small number of reported lawsuits involving prison
suicides could be that the decedents had fewer supportive family members in the community who
might be interested in pursuing litigation than did jail victims. The “typical” jail suicide victim is
“an unmarried, intoxicated Caucasian male about 22 years of age who lacks a significant history of
incarceration” (Robertson, 1993, p. 808) and is newly admitted to the jail. In other words, the jail
suicide victim might be less than 48 hours removed from the community. Prison suicide victims,
on the other hand, have substantially different characteristics and are far more removed from the
community and family.

*

Mr. Collins is an Olympia, Washington, attorney specializing in correctional law. A graduate of the University of
Washington School of Law, he is co-editor of the Correctional Law Reporter and Community Corrections Reports
on Law and Correctional Practice.

†

72 Corpus Juris Secundum Section 78 (1978).

60

Two Roads to the Courthouse
The fundamental legal vehicles and theories used in either jail or prison suicide litigation are
similar. Two different legal vehicles support liability claims against correctional officials following
an inmate suicide — civil rights actions and tort suits.
Civil Rights Actions
Such claims, brought pursuant to 42 USC Section 1983, allege that a person, acting under
state law, violated or acted in such a way as to cause a violation of the decedent’s constitutional
rights. A civil rights action can seek injunctive relief as well as compensatory and punitive
damages. A successful plaintiff in a Section 1983 action is entitled to an award of attorneys’ fees,
plus any award for damage or other relief a court might give (42 USC Section 1997e). A “lodestar”
award, which could be adjusted somewhat depending on the facts of the case, is computed by
multiplying the hours the lawyer spent on the successful portions of the case times the prevailing
hourly rate in the community for lawyers of similar skill and experience. With hourly rates for
attorneys now often exceeding $100 per hour in all but the smallest communities, such an award can
be substantial.
Competing against the possibility of a sizable award for attorneys’ fees is the “qualified
immunity” defense in civil rights cases. Unless the plaintiff can establish that the defendants
violated a “clearly established” constitutional right, no damages can be awarded (Harlow v.
Fitzgerald, 1982). It is not enough that a general principle be clearly established; the facts of prior
cases must be at least somewhat similar to facts of the current case to clearly establish a right
(Hansen v. Soldenwagner, 1994). Given the comparatively small number of prison suicide cases
and hence the lack of factually similar precedents, it is very possible that the qualified immunity
defense will provide substantial liability protection from damages for prison officials named in civil
rights actions.
Tort Suits
Tort suits allege only that the defendant was negligent in a way that caused, or failed to
prevent, the suicide. A tort suit seeks only damages. While either action may be brought in state
or federal court, a civil rights action is more likely to be brought in federal court, although state
courts enjoy the jurisdiction to consider a Section 1983 action. A tort action may not be brought
independently in federal court, but a federal court has the discretion to consider such a claim as a
companion to a civil rights claim arising out of the same incident — known as “pendent
jurisdiction” (Roberts v. City of Troy, 1985). In practice, a plaintiff may allege that the same facts
demonstrate both negligence (tort) and a civil rights violation so as to maximize the chances of
winning a lawsuit. Thus, the same lawsuit may use the same facts to reflect both a tort and a
violation of the decedent’s civil rights. In other cases, a plaintiff may pursue a civil rights claim in
federal court and a tort claim in state court.

Courts as Agents of Reform
Over the last 25 years, reform litigation under Section 1983 has been the greatest force for
positive change in U.S. corrections. Recent Supreme Court decisions dealing with a variety of
correctional subjects, however, have robbed Section 1983 and the federal courts of much of their
clout. Moreover, while major class action suits are still possible, they are becoming more and more
61

costly and difficult to bring (Dolby, 1994). The threat of damages through tort litigation can
produce reform, but tort claims are rarely brought as class actions and a court in a tort case cannot
enter an injunction requiring officials to implement improvements. Therefore, the pressure for
reform in tort claims differs somewhat from Section 1983 suits, where a court’s order can force
officials to directly address and correct problems.

Suicide Claims and Section 1983 Actions
The most common claim under a civil rights action is that the acts or omissions of the prison
staff resulted in a violation of the decedent’s rights under the Eighth Amendment to be free from
cruel and unusual punishment. Constitutional claims might also be based on a failure to provide a
reasonably safe environment or on a failure to train staff properly (Cohen, 1992). Under any of
these theories, the defendants’ mental state is equally important in establishing liability as to what
actually happened to the decedent. Defendants must be shown to have been “deliberately
indifferent” to the needs of the decedent, although, as will be discussed later, the definition of
deliberate indifference varies. Proving deliberate indifference is not easy.
The Eighth Amendment and Deliberate Indifference
Probably the most common type of civil rights claim following a prison suicide is an Eighth
Amendment claim asserting inadequate medical care. “Medical care” in this context clearly includes
mental health care, and this discussion uses the two phrases interchangeably. To win such a claim,
the plaintiff must establish that prison officials were deliberately indifferent to the decedent’s serious
mental health needs. Both medical and non-medical staff can be liable.
The “serious medical care need” part of the equation virtually speaks for itself, as the
successful suicide demonstrates a serious mental health problem. Proving the suicide alone,
however, will not show a violation of the constitution, nor will showing that failures on the part of
the staff contributed to the suicide. Only if the failures are so grievous as to reach the level of
deliberate indifference will an Eighth Amendment violation be found.
The phrase “deliberate indifference” made its Supreme Court debut in a 1976 case involving
medical care in prison (Estelle v. Gamble, 1976). Based on Estelle and other decisions, such as
Hudson v. McMillian (1992), deliberate indifference was generally defined as conduct that fell
somewhere between negligence and willful or purposeful conduct. Most lower federal courts
defined the phrase in terms of recklessness but differed on their definitions of that term. Some
courts used the definition in civil law, which permits consideration of not only what a defendant
knew, but also what the defendant should have known. Thus, under this theory, one could argue
that if a prison official should reasonably have known an inmate was suicidal and took no action to
prevent the attempted suicide, the official was deliberately indifferent. Other lower courts applied
the more rigid approach of criminal law to recklessness, where actual knowledge alone would
suffice to show recklessness.
In June 1994, the U.S. Supreme Court further defined deliberate indifference (Farmer v.
Brennan, 1994). The Court agreed that the term should be defined in terms of recklessness and
adopted the criminal law approach using actual knowledge. Thus, to be deliberately indifferent, an
official must now have actual, not implied or constructive, knowledge of a serious medical need
(such as an inmate’s mental status) and then fail to make a reasonable preventive response to that
known need. Even knowledge of an inmate’s mental status or other indicators of potentially suicidal
behavior, however, might not be enough under Farmer. Writing for an eight-member majority
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(Justice Thomas concurred in the result but did not join the majority’s reasoning), Justice Souter said
an official “must both be aware of facts from which the inference could be drawn that a substantial
risk of serious harm exists, and he must also draw the inference” (Farmer v. Brennan, 1994, p.
1979). This reasoning could create an ironic dilemma in a prison environment. For example, a
correctional officer trained in the recognition of symptoms of potential suicide who fails to act in
the face of certain facts could be liable under Farmer. By contrast, a poorly trained officer who sees
the same facts but has no training in their interpretation would escape liability.
Failure to Train
Although failure to train commonly appears as an issue in prison suicide cases, establishing
liability on the basis of inadequate training is very difficult. The U.S. Supreme Court ruled several
years ago that a plaintiff must show that officials were deliberately indifferent to the inmates’
constitutionally protected rights (Canton v. Harris, 1989). Deliberate indifference in a failure-totrain claim, however, does not require a showing of a defendant’s actual knowledge of a problem.
Instead, according to the Farmer ruling, knowledge can be attributed to officials when the need to
train is “so obvious, and the inadequacy so likely to result in the violation of constitutional rights,
that the policy makers of the city can reasonably be said to have been deliberately indifferent to the
need” (Farmer v. Brennan, 1994, p. 1981).
Applying the failure-to-train teachings from Canton to a case involving custodial suicide,
one court has said that to succeed, a plaintiff must “1) identify specific training not provided that
could reasonably be expected to prevent the suicide that occurred and 2) ...demonstrate that the risk
reduction associated with the proposed training is so great and so obvious that the failure of those
responsible for the content of the training program to provide it can reasonably be attributed to a
deliberate indifference to whether [the inmates] succeed in taking their lives” (Colburn v. Upper
Darby Township, 1991, at 1030).
Current Trends in Section 1983 Suicide Litigation
Almost all recent custodial suicide civil rights decisions have come from jails and typically
involve the suicide of an inmate very new to the facility. The clear trend in these cases, however,
makes recovery for the plaintiffs very difficult. If one adds the decision in Farmer plus the defense
of qualified immunity, recovery of damages for plaintiffs in prison suicide cases will be even more
difficult than it has been in the past. Federal courts have consistently held that only in the event of
a “strong likelihood of suicide” are inmates constitutionally entitled to protection (Robertson, 1993,
p. 816). Case law indicates that this threshold is not met unless the following elements are present:
1) the inmate in question had threatened or attempted suicide, 2) the threat or attempt was known
to jailers, and 3) the episode was somewhat recent. Farmer re-emphasizes only the second of these
elements.
In summary, a civil rights complaint, to succeed, must establish that the defendants had
actual knowledge that there was a strong likelihood an inmate was suicidal and that officials took
no reasonable action to prevent the suicide from occurring.
While federal courts over the years have pushed correctional systems to improve in many
different ways, decisions regarding custodial suicide have not often been part of this trend. For
example:

63

Federal courts have held that two elementary precautions — cursory
searches and limited monitoring — discharge jailers from Section
1983 liability. These measures pale in comparison to recommended
protections, which include 1) architectural design that precludes
opportunity for suicide; 2) constant observation and supervision of
suicide-prone persons; 3) multiple-occupancy housing; 4) diversion
of inebriated offenders to detoxification centers or other alternate
services; 5) crisis intervention; and 6) psychiatric evaluation of highrisk inmates and hospitalization for those diagnosed an “actual
suicide risk.” The considerable discrepancy between what is
recommended by commentators and what is actually required by
federal courts speaks poorly of Section 1983 as a vehicle of jail
reform (Robertson, 1993, p. 825).
If federal courts are unwilling to impose duties no more basic than screening arrestees for
suicide risk as they enter the jail (Hayes, 1989), it is safe to say that, at the present time, decisions
from the federal courts will not be a strong motivating factor for improved suicide prevention
practices in prisons.
Tort Suits
If case law under Section 1983 offers little assistance to the plaintiff, tort law could offer a
somewhat greater chance of recovery. Under a tort theory, the question is not whether officials were
deliberately indifferent to a serious risk of which they had actual knowledge, but that they had a
duty to protect a prisoner from harming himself when such harm was reasonably foreseeable (Scott
v. State, 1993). Courts generally hold that the official’s duty arises when he/she knows or has
reason to believe that the inmate might harm himself.
Liability based on a civil rights claim and liability based on a tort theory thus have two
major differences. First, constructive knowledge of a potential problem (should have known) can
trigger the duty to take precautionary measures in a tort action, compared to the requirement of
actual knowledge imposed by Farmer in a civil rights claim. Second, establishing foreseeability of
a suicide is generally easier in a tort claim than in a civil rights action. In the former, foreseeability
is established when something, such as a suicide, is shown to be “probable in the light of ordinary
prudence” (Robertson, 1993, p. 827) — in contrast to the “strong likelihood of suicide” test in civil
rights cases.
As an example of the difference between the two types of actions, consider Hutchinson v.
Miller (1989). Jail staff, in violation of the facility’s policy, failed to check a detainee every 15
minutes. The detainee had made repeated requests to be moved to a new cell because of threats
from other inmates. With one hour between checks, the inmate was found dead. The court found
that the actions of jail staff did not amount to deliberate indifference, thus preventing a civil rights
claim from succeeding. The court did find, however, that the facts supported a claim for negligence
under common law tort theory.
While a tort approach in general seems to be potentially more fruitful for the plaintiff, some
states impose immunity barriers against suits for the government that could limit or bar such actions
altogether. Sometimes the product of legislation or judicial intervention, these barriers could allow
government agencies or officials to be immune from damages for some or all of their actions (Tittle
v. Mahan, 1991; Agee v. Butler County, 1991).
64

It is beyond the scope of this discussion to analyze the varying immunity protections of all
50 states. Suffice it to say that the proposition in general tort law that a prison official has a duty
to protect a prisoner from harming himself when such harm is reasonably foreseeable cannot be
applied in at least some states because of those limitations. Therefore, plaintiffs in these states will
have no choice but to seek recovery through a civil rights action.

So Much for Theory — What About the Facts?
The discussion about legal tests is perhaps of limited interest to the practitioner working in
a prison. To that person, the ultimate question is, “Where is the risk of liability?”
System Issues
Most recently reported cases about custodial suicide have involved a single suicide victim
and examined only what happened to that decedent. Some cases have addressed a facility’s overall
ability to prevent suicides, stating that identification, treatment, and supervision of a suicidal inmate
are the necessary components of a constitutionally acceptable basic mental health program (Ruiz v.
Estelle, 1983; Lightfoot v. Walker, 1980).
These cases sweep the prison’s ability to deal with inmate-suicide-related issues up into a
broad attack on the institution’s overall mental health system (see Casey v. Lewis, 1993, for
example). In finding that the Arizona Department of Corrections mental health system violated the
Eighth Amendment, the court noted deficiencies in intake screening at the women’s prison, failure
to review records of inmates transferred within the system, shortages of mental health staff,
inadequate programming for mentally ill inmates at one institution, delays in assessment and
treatment, inappropriate use of lockdown, and inadequate monitoring of medication.
Individual Cases
Because no substantial body of case law deals with prison suicides and because the basic
facts can vary from case to case, it is difficult to make general statements of principle that provide
much more guidance than “do not be negligent!” Civil rights case law from jail suicides provides
little guidance. Several common themes are repeated in custodial suicide cases, however, that at
least help define where risks exist. While the same facts can be litigated as a tort suit or civil rights
action, the difference between the two is how intensely the facts are scrutinized. Cases are subject
to three basic areas of focus.

65

Recognizing Suicide Threats
Should prison staff have recognized that an inmate was potentially suicidal? Because of the
requirement of actual knowledge of a strong likelihood of suicide, proving the threat has been
difficult in jail cases. For instance, courts have held that no general constitutional duty exists to
screen inmates for potential suicide (Belcher v. Oliver, 1990). In prison, however, the practical
burden of showing a threat of suicide could be somewhat easier to prove, as the inmate would have
been more familiar to prison staff and perhaps have had a record of prior suicide attempts or mental
health problems about which staff were aware.
Greater knowledge of a victim’s mental health history could be the greatest difference
between jail and prison suicide litigation, as so much jail litigation focuses on what staff knew or
should have discovered about an arrestee within the first hours or days of his or her entry into the
facility. In contrast, prison officials would probably know a great deal more about inmates who
commit suicide, and the litigation can focus on the question of what the officials did with the
knowledge they had.
Supervision and Response
Having identified the inmate as suicidal, were proper precautionary measures ordered, and
were they carried out? Was the inmate placed on a suicide watch, was the intensity of that watch
consistent with the urgency of the inmate’s case, and was the watch carried out as ordered? Was
proper medical care given?
Typically, jail suicide cases do not delve into questions regarding the adequacy of mental
health care given the decedent. Instead, they focus on the responses of non-medical staff to such
issues as failing to closely monitor the suicidal inmate (Buffington v. Baltimore County, 1990) or
failing to conduct searches to adequately reveal instruments of suicide (Matje v. Leis, 1983).* In
contrast, the adequacy of the professional treatment the decedent received appears to arise more
commonly in the scant body of prison suicide cases (Waldrop v. Evans, 1989; Torraco v. Maloney,
1991).
Emergency Response
Once the attempted suicide was discovered, was the response proper? The courts will not
receive well a response that treats a hanging inmate as a crime scene and leaves the victim dangling
while staff wait for investigators or the medical examiner to arrive, yet this situation has arisen more
than once (Hake v. Manchester Township, 1985; Heflin v. Stewart County, 1992).† Custodial staff
*

Detainee hid drugs she used to commit suicide in her diaphragm, which they did not search, although jail staff had
reason to know where drugs were hidden.

†

But see also Reed v. Woodruff County (1993), in which the court found no deliberate indifference, as the police officer,
who was also a trained medical technician, decided a hanging inmate was dead and did not begin life-saving
measures. Plaintiffs provided no evidence to suggest life-saving measures would have done any good.

66

not trained to determine medically whether someone is dead should normally treat the scene as a
medical emergency, not as a sterile crime scene.
Other Factors
Within these three general areas of concern are several other areas of potential focus in
prison suicide litigation. First, the question of foreseeability is a critical part of both a civil rights
and a tort claim. Courts in tort suits (generally involving jail suicides) have recognized several
indicators of foreseeability (Kappeler, Vaughn, and del Carmen, 1991). Several, if not all, of them
are relevant in the prison setting as well:
•

Actual suicide attempts while the detainee is in custody;

•

Detainee’s statement of intent to commit suicide;

•

Detainee’s history of mental illness;

•

Health care professional’s determinations of detainee’s suicidal
tendencies;

•

Detainee’s emotional state and behavior;

•

Circumstances surrounding the detainee’s arrest; and

•

Detainee’s level of intoxication or drug dependence (Kappeler et al.,
1991, pp. 381, 384).

Second, basic organization and staffing of the mental health system is a factor. Without
a functional mental health system, an institution cannot be expected to meet the needs of the suicidal
inmate.
Third, failure of the medical staff to properly diagnose or treat suicidal inmates is a factor.
In Greason v. Kemp (1990), for example, spending only a few minutes with a patient who entered
the prison on antidepressant medication, not taking the time to read the patient’s clinical file (which
would have revealed a lengthy history of mental problems, hospitalization, and warnings about the
risks of taking the patient off his medications), and failure to examine the inmate’s mental status
were facts that allowed a jury to find deliberate indifference. Inadequate numbers of medical staff
could contribute to their failures, as many are overwhelmed by the sheer volume of demand for their
services.
Fourth, the Greason decision points up one value of examining prior records — obtaining
relevant information for diagnosis and treatment. Prior records might also show a history of
attempted suicide, which in turn could suggest the need for special precautions.
Fifth, for want of a better word, is carelessness. In Lewis v. Parish of Terrebonne (1990),
an inmate had been taken by jail staff to a local hospital to have his stomach pumped following the
claim that he had taken a large number of pills. From the emergency room, the inmate was taken
to a mental hospital for examination. The psychiatrist wrote a letter to the jail, indicating the inmate
was suicidal and recommended that special precautions be taken. The doctor gave the letter to the
67

transport deputy to give to the warden. The deputy left the envelope from the psychiatrist on the
jail booking desk. Shortly thereafter, the inmate hit the officer and was immediately placed in
solitary confinement. The warden did not open and read the letter although he knew of the inmate’s
earlier suicide threat and attempt. Only after the inmate committed suicide in solitary confinement
did the warden look at the letter.
Sixth, facility design — protrusions such as hooks or pipes that could be used in a suicide
attempt — are a recognized architectural concern (Atlas, 1989, p. 161). While facility design has
been an issue in a handful of cases, it has not fared well as the basis for liability. Two opinions in
Tittle v. Jefferson County Commission (1994) provide an example. The suit sought damages in part
because cells contained an exposed pipe near the ceiling, from which the victim hanged himself.
In the first Tittle opinion, a panel of the 11th Circuit opined that the majority of 57 suicide attempts
during a 2-year period (including 4 successful suicides within 12 months) were the result of hanging
from the pipes, and the sheriff’s concern about the pipes’ presence, provided enough evidence to
raise the issue at trial as to whether the defendants were deliberately indifferent to a dangerous
design flaw in the jail. In the second opinion, after an en banc review of the first decision, the court
overturned it, saying that the prior history of suicides did not show that “all prisoners of the
Jefferson County Jail are substantially likely to attempt suicide” (Tittle v. Jefferson County
Commission, 1994, p. 1540).
The same plaintiffs brought a tort action against the jail’s architects, only to lose that case
as well (Tittle v. Giattina, Fisher & Co., Architects, 1992). The court there said that, while an
architect has a duty to design a building that is safe for its intended use, the duty did not extend to
preventing suicides, citing a decision of an Illinois appeals court (La Bombarde v. Phillips Swager
Associates, Inc., 1985). The court also noted the large number of variables affecting a potential
suicide that are clearly beyond the architect’s control. In the midst of this prolonged litigation,
however, the defendants covered up the pipes in the facility and updated intake screening and staff
training policies.
Despite the fate of the design issue in the Tittle cases, claims of negligence or deliberate
indifference based on design flaws retain at least theoretical viability, especially in the case that
combines an inmate known to be suicidal with a cell with exposed lighting fixtures, air vents, or
other design features that all but say “place noose here.”
Seventh, good record keeping is one of the most important parts of risk management. One
author, writing about potential liability for psychiatrists and psychologists following patients’
suicides, recommended that paranoia be a guide for record keeping: “As a general rule...clinicians
should write their notes as if a lawyer were sitting on their shoulders, reviewing every word”
(Bongar, 1991, p. 169). While it might be something of an exaggeration, the basic points are sound.
Convincing a judge or jury that something happened that is not noted in the written records, when
normally it should be noted, is very difficult.
Good documentation will help the prison avoid liability by providing a method by which
staff become aware of potential problems and demonstrate their response to those problems. Poor
documentation can work against the facility, and missing documentation can imply actions that
should have occurred but did not. For instance, if an inmate was on a 10-minute suicide watch and
a log showed gaps of an hour or more between checks, it would be virtually impossible for
defendants to convince a judge or jury that the necessary checks were in fact made.
Documentation can also reflect some of the lack of cooperation problems that often exist
between custody and mental health staff. Line staff who do not have confidence in the judgment
of mental health staff might carefully document inmate referrals to cover themselves in the event

68

of a problem. Similarly, mental health records might show failures of the custody staff to cooperate
with treatment plans.
Eighth, sharing information, especially between custody and medical/mental health staff,
is closely related to sound record keeping. Custody staff can be the source of valuable information
regarding an inmate’s behavior in the cellblock and can serve as the eyes of the mental health staff.
Distrust between these two departments is common, and the greater it becomes, the more likely it
will be played up in litigation, even to the point of the plaintiff’s lawyers trying to use the concerns
of one department to demonstrate the failings of the other.
Ninth, failure to follow policy will not necessarily show negligence and is even less likely
to indicate deliberate indifference. It can be relevant to either determination, however. The most
enlightened policies and procedures concerning suicide prevention can become a noose around the
neck of prison officials if those policies and procedures are not followed. This is particularly true
when those failures to follow policy are known to supervisory officials, are seen as playing a critical
role in allowing the inmate to commit suicide, or are related to prompt discovery of the attempt.
Finally, as noted earlier, failure-to-train claims might commonly be made in custodial
suicide cases, but they seldom succeed — which is not to suggest that training and liability are
unrelated. Realistically, the risk of liability from inadequate training is simply that poorly trained
staff will make mistakes, which become the focal point of the lawsuit. State indemnification laws
suggest that, in the great majority of cases, the government will in fact bear the cost of litigation,
including any damages, regardless of who the court finally holds to be liable. Thus, the agency —
and the taxpayers — pay the costs of inadequate training, even if the lawsuit does not succeed on
a failure-to-train claim.

Summary
The advice and recommendations of the correctional profession to itself about preventing
suicide are more relevant and important in meeting the goal of reducing prison suicides than
anything the federal courts say the constitution demands. While courts recently have not been as
active in the area of custodial suicide as in years past, agencies still must recognize that they have
legal duties to protect prison inmates, including those who are suicidal. Failures in the general areas
of recognizing suicide threats, protection and treatment, and emergency response can produce
liability. The lawsuit that seeks to recover damages from an inmate’s suicide will probably fare
better if it is brought as a tort claim alleging negligence than if brought as a civil rights action,
except in those states where state law bars such a damages claim. When a tort claim can be
maintained, it will be easier for the plaintiff to introduce current, contemporary correctional
practices as benchmarks against which to measure the defendant’s acts or omissions.

69

Chapter 7
SUMMARY AND CONCLUSIONS
Observers historically have assumed that, while the risk of suicide looms large in jail among
inmates facing the initial stages of confinement, such risk dissipates over time in prisons as
individuals become more comfortable or tolerant of their predicament and develop skills to cope
with life behind bars. This assumption has not been empirically studied; it is far too simplistic and
ignores both the process and individual stressors of prison life. Prison suicide must be viewed in
the context of a process by which an inmate is (or becomes) ill-equipped to handle certain stressful
factors of confinement (Bonner, 1992a). Over time, these factors can include loss of outside
relationships, conflicts within the facility, victimization, further legal problems, physical and
emotional breakdown, and a wide variety of other problems. When the inmate cannot effectively
cope with these stressors, the result can be varying degrees of suicidal behavior — from ideation
to contemplation, attempt, or completion.
Although the rate of suicide in prisons is far lower than in jails, it remains disproportionately
higher than the general population and a significant public health problem. During the past 10
years, the rate of suicide in prisons throughout the country was 20.6 deaths per 100,000 inmates.
In addition, states with small prison populations appear to have exceedingly high rates of suicide
— often more than two and one-half times the national average. Yet while the prison suicide rate
has gradually decreased since 1984, punctuated by a dramatic decline after 1989, the rate increased
noticeably during 1993. In fact, 15 states experienced higher rates of prison suicide during 1993
compared to their 9-year (1984 to 1992) averages.
The majority of DOCs throughout the country have not comprehensively adopted the suicide
prevention standards advocated by either the National Commission on Correctional Health Care or
the American Correctional Association. Such standards include the six critical components of a
suicide prevention program: staff training, intake screening/assessment, housing, levels of
supervision, intervention, and administrative review. Although NCIA found that 79 percent of the
DOCs had a suicide prevention policy, 15 percent did not have a policy but had varying numbers
of protocols in other DOC directives. Six percent of the departments did not address the issue of
suicide prevention in any written policy or directive. More than a quarter (27%) of all DOCs had
either no policy or a policy that contained only one or two of the six critical components of suicide
prevention. Only 15 percent of all DOCs had policies that contained all or all but one of the
components. Two of those prison systems were Louisiana and Pennsylvania, which have
experienced gradual reductions in their suicide rates that parallel the national trend. The Elayn Hunt
Correctional Center in Louisiana and State Correctional Institution-Retreat in Pennsylvania
exemplify highly effective suicide prevention programs.
As a result of litigation, many states have improved their general conditions of confinement
and implemented specific programs designed to improve prison health care, including suicide
prevention. Recent Supreme Court decisions, however, have robbed civil rights laws and the federal
courts of much of their reform clout. And while major civil class-action suits are still possible, they
are becoming more and more costly and difficult to prove. With regard to liability for prison
suicide, federal courts have consistently held that only when a strong likelihood of suicide exists are
inmates constitutionally entitled to legal protection. The “strong likelihood” threshold includes a
threatened or attempted suicide known to personnel in the recent past. It is safe to conclude that

70

future decisions from the federal courts will not be a strong motivating factor for improved practices
to prevent prison suicides.
The higher rate of prison suicides experienced in 1993 could indicate an upward trend or be
merely an aberration. Observers have noted that several recent developing trends suggest higher
suicide rates in the future. These recent trends (e.g., mandatory sentencing laws, dramatic increases
in life sentences, AIDS, and the graying of inmate populations) have instilled despair and
hopelessness in inmates. Future efforts to prevent prison suicides will be predicated on several
factors: further research, resources, and progressive prison management.
Large-scale, prospective studies of prison suicide and empirical studies on the process of
custodial suicide are needed. As the awareness of inmate suicide as a serious health problem within
prisons continues to grow, resources must follow. Some encouraging signs are apparent. For
example, the National Institute of Corrections is currently providing technical assistance to
departments of correction and jails in various specialized areas of correctional health care, including
developing comprehensive plans for suicide prevention.”* Other resources are available, including
a recently released comprehensive training manual on preventing prison suicides produced jointly
by the New York State Office of Mental Health, Department of Correctional Services, and
Commission of Correction. Suicide Prevention and Intervention in State Correctional Facilities is
geared toward an 8-hour staff training seminar and includes 10 modules of instruction: overview
of the problem, a model for understanding suicide, myths and misconceptions about suicide,
substance abuse and suicide, mental illness and suicide, screening inmates for suicide risk,
communication skills, suicidal inmates in the housing unit, accessing crisis and other mental health
services, and the impact of suicide on the staff.†
Finally, future success in reducing prison suicides throughout the country will rely not only
on progressive prison administrators’ developing comprehensive and operational suicide prevention
policies, but also on the attitude enunciated earlier by EHCC Warden C.M. Lensing: “You need
to stay one step ahead of the game. When you put suicide prevention kits in each housing unit,
place social workers in the cellblocks to assess suicidal inmates each day, and schedule suicide
prevention training every Friday, you symbolize to all staff the commitment we have to suicide
prevention.”‡ The prevention of future prison suicides might very well depend on the attitude
*

See National Institute of Corrections, Annual Program Plan for Fiscal Year 1995, (Washington, D.C.: U.S.
Department of Justice, 1994), p. 24.

†

For more information on Suicide Prevention and Intervention in State Correctional Facilities — Trainer’s Manual,
contact Judith F. Cox, Acting Director, Bureau of Forensic Services, New York State Office of Mental Health, 44
Holland Avenue, Albany, New York 12203, telephone 518/474-7275; or James F. Newton, Director, Correctional
Mental Health, New York State Department of Correctional Services, 875 Central Avenue, Albany, New York
12203, telephone 518/457-5067.

‡

Interview with author, June 2, 1994.

71

displayed toward whether to treat the increase in prison suicides during 1993 as an aberration or as
a signal of an upward trend.

72

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80

Belcher v. Oliver, 898 F.2d 32 (4th Cir. 1990).

81

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82

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83

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84

Appendix A
SAMPLE SUICIDE PRECUATION PROTOCOLS*

If any staff suspects that an inmate is depressed and/or suicidal, the medical
department should be notified. The physician and/or on-call psychiatrist should then
be consulted. Any of the following levels of precaution may be recommended:
LEVEL 1
In most circumstances, this level will pertain to persons who have actually
recently attempted suicide. The on-call psychiatrist will have been notified.
Efforts will be in progress to have the inmate committed to a mental health
facility.
The inmate should be in a “safe room” or in the health clinic. Health staff should
provide one-to-one constant attention while the person is awake, with visual
checks every five to ten minutes while the inmate is asleep in a safe environment
(described in Level 2). Toileting and bathing may or may not be visually
supervised, depending on the inmate’s mood at the time; if visually
unsupervised, staff should be standing close by with the door slightly ajar.
LEVEL 2
This level will pertain to inmates who are considered at high risk for suicide.
The on-call psychiatrist will have been consulted. Efforts will probably be made
to have the inmate committed to a mental health facility.
The person should be either in a “safe room” or in the health clinic. Safety
precautions should be observed. These should include searches of room and
clothes for removal of all potentially harmful objects such as glass, pins, pencils,
pens, and matches. Plastic bags should be removed. The room should be near
the staff office, with no access to breakable glass and no electrical outlets (or
outlets that can and should be turned off.) There should be no bed in the room
if possible, and no pipes from which sheets could be hung. There may be a
mattress and pillow on the floor. The person may have clothes (no belts), linen,
and blankets. If the inmate verbalizes or demonstrates immediate intent to harm
himself/herself, bedding should be removed and the health staff notified. The
person should be checked at least every five minutes while awake and every
*

Reprinted/reformatted from the National Commission on Correctional Health Care’s Standards For
Health Services in Prison (1992) with permission from the Echo Glen Children’s Center,
State of Washington.

85

ten minutes while asleep. He/she should have one-to-one attention when out
of room, if potentially harmful objects (pencils, TV, etc.) are brought into room,
or if he/she seems unusually distraught. Toileting and bathing: same as for
Level 1.
LEVEL 3
This level will pertain to persons whom the physician or on-call psychiatrist
feels are at moderate risk for suicide. They may be inmates who have previously
been on Level 1 or 2 and whose mental status is improving.
Safety precautions should be taken. These should include searches of room
and clothes for removal of obviously potentially harmful objects, such as broken
glass, pins and matches. Plastic bags should not be permitted. Bed and linen
may be allowed in room. The person may have writing materials (and TV in
the health clinic) at staff discretion, but they should be removed when not in
use. Toileting and bathing may be done as in the normal routine. The person
should be checked visually at least every ten minutes while awake, every onehalf hour while asleep.
LEVEL 4
This level will most often pertain to inmates who are at risk for becoming
severely depressed/suicidal. This assumption may be based on past history.
The person may be dealt with as in the normal unit routine; however staff should
observe the inmate for symptoms of depression and signs of suicidal ideation,
and should notify health staff if new signs or symptoms occur. The person should
be checked visually at least every half hour awake and asleep.
The mental status of any given inmate may vary greatly from day-to-day and sometimes
from hour-to-hour; therefore, it is imperative that staff have good observational skills
and knowledge of signs and symptoms to look for. If any staff member has reason to
feel that a person who is already on a precaution level should be moved to a higher
level of precaution, the medical department should be notified, and the physician and/
or psychiatrist again consulted.

86

Appendix B
TOTAL PRISON SUICIDES AND RATES BY STATE: 1984-1992
1984

1985

1986

STATE

Suicides

Total
Population

Rate

Suicides

Total
Population

Rate

Suicides

Total
Population

Rate

AL
AK*
AZ
AR
CA
CO
CT*
DE*
DC*
FL
GA
HI*
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI*
SC
SD
TN
TX
UT
VT*
VA
WA
WV
WI
WY
FBOP*

4
1
1
1
18
1
2
0
0
7
3
0
1
4
1
1
1
1
1
0
9
1
3
4
1
2
2
1
1
1
1
0
5
2
1
1
2
0
5
1
3
1
2
9
1
0
1
2
1
0
0
10

8,866
1,855
7,845
4,346
41,785
3,230
5,375
1,890
5,973
26,914
15,668
1,734
1,186
16,854
9,392
2,839
4,033
4,845
10,575
419
12,164
4,974
13,084
2,323
6,115
8,800
882
1,733
3,468
547
10,261
2,043
33,249
16,459
434
18,351
6,960
3,439
13,126
1,236
8,371
913
7,227
36,682
1,302
558
9,786
6,281
1,524
4,902
774
32,121

45.1
53.9
12.7
23.0
43.1
31.0
37.2
—
—
26.0
19.1
—
84.3
23.7
10.6
35.2
24.8
20.6
9.5
—
74.0
20.1
22.9
172.2
16.4
22.7
226.8
57.7
28.8
182.8
9.7
—
15.0
12.2
230.4
5.4
28.7
—
38.1
80.9
35.8
109.5
27.7
24.5
76.8
—
10.2
31.8
65.6
—
—
31.1

0
4
4
1
17
0
4
0
0
5
5
0
1
6
4
1
1
2
2
1
1
4
6
3
1
3
3
2
2
1
2
1
7
2
1
1
3
0
2
1
2
1
2
8
3
0
3
3
0
0
0
6

9,541
1,934
8,587
4,504
50,111
3,369
5,771
2,189
6,496
28,759
16,047
1,881
1,303
18,279
9,964
2,832
4,538
4,956
10,637
1,100
12,671
5,473
16,003
2,485
6,392
9,926
1,075
1,830
3,817
642
10,912
2,225
35,322
17,498
434
20,539
7,127
3,688
14,260
1,327
9,242
1,042
7,000
37,532
1,523
657
10,767
6,418
1,796
5,429
811
36,640

—
206.8
46.6
22.2
33.9
—
69.3
—
—
17.4
31.2
—
76.7
32.8
40.1
35.3
22.0
40.4
18.8
90.9
7.9
73.1
37.5
120.7
15.6
30.2
279.1
109.3
52.4
155.8
18.3
44.9
19.8
11.4
230.4
4.9
42.1
—
14.0
75.4
21.6
96.0
28.6
21.3
197.0
—
27.9
46.7
—
—
—
16.4

0
2
5
0
13
2
2
1
1
3
5
1
0
4
1
1
2
2
5
0
6
3
4
3
1
3
2
0
2
0
3
0
3
1
0
8
1
2
7
0
0
1
2
9
1
0
4
4
0
0
0
6

10,190
1,999
9,296
4,578
59,111
3,677
6,382
2,551
6,226
31,629
17,343
1,975
1,418
19,456
10,209
2,942
5,261
5,221
10,684
1,205
13,030
5,538
18,836
2,515
6,866
10,182
980
1,885
4,445
797
12,102
2,367
38,647
17,902
441
22,179
7,598
4,001
14,824
1,370
10,348
1,040
7,182
38,534
1,821
603
11,119
5,979
1,200
5,367
865
40,864

—
100.1
53.8
—
22.0
54.4
31.3
39.2
16.1
9.5
28.8
50.6
—
20.6
9.8
34.0
38.0
38.3
46.8
—
46.0
54.2
21.2
119.3
14.6
29.5
204.1
—
45.0
—
24.8
—
7.8
5.6
—
36.1
13.2
50.0
47.2
—
—
96.2
27.8
23.4
54.9
—
36.0
66.9
—
—
—
14.7

TOTAL

121

446,212

27.1

132

485,301

27.2

126

522,780

24.1

*Dual system of both pre-trial and sentenced inmates.

87

1987

1988

1989

STATE

Suicides

Total
Population

Rate

Suicides

Total
Population

Rate

Suicides

Total
Population

Rate

AL
AK*
AZ
AR
CA
CO
CT*
DE*
DC*
FL
GA
HI*
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI*
SC
SD
TN
TX
UT
VT*
VA
WA
WV
WI
WY
FBOP*

0
2
4
2
16
1
3
0
1
6
6
1
0
3
7
0
3
1
0
2
1
1
1
4
1
4
0
1
3
0
4
0
2
3
2
4
5
1
3
3
5
1
4
8
2
0
1
2
1
3
1
10

11,020
2,109
10,780
5,324
65,041
4,377
6,923
2,733
7,368
31,924
18,522
2,100
1,340
19,850
10,871
3,109
5,710
5,536
11,206
1,238
12,751
7,395
21,900
2,694
6,020
11,343
1,165
2,029
4,371
845
13,428
2,614
40,842
17,421
481
23,943
8,430
4,309
15,877
1,440
11,004
1,128
7,253
38,125
1,818
751
11,410
5,870
1,089
5,823
852
43,152

—
94.8
37.1
37.6
24.6
22.8
43.3
—
13.6
18.8
32.4
47.6
—
15.1
64.4
—
52.5
18.1
—
161.6
7.8
13.5
4.6
148.5
16.6
35.3
—
49.3
68.6
—
29.8
—
4.9
17.2
415.8
16.7
59.3
23.2
18.9
208.3
45.4
88.7
55.1
21.0
110.0
—
8.8
34.1
91.8
51.5
117.4
23.2

3
1
5
2
17
3
5
1
2
2
4
1
2
4
1
0
0
1
4
2
0
1
4
3
2
2
0
0
5
1
4
0
4
1
1
12
2
2
7
2
1
0
1
10
0
0
1
4
1
0
1
7

11,251
2,307
12,012
5,457
73,909
5,016
7,516
3,045
8,509
34,276
18,659
2,155
1,477
21,081
11,444
3,311
5,595
6,227
11,895
1,249
13,539
7,930
24,980
2,930
6,316
12,207
1,159
2,178
4,898
983
14,629
2,751
44,560
17,294
520
25,861
8,850
4,703
17,494
1,918
12,262
1,030
7,354
39,525
2,091
710
12,702
6,519
1,399
6,014
892
45,650

26.7
43.3
41.6
36.7
23.0
59.8
66.5
32.8
23.5
5.8
21.4
46.4
135.4
19.0
8.7
—
—
16.1
33.6
160.1
—
12.6
16.0
102.4
31.7
16.4
—
—
102.1
101.7
27.3
—
9.0
5.8
192.3
46.4
22.6
42.5
40.0
104.3
8.2
—
13.6
25.3
—
—
7.9
61.4
71.5
—
112.1
15.3

1
2
3
0
19
2
3
0
2
4
2
2
1
4
1
1
2
2
5
1
4
3
7
2
1
3
1
1
0
0
5
0
10
3
0
5
4
1
8
1
2
0
1
7
1
1
5
1
0
1
0
11

11,815
2,556
13,148
5,777
83,893
5,525
8,777
3,382
9,315
39,566
20,840
2,291
1,641
24,712
12,353
3,907
5,464
6,406
12,896
1,439
15,730
8,646
29,006
3,114
6,623
14,819
1,206
2,391
5,367
1,197
15,674
3,004
51,227
17,663
509
30,300
9,818
5,841
19,236
2,476
14,207
1,277
7,897
43,191
2,433
746
14,351
6,434
1,478
6,446
905
53,278

8.5
78.2
22.8
—
22.6
36.2
34.2
—
21.5
10.1
9.6
87.3
60.9
16.2
8.1
25.6
36.6
31.2
38.8
69.5
25.4
34.7
24.1
4.2
15.1
20.2
82.9
41.8
—
—
31.9
—
19.5
17.0
—
16.5
40.7
17.1
41.6
40.4
14.1
—
12.7
16.2
41.1
134.0
34.8
15.5
—
15.5
—
20.6

TOTAL

139

554,654

25.1

139

598,239

23.2

146

672,193

21.7

*Dual system of both pretrial and sentenced inmates.

88

1990

1991

1992

STATE

Suicides

Total
Population

Rate

Suicides

Total
Population

Rate

Suicides

Total
Population

Rate

AL
AK*
AZ
AR
CA
CO
CT*
DE*
DC*
FL
GA
HI*
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI*
SC
SD
TN
TX
UT
VT*
VA
WA
WV
WI
WY
FBOP*

4
2
2
2
17
0
2
1
1
2
3
1
1
4
2
2
0
0
3
1
3
1
5
3
3
4
1
2
2
0
2
0
1
3
0
4
5
0
7
1
1
0
3
1
3
0
4
1
0
0
0
8

13,142
2,427
14,115
6,533
94,050
6,057
10,101
3,474
9,121
43,920
22,302
2,370
1,857
27,516
12,736
4,307
5,635
7,705
13,849
1,548
16,899
9,183
31,240
3,179
6,724
14,946
1,393
2,382
5,640
1,407
16,743
3,195
54,895
18,605
527
31,501
10,502
6,102
21,399
2,377
15,529
1,360
8,380
49,316
2,459
787
14,507
7,995
1,504
7,247
796
59,002

30.4
82.4
14.2
30.6
18.1
—
19.8
28.8
11.0
4.6
13.5
42.2
53.9
14.5
15.7
46.4
—
—
21.7
64.6
17.8
10.9
16.0
94.4
44.6
26.8
71.8
84.0
35.5
—
11.9
—
1.8
16.1
—
12.7
47.6
—
32.7
42.1
6.4
—
35.8
2.0
122.0
—
27.6
12.5
—
—
—
13.6

3
1
1
2
15
4
9
1
1
3
2
0
1
2
0
0
3
2
2
0
2
3
3
2
1
1
1
2
2
0
1
0
6
2
0
4
3
2
3
1
3
1
4
11
0
1
3
2
0
0
0
11

13,894
2,432
15,286
7,385
95,642
7,342
10,573
3,717
9,716
46,533
23,644
2,444
2,056
29,115
13,008
4,527
5,774
8,110
14,508
1,564
18,390
9,991
31,517
3,453
8,915
15,467
1,441
2,539
5,848
1,590
18,032
3,137
57,862
19,115
534
35,446
10,694
6,494
22,794
2,783
15,962
1,391
9,288
50,516
2,798
908
16,929
8,343
1,534
7,686
920
64,611

21.6
41.1
6.5
27.1
15.7
54.5
85.1
26.9
10.3
6.4
8.5
—
48.6
6.9
—
—
52.0
24.7
13.8
—
10.9
30.0
9.5
57.9
11.2
6.5
69.4
78.8
34.2
—
5.5
—
10.4
10.5
—
11.3
28.1
30.8
13.2
35.9
18.8
71.9
43.1
21.8
—
110.1
17.7
24.0
—
—
—
17.0

1
3
7
2
15
2
1
1
1
6
1
1
0
3
1
0
0
2
4
2
1
8
3
3
4
2
0
0
3
0
1
1
7
5
0
2
4
2
4
0
3
0
2
9
1
0
2
3
0
3
1
6

16,035
2,599
16,316
7,627
103,812
7,535
11,055
3,975
9,798
48,466
25,081
2,674
2,219
31,640
13,166
4,995
5,930
8,729
16,350
1,519
18,990
10,395
35,433
3,832
7,898
16,198
1,521
2,604
5,982
1,758
18,110
3,288
61,736
20,642
536
37,991
12,211
6,375
24,227
2,783
16,327
1,390
10,569
51,592
2,968
873
16,996
9,027
1,687
8,812
958
72,092

6.2
115.4
42.9
26.2
14.4
26.5
9.0
25.2
10.2
12.4
4.0
37.4
—
9.5
7.6
—
—
22.9
24.5
131.7
5.3
77.0
8.5
78.3
50.6
12.3
—
—
50.2
—
5.5
30.4
11.3
24.2
—
5.3
32.8
31.4
16.5
—
18.4
—
18.9
17.4
33.7
—
11.8
33.2
—
34.0
104.4
8.3

TOTAL

118

730,486

16.2

127

774,198

16.4

133

825,322

16.1

*Duel system of both pretrial and sentenced inmates.

89

Appendix C
SUICIDE PREVENTION PROTOCOLS OF THE ELAYN HUNT CORRECTIONAL CENTER
ARDC PRELIMINARY HEALTH SCREENING*
Name: _______________________
DOC#: _______________________
Parish: _______________________

DOB #: ___________________________ Age: ___________________
Race: ____________________________ PPD: ___________________
Allergies: _________________________
(date applied)

Vision (Snelling Chart):

Left 20/__________ Right 20/__________

Highest grade completed: ________________________ Any Special Education Classes?
Language:

q English

q Spanish

q French

Medical Insurance:

q Yes

q No

Religion:

1.

Currently taking any prescribed medications?
q Yes
If yes, specify name of medication and date/time of last dose:
Medication/Dosage
Last Dose

q Other (Specify):

q No
Verified By:

(If additional space is needed, use back of this page and note.)

q Yes

q No (If yes, specify)

2.

Any current health problems?

3.

To your knowledge, have you been exposed to any infectious diseases?
(If yes, specify):

q Yes

q No

To you knowledge, did you receive your childhood immunizations?

q Yes

q No

4.

Have you ever been treated or hospitalized for any medical or mental problems?
(If yes, specify):
Hospital or Physician
Date
Reason

To your knowledge, do you have any scheduled clinical appointments?
(If yes, specify):
5.

Are you presently on any prescribed diet?

q Yes

q Yes

Do you engage in any type of exercise on a regular basis
q Sports
q Weight-Lifting
q Calisthenics

q Yes
q No
Comments:

q Yes

q No

q No

Length of Stay

q No

q Yes (specify): __________________________

Are you eating and sleeping without difficulty?
Describe any difficulty noted:

Do you smoke?

q Yes

q No

q No

Amount/Day: _________ How Long? _________ Years

*

Reprinted/reformatted with permission from the Louisiana Department of Public Safety and Corrections.

90

q Yes
q Asthma

q No (If yes, specify):
q Other

6.

Are there any illnesses that run in your family?
q HBP
q ASHD
q DM
q Cancer

7.

Do you have any dental problems?
If yes, specify:
If URGENT, note disposition:

8.

Do you use alcohol?
q Yes
q No
What kind?
How often? q Daily
q Weekends
q Occasionally
How much?
Last time used?
q Less than week
q Less than 6 months
q More than _____ year(s)
Do you use drugs?
How much?
Mode of use?
Last time used?

q Yes

q Yes

q No

q No

What kind?
How often?

q IV
q Other
q Less than week
q More than _____ year(s)

q Less than 6 months
q Other:

Have you ever had a problem following withdrawal from alcohol or drug use?
What kind of problem? q Seizures q Depression q Suicide Attempt
q Other (describe):
9.

q Less than year

q Less than year
q Yes

General Appearance (check):
9.1)

9.2)

9.3)

Psychological
q Alert
q Calm

q Oriented
q Depressed

q Anxious/Nervous
q Attentive

Musculoskeletal System
q Ambulates without difficulty
q Visible deformity

q Ambulates with difficulty
q Prosthesis (describe):

Integumentary System
q Bruises
q Needle Marks
q Jaundice
q Rashes

q Lesions
q Clear

States can read
States can write
Appears to understand
Appears able to follow instructions
Appears able to provide accurate information

q Yes
q Yes
q Yes
q Yes
q Yes

q Limited
q Limited
q Limited

DISPOSITION
q General population/chart review by RN and MD
q General population, needs chart reviews of medications by MD
q General population with prompt referral for the following reasons:
q 45 and above
q Acute health problems
q Scheduled appointment at outside facility
q Other (i.e., need for special duty status, issue of “particular concern,” etc.)
q Refer to MD for emergency treatment today
Preliminary Health Screening Performed By:
Date/Time:

91

q No
q No
q No
q No
q No

q No

NAME: __________________________ DOC #: _____________ AGE: __________ R/S: _______
DATE/TIME: ___________
q PT

q PV

q Impact

Other

SORT
0-#5
O-R
O-R
O-R
O-R
X = Scale
C = O/R

SUICIDE HX
Current Id:
Past Id:
Gestures:

1.
2.
3.
4.
5.

Special
MENTAL HEALTH HX
Comments:

Hospital:
Outpatient:
Med Current:
Past:
SUBSTANCE ABUSE

Immediate Recommendations:

Alcohol:
Drugs:
IV
TX
Last Use of Alcohol:
Last Use of Drugs:
How are you doing now?
SUMMARY
q No major MH problems
q Sit. Distress _________
q Psychosis active/remit
q Substance abuse

_____
_____
_____
_____
_____

1.
2.
3.
4.
5.

andard
_____

6.

Other (specify)

Signature:

ADULT RECEPTION AND DIAGNOSTIC CENTER
HUNT CORRECTIONAL CENTER
ASSESSMENT AND INTERVENTION SCREENING
CLINICAL REPORT
DATE:
NAME:
EDUCATION CLAIMED:

DOC #:
IQ EST:

DOB:
RACE/SEX:

MMPI CODE:

SERVICE CODE:
LEVEL OF CARE:

92

•••••••••••••••••••••••••••••••••••••••••••••••••••••
Suicidal tendencies:

INTERVIEW:

1.
2.
3.
4.
5.
6.
7.

Reportedly there was:
1.
2.
3.
4.
5.
6.
7.
8.

no mental health history.
mental health evaluation.
treatment in jail only.
psychiatric hospitalization.
outpatient mental health treatment.
treatment for behavior problems only.
substance abuse treatment.
self-report of prior problems only.

none known.
current suicidal ideation.
recent suicidal gesture.
prior suicidal ideation.
prior suicidal gesture.
multiple suicidal gestures.

CURRENT FUNCTIONING:
Psychomotor activity:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

IF TREATED, ANSWER THE FOLLOWING TWO:
Psychotropic medication:
1.
2.
3.
4.
5.
6.
7.
8.

was not prescribed.
included anti-psychotic.
included anti-depressant.
included anti-manic.
included anti-anxiety.
included anti-seizure.
prescription unknown.

Orientation for:
1.
2.
3.
4.
5.
6.

Previous diagnosis:
1. is unknown.
2.
Substance abused (by history):
1.
2.
3.
4.
5.
6.

within normal limits.
slow or lethargic.
rapid and hyperactive.
resting tremor.
intentional tremor.
bradykinesia.
muscular rigidity.
decreased eyeblink rate.
abnormal posture maintained.
akathisia.

all spheres is demonstrated.
person is deficient.
place is deficient.
time is deficient.
situation is deficient.

Thought processes:

none known.
alcohol.
marijuana.
cocaine.
a wide range of drugs.

1. logical, coherent & relevant.
2. flight of ideas.
3. illogical and psychotoform.
4.

NAME:

3. somewhat loosened.
4.
Sensorium:

Delusions:
1. were not elicited.
2. with paranoid content.
3. with grandiose content.
4.

1.
2.
3.
4.
5.
6.
7.

Associations:
1. tight, within normal limits.
2. markedly loosened.

Mood:

93

clear with no hallucinations.
some hypnogogic phenomena.
auditory hallucinations.
visual hallucinations.
olfactory hallucinations.
above claims are suspect.

DOC #:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

level, calm, WNL.
mildly depressed.
moderately depressed.
severely depressed.
elevated (hypomanic).
very elevated (manic).
mildly anxious.
moderately anxious.
severely anxious.

Speech:
1.
2.
3.
4.
5.
6.
7.
8.
9.

Affect is:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

appropriate w / adequate range.
flat.
labile.
inappropriate.
silly.
sad.
pleasant.
angry.
fearful.

within normal limits.
discontinuity (stuttering).
excessively low in volume.
excessively high in volume.
mute.
contains some neologisms.
shows some deficits in syntax.
syntax impaired (word salad).

Attitude:
1.
2.
3.
4.
5.
6.
7.
8.

cooperative with interview.
hostile.
friendly.
guarded & withholding.
manipulative.
indifferent.
marginally cooperative.

Impression:
1.
2.
3.
4.
5.

no serious, treatable syndrome.
antisocial personality.
malingering.
substance abuse (by history).

ADDITIONAL CLINICAL COMMENTS (IF ANY)

94

ADULT RECEPTION AND DIAGNOSTIC CENTER
HUNT CORRECTIONAL CENTER
ASSESSMENT AND INTERVENTION SCREENING
INSTITUTIONAL REPORT
DATE:
NAME:

DOC #:

RACE/SEX:

OFFENSE:

SENTENCE:

SERVICE CODE:

LEVEL OF CARE:

Criminal history summary:
1.
2.
3.
4.

no prior arrests.
property offenses.
drug offenses.
sex offenses.

5.
6.
7.

violent offenses.
not available.

4.
5.
6.

somewhat above average.
considerably above average.
extremely high.

Estimated probability of institutional violence is:
0.
1.
2.
3.

extremely low.
considerably below average.
somewhat below average.
average.

Recommendations:
A
B1
B2
B3
C
D
E
F
G
S

No current need for mental health intervention.
Psychological consultation.
Psychiatric consultation.
Neurological consultation.
Self-referral (prn) instructions.
Substance abuse treatment referral.
Professional follow-up within two weeks.
Immediate professional attention.
Inpatient mental health treatment.
Suicide watch.

Examiner

Clinical Psychologist (Director)

Title of Examiner

NOTE:

Additional clinical information may be found in the subject’s medical file. That information is privileged under
LA R.S. 37:2363, and is inappropriate for inclusion in the institutional record under provisions of the Louisiana
Administrative Code 46:1309 and Standard 3-4377 of the American Correctional Association.

95

FORM A
MENTAL HEALTH BEHAVIORAL CHECKLIST
(THIS FORM IS TO BE COMPLETED ONLY WHEN A SUICIDE WATCH IS INITIATED)
NAME:

DOC#:

DATE:

TIME:

LOCATION:
Yes
*1.
*2.
3.
4.
5.
6.
7.
8.
*9.
*10.
11.
12.

Comment

Self-Destructive Act
Suicide Ideation
Critical Changes in Situation
Depressed
Mood Changes
Agitated
Hostile
Insomnia/Hypersomnia
Gives Away Property
Bizarre Behavior
Homicidal Ideation
Other

•••••••••••••••••••••••••••••••••••••••••••••••••••••
*If any of these items with the asterisk are checked, suicide precautions should be initiated.
Mental Health Notified:
(Name)

(Time)

Action Taken:
Supervisor’s Signature:

Date:

Reporting Officer:

Date:

Definitions:
1. Self-destructive acts — cuts self, hangs, makes noose, bashes head against wall.
2. Suicide Ideation — talks of suicide, indirectly talks of suicide (the world would be a better place without me).
3. Critical Changes — death of loved one, major change in health status, change in loved one’s health, change in marital
or significant relationship, additional sentence, appeal denied, dropped from IMPACT or other special program.
4. Depression — cries, emotionally flat, apathetic, withdrawn, uncommunicative, verbalize hopelessness/worthlessness,
moves/speaks slowly, difficulty carrying out routine tasks.
5. Mood Changes — severe changes in mood from sad to happy or happy to sad.
6. Agitation — offender begins pacing, has excessive body movements or excessive speech.
7. Hostility — out of character hostility; offender normally cooperative becomes hostile.
8. Insomnia/Hypersomnia — sleeps too little or too much (not one sleepless night or one period of sleeping too much).
9. Gives Away Personal Possessions — pays debts, says goodbye to friends.
10. Bizarre Behavior — speaks in nonsensical manner, expresses bizarre ideas, inattentive to surroundings (appears to be
attending only to his own thoughts, appears “lost”), rapid speaking with overflow of ideas, talks to self, appears to be
hallucinating.
11. Homicidal Ideation — talks of homicide; indirectly talks of homicide; threatens to hurt or kill someone.
12. Other — any observation that reporter feels significant; describe briefly.

96

HUNT CORRECTIONAL CENTER
FOR YOUR INFORMATION
TO:

Assessment and Intervention
Hunt Correctional Center

FROM:
(Department, Section, Etc.)

DATE:
INMATE NAME:

DOC#:

LOCATION:

(CHECK ANY APPROPRIATE BOX)
Inmate has refused to take medication and has not signed refusal form.
Inmate has refused to take medication and has signed refusal form.
Problems sleeping.
Problems in dorm.
Inmate request to see A & I.
Other

Inmate has been informed how to contact A & I.
Response necessary.
No response necessary.
Remarks (if any):

Signature
Title

97

FORM B

MENTAL HEALTH MANAGEMENT ORDER
NAME: DOC#:

LOCATION:

BEGIN: STANDARD WATCH:
DISCONTINUE:

EXTREME WATCH:

CONTINUE:
CHANGE TO:
MANAGEMENT INSTRUCTIONS:
HOUSING:
PROPERTY:
OBSERVATION FREQUENCY:
OTHER:

DATE AND TIME EXAMINED:
DATE AND TIME OF ORDER:

ORDERED BY:

TITLE:

CONCURRENCE BY:

TITLE:

Any change requires a new Mental Health Management Order.
Copies: Medical Records, Security, Mental Health.

98

FORM C
SUICIDE WATCH LOG SHEET
(To be completed at least every 15 minutes)

OFFENDER’S NAME:

DOC #:

DATE:

Circle One — 6: 00 a.m. to 6:00 p.m. / 6:00 p.m. to 6:00 a.m.

Circle One — Extreme / Standard

Please record the time of the observation, check ( ) the behavior
you observe, or write in the appropriate space the behavior you
observe, and sign.

NAME OF THERAPIST:

Time

acting out
(racking down,
yelling, throwing
things, flooding
cell, etc.)

sitting
quietly
or
standin
g at
bars

sleeping

using
bathroo
m

99

talking
to
others

laughin
g or
crying t
o self

selfstimulating
(rocking,
masturbating,
talking to
self, singing)

Officer’s Signature

Please check if the inmate ate his/her meals and record the time of each meal. Also record the time of his/her shower.
Breakfast time:
Lunch time:
Dinner time:
Time of Shower:

100

HUNT MENTAL HEALTH
CLINICAL SOCIAL WORK NOTE
Patient:

DOC #:

Date:

Time:

HUNT/ARDC

a.m./p.m.

THEME OF SESSION/CHIEF COMPLAINT:

MENTAL STATUS EXAM:
MOOD/AFFECT:

q Appropriate
q Flat

q Euphoric
q Labile

q Depressed
q Other

PSYCHOMOTOR ACTIVITY:

q WNL

q Increased

q Decreased

FACIAL EXPRESSION:

q WNL
q Expressionless

q Sad
q Avoids Gaze

q Serious
q Other

SPEECH:

q WNL

q Slowed

q Pressured

ORIENTATION:

q WNL

Not oriented to

JUDGMENT:
INSIGHT:

q WNL
q WNL

q Flawed
q Poor

INTERVIEW BEHAVIOR:

q WNL
q Dramatic
q Uncooperative

q Aggressive
q Manipulative
q Guarded

THOUGHT CONTENT:

q
q
q
q

FLOW OF THOUGHT:

q Bizarre
q Withdrawn
q Restless

WNL
q Grandiose
q Suicidal
Delusional
q Paranoid
q Phobic
Blame-avoidant
q Excessive religiosity
A/___V hallucinations q
Claimed

q WNL
q Tangential

q Loose associations
q Circumstantial

ASSESSMENT:
q No distress noted at this time
q Manipulation observed
q Situational depression/anxiety
q Possible threat to self/others

q Mute

q Homicidal
q Hypochondriasis
q Observed

q Blocking
q Unable to assess

q Possible malingering
q Psychotic symptoms
q Stress reaction

PLAN:
q
q
q
q
q
q
q

Psychiatric referral
Self referral instructions given
Referred to case manager for follow-up
Warned against making invalid MH emergencies
Threat to security
Suicide Watch
q Begin
MH Observation
q Begin

MSW

BCSW

101

q Medical referral
q See PRN
q DB action, malingering
q Continue
q Continue

q Discontinue
q Discontinue

Appendix D
SELECTED PROCEDURES OF THE
PENNSYLVANIA DEPARTMENT OF CORRECTIONS

CHAPTER IX:
“PROCEDURES FOR DEALING WITH POTENTIALLY SUICIDAL
INMATES AND INMATES WHO ATTEMPT SUICIDE”
OF THE

MENTAL HEALTH PROCEDURES MANUAL*

COMMONWEALTH OF PENNSYLVANIA
Department of Corrections
October 27, 1993

*Reprinted/reformatted with permission from the Pennsylvania Department of Corrections.
95

IX-00

GENERAL CONSIDERATION
Suicide and self-injurious acts are a serious danger in any correctional
setting. Aspects of the correctional environment such as the authorization
structure, perceived callous treatment by some staff, and social isolation
may foster self-injurious acts. Moreover, areas of the prisons such as the
Restricted Housing Units (RHUs) appear to be the sites of a large
proportion of self-destructive acts. Therefore, early identification,
appropriate housing and monitoring, and proper treatment of potentially
self-destructive inmates is critically important, both for the individuals
in need of service and for the institutions charged with their care.

IX-01

PURPOSE
Each institution shall establish procedures for suicide prevention and
intervention. The purpose of this chapter is twofold: (1) to provide
guidelines for the development of institutional procedures and (2) to aid
staff in identifying the individual inmate needs in relation to suicide risk
potential.

IX-02

ASSESSMENT OF SUICIDE RISK
Suicidal potential can be evaluated by using the criteria which are listed
below. They are intended to help staff formulate a plan of prevention
and treatment.
A)

Suicidal Plan: The potential for suicide is greater when there is a
well organized and detailed plan developed by the inmate. The
potential also increases when the means of the suicide identified in
the plan is readily available to the inmate and can be lethal.

B)

Prior Suicidal Behavior: The potential for suicide is greater if the
individual has experienced one or more prior attempts of a lethal
nature or has a history of repeated threats and depression.

C)

Stress: The potential for suicide is greater if the individual is
subject to stress from increased pressures such as but not limited
to the following:
1.

Difficulties in coping with legal problems.

2.

The loss of a loved one through death or divorce.
96

3.

The loss of valued employment (e.g., high paying position
in Correctional Industries).

4.

Anniversary of incarceration date or offense.

5.

Serious illnesses or diagnosis of terminal illness.

6.

Threats or perceived threats from peers.

7.

Sexual victimization, particularly after the first submission.

8.

Placement in RHU.

9.

Unexpected punishment (e.g., misconduct or additional
sentence or parole denial).

10.

Cell restriction.

11.

Recent transfer from another institution or county facility.

12.

Any movement to and from RHU (watch closely for several
hours).

13.

Somatic complaints of a vague nature which do not respond
to treatment.

D)

Prior Suicidal Behavior of Significant Other: The potential for
suicide is greater if a parent, spouse or other close relative has
attempted or committed suicide.

E)

Symptoms: The potential for suicide is greater if the individual
manifests such symptoms such as:
1.

Auditory and visual hallucinations, particularly command
hallucinations.

2.

Delusions.

3.

Any change from the individual’s sleep pattern. This may
be manifested by either a decrease or increase in sleep.

4.

Any change from the individual’s ordinary eating pattern.
This may be manifested by either a decrease or an increase
in the individual’s appetite with an accompanied decrease
or increase in weight.
97

5.

Social withdrawal.

6.

Apathy.

7.

Despondency.

8.

Severe feelings of hopelessness and helplessness.

9.

General attitude of physical and emotional exhaustion.

10.

Agitation through such symptoms as tension, guilt, shame,
poor impulse control or feelings of rage, anger, hostility or
revenge.

11.

Giving away personal property.

12.

Removal of all visitors from visiting list.

13.

Sudden elevated mood (“everything’s OK attitude”).

F)

Personal Resources: The potential for suicide is greater if the person has
no family or friends, or his family and friends are unwilling to help.
Potentiality is greater if a significant other evidences a defensive, rejecting,
punishing attitude, or denies that the individual needs help.

G)

Acute vs. Chronic Aspects: The potential for suicide is greater when
there is a sudden onset of specific symptoms, a recurrent outbreak of
similar symptoms, or a recent increase in long-standing maladapted traits.

H)

Medical Status: The potential for suicide is greater when there is a
chronic, debilitating illness, especially when it involves an alteration of
body image or life style.

A person considering suicide does not demonstrate all of these signals.
Generally, the more characteristics the individual has, the greater the potential
for self-destruction. All suicide attempts, including gestures, must be taken
seriously.
Each institution will write local policy to indicate whether they plan to use this
instrument or alternate (e.g., Beck Inventory) to assess the potential for self-harm.

98

IX-03

IX-04

SCREENING/ASSESSMENT
A)

All staff who have contact with inmates shall be trained annually
on the signs and symptoms of suicidal behavior (e.g., threats,
depression, self-mutilation). If a staff member observes this
behavior, the unit manager shall be notified, and a referral shall be
made to the chief psychologist or his/her designee. In the absence
of the unit manager, the staff person shall contact the shift
commander. The unit manager or shift commander shall
immediately contact the chief psychologist or designee and brief
him/her on the situation.

B)

The chief psychologist or designee shall assess the inmate’s suicidal
potential in the most appropriate area depending on the inmate’s
level of agitation and security needs (e.g., inmate’s cell,
psychologist’s office or observation area”).

C)

Based on the screening, a referral to the psychiatrist may be
necessary for further evaluation and treatment. If the psychiatrist
determines the inmate is a danger to self and/or others, he/she
shall order a watch with a recommendation for a specific level of
observation. The watch may only be reduced or terminated by the
ordering physician.

D)

In the absence of the psychiatrist, the chief psychologist or designee
with authorization of the senior ranking official can also order
specific levels of observation. Without a mental health professional
available, the senior ranking official (in consultation with the
institutional nursing supervisor or charge nurse) can authorize
similar levels. However, a psychiatrist shall be contacted
immediately after the watch is instituted. The inmate shall be
evaluated by a physician on the next daily round and by the
psychiatrist or psychologist the next working day.

LEVELS OF OBSERVATION AND HOUSING
A)

Each institution shall provide an observation area to monitor suicidal
inmates. Such an area requires well lit, adequately ventilated and
heated cells which allow for quiet and for necessary communication
with appropriate treatment and custody staff. The area should be as
nearly suicide-proof as possible (i.e., without protrusions of any kind
that would enable the inmate to hang him/herself). Insofar as
possible, observations shall be conducted in infirmary areas, Mental
Health Unit settings (if a MHU is available in the facility), or other
areas outside of the Restrictive Housing Unit.
99

B)

Staff safety shall be a critical consideration in deciding where to
conduct the observation. Custody and supervisory staff shall not
enter a cell until sufficiant staff is available to handle the patient.

C)

Individuals placed in these settings shall be provided with basic
items needed for personal hygiene as well as items such as eyeglasses
and writing materials. If mental health staff judge there is imminent
danger that an inmate will destroy an item or use it to induce selfinjury, the inmate may be deprived of the item; however, every effort
will be made to provide a substitute for the item or allow the inmate
to use the item under the supervision of an officer.

D)

A suicidal inmate shall not be housed or left alone unless constant
supervision can be maintained.

E)

The different levels of observation require different types of
restrictions. In all cases, the least restrictive measures shall be
determined by the psychiatrist, chief psychologist or designee, and
the senior ranking official (in consultation with the institutional
nursing supervisor or charge nurse) based on the inmate’s security
needs. If the inmate is behind a locked door, the observing staff
shall be able to open the cell door immediately.
The levels of observation are described below. Post orders for the
observation shall specify the officer’s duties in providing for
custody and control and the treatment staff responsibility in
providing clinical services.
1.

Constant Watch: This is the most restrictive watch and
requires constant visual contact with recording of
observation every 15 minutes. If the mental health staff
determine that it is necessary to remove the inmate’s clothing
to prevent self-harm, then a paper gown will be provided.
If this level of observation is deemed necessary, then a
mental health commitment shall be initiated as soon as
possible, if appropriate.

100

IX-05

2.

Close Watch: This is less restrictive than constant; however,
there is still potential danger for self-injurious behavior (e.g.,
an inmate cannot give a firm commitment not to harm him/
herself). Visual checks are made on an irregular schedule
that does not develop a pattern but at least one within every
15-minute period. The type of clothing and cell items
permitted are based upon the inmate’s security needs and
current behavior. A log is kept of the visual checks, and a
record is maintained for the approved clothing and related
items.

3.

Regular Watch: This is the least restrictive level of
observation and is usually the last step prior to release from
observation. Visual checks shall be made in such a fashion
that the inmate is not aware of a pattern developing, but at
least within a 30-minute period and are recorded in a log.

4.

A Treatment Plan shall be designed by the Psychiatric
Review Team (PRT) with goals to reduce the level of
restriction as soon as possible and eventually discharge the
inmate from the observation area to a follow-up plan. If
appropriate, double celling shall be considered, particularly
for patients under regular or close watch. Entries shall be
made on the DC-14.

GOVERNING AUTHORITY OVER THE WATCHES
A)

Operation of the watches in the infirmary areas is governed by the
standards of the National Commission on Correctional Health Care
(NCCHC). Admissions or discharges can only be ordered by a
physician. A qualified health care professional (e.g., licensed
psychologist, registered nurse and physcian) can place an inmate in
observation in the infirmary for up to 24 hours; however, after
this period a formal admission or release is required,

B)

Operation of the watches in the Mental Health Units shall be
governed by the administration and clincial staff of the MHU, and
service delivery is governed by Chapter 5320, Draft Regulations
for Inpatient Forensic Psychiatric Programs of the Department of
Public Welfare (DPW).

C)

Confinement outside of the infirmary areas is governed by the 801
and 802 Administrative Directives. Insofar as possible, each inmate
shall be allowed privileges and personal property, encouraged to
101

exercise, and provided reading and legal materials consistent with
his/her level of custody within the guidelines established by
directives.

D)

IX-06

1.

In cases where an inmate is placed in observation outside
the infirmary, he/she shall be given written notice of the
reasons for Administrative Segregation utilizing a DC 141
Other Report Form. A hearing is scheduled shortly after
placement in observation status according to the provision of
DC-ADM 802.

2.

Inmates placed in observation status outside the infirmary
must be given a right to due process whereby they are
presented with the reasons for Administrative Segregation
and are given the opportunity to discuss the situation with
an administrative review authority [e.g., the Deputy who
sits on the Program Review Committee (PRC)].

3.

The PRC controls the level of observation outside of the
infirmary areas and segregation based on the
recommendations made by members of the Psychiatric
Review Team (PRT). Privileges are recommended by the
mental health staff and authorized by the PRC.

Each institution will write local policy to ensure close collaboration
between the health care, treatment, and custody departments and
compliance with the NCCHC standards, DPW regulations, and the
801 and 802 directives. Although PRC technically controls
confinement outside of the infirmary, it is critical that levels of
observation are based upon physician’s/psychiatrist’s “order” to
minimize liability placed upon non-medical staff.

USE OF MECHANICAL AND CHEMICAL RESTRAINTS
A)

Restraints shall be used for medical purposes to protect mentally
disordered inmates from harming themselves or others. (Refer to
Department of Corrections Administrative Directive 201, “Use of
Force”). They are only applied after the consideration and/or use of
any available less restrictive measures, such as counseling.
Restraints are employed for the minimal amount of time that is
necessary and not as punitive measures.

B)

The order to use restraints shall be under the direction of a
physician, and nursing personnel shall supervise the
102

administration of the restraints. Facility manager or senior ranking
official or designee may authorize the use of restraints. In this
instance, the manager or designee shall immediately consult a
licensed physician to obtain permission and consultation. A
licensed physician or nurse must examine the inmate within eight
(8) hours or earlier. Staff shall complete an Extraordinary
Occurrence Report every time restraints are used.
C)

IX-07

Local policies and procedures shall be developed to cover the
authorization, application, monitoring and documentation of their
use.

MENTAL HEALTH COMMITMENT
If the individual remains a high suicidal risk, the institutional mental
health staff shall initiate a mental health commitment to a licensed
inpatient facility using established local procedures for processing the
necessary commitment.

IX-08

A)

Emergency Involuntary (302) Commitments may be initiated to a
Department of Welfare Forensic State Hospital or one of the Mental
Health Units in the DOC system.

B)

Long Term Involuntary (304) Commitments may be initiated to a
Department of Welfare Forensic State Hospital.

C)

Voluntary (201) Commitments may be pursued if a Mental Health
Unit is housed in the SCI.

TREATMENT PLANNING AND RESPONSIBILITIES
A)

Psychiatric Review Team (PRT): The PRT members (the inmate’s
unit manager, health care administrator, unit counselor/DATS,
psychiatrist, unit psychologist, and any other staff deemed
appropriate by the Superintendent are included) shall meet within
three working days of the inmate’s placement in observation to
discuss present and future interventions. The PRT shall develop an
aftercare plan based on the inmate’s therapeutic needs. The
Psychiatric Review Team shall monitor the inmate’s progress for
at least 30 days after his/her release from observation, and longer
if determined by team members based on the inmate’s risk level.

103

B)

Continuity of Care: An Aftercare Plan is developed by the PRT
based on the inmate’s therapeutic and custodial needs.
Recommendations for Special Needs Unit placement, if one is
available in the facility, monitoring via the regular institutional
tracking system, and/or weekly counselor or psychologist contacts
are possible components of a plan. The PRT monitors the inmate’s
progress for at least 30 days after his/her release from observation,
and longer if determined by team members based on the inmate’s
risk level.

C)

Unit Psychologist and Counselor/DATS: Based upon the
recommendation of the PRT, both the unit psychologist and
counselor/DATS, as part of the PRT shall visit the inmate daily
while the individual is on a continuous or close watch. Afterward,
follow-up is determined by the PRT.

D)

Psychiatrist: The psychiatric visits are determined by the
psychiatrist’s availability during a one week period. If the inmate
is on continuous or close watch, the treating psychiatrist visits the
inmate every day of his/her service and no less than once a week
on any watch.

E)

Physician: The institutional physician shall visit the inmate daily.

F)

Chief Psychologist: The chief psychologist or designee shall
arrange for timely mental status examinations and monitor the
daily adjustment of all inmates in the observation area. The chief
psychologist shall chair the treatment planning meetings and insure
that recommendations are provided to the Program Review
Committee.

G)

Unit Manager: The unit manager shall provide input into the
inmate’s current situation, and assists in the implementation of
the follow-up plan after the inmate’s release from observation.

H)

Nursing Staff: The nursing staff shall open a psychiatric inpatient
record upon inmate admission. The registered nurse shall be the
contact person for the psychiatrist and shall assure that the original
Risk Assessment Form is placed into the psychiatric inpatient
record. Nursing documentation, to include psychiatric behavior
and physical assessment (e.g., hands-on restraint check if
applicable), shall be completed at no more than two hour intervals
unless otherwise specified by the psychiatrist order.

104

I)

Training Officer: The training officer shall insure that all contact
staff receive one hour of training per year in suicide prevention
and one hour in signs of mental disturbance. The training sessions
shall be team taught by a member of the treatment staff and a
management or supervisory level custody staff.

105

POLICY STATEMENT
Commonwealth of Pennsylvania · Department of Corrections

Policy Subject:

Policy Number:

CLINICAL REVIEW OF SUICIDE
Date of Issue:

February 26, 1993
I.

Authority:

7.3.5
Effective Date:

Joseph D. Lehman

March 26, 1993

AUTHORITY

The Authority of the Commissioner of Corrections to direct the operation
of the Department of Corrections is establised by Section 201, 206, 506,
and 901-B of the Administrative Code of 1929, Act of April 9, 1929, P.L.
177, No. 175, as amended.
II.

PURPOSE

The purpose of this policy is to establish a systematic method for
conducting clinical reviews of suicides committed by inmates under the
Department of Corrections supervision.
III.

APPLICABILITY

The policy, guidelines and procedures contained herein are applicable
to all Department of Corrections facilities and staff members.
IV.

DEFINITIONS
“Clinical Review”: A clinical review is a process of reviewing a
suicide or attempted suicide from a clinical perspective. The
process includes reviewing all known factors in the case in an
effort to determine what brought about the suicide or attempted
suicide, detect signs and symptoms, develop a plan to correct or
deter similar incidents in the future, if possible, and collect
pertinent data to be used in training of all staff in order that they
106

may become more proficient in detecting potential suicidal
incidents before they occur.
“Clinical Review Team”: A Clinical Review Team shall consist of
an interdisciplinary team of correctional professionals including
administration, counseling, psychological, psychiatric, medical and
custodial services.
“Suicide”: As applied in this policy suicide shall mean the act or
instance of taking one’s own life voluntarily and intentionally by a
person of sound mind or during acute depressive episodes, acute
mental illness episodes or periods of acute exacerbation of a
chronic mental illness, or while under the influence of an agent
either injected, ingested, inhaled or absorbed which caused the
person to act irrationally and irresponsibly.
V.

POLICY

It is the policy of the Department of Corrections that the superintendent
of a department facility shall cause a clinical review, of all successful
inmate suicides, to be conducted by appropriate staff. In cases of
attempted suicide, it will be up to the discretion of the superintendent as
to whether or not a clinical review shall be conducted.
The clinical review shall be a learning experience and, as such, shall be
conducted in an open and honest manner with contributions
encouraged from all staff in order to sharpen staff detection skills and
help prevent unnecessary loss of life due to suicide. All information
gathered as a result of the clinical review shall be confidential.
VI.

PROCEDURES
A)

Each superintendent shall establish within his/her facility a
clinical review team whose function will be to conduct an indepth clinical analysis of all successful suicide cases and any
other cases designated by the superintendent.

B)

The exact composition of the clinical review team will be
determined by the superintendent and will to some extent
depend on the nature of the incident to be reviewed.
However, at a minimum, the Review Team shall contain the
following staff: consulting psychiatrist, a psychologist (or
PSAS if psychologist is unavailable), inmate’s counselor,
director of treatment (in liew of DOT, the Deputy
Superintendent for Treatment or Counselor Supervisor or Unit
Manager may be substituted) and a supervisor level
107

corrections officer. Such other staff members as the
superintendent feels are necessary may be added to the
team as needed.
C)

It will be the function of the clinical review team to conduct
an in-depth review of all successful suicide cases and of any
other cases referred to the team by the superintendent. The
focus of the review should be two-fold: What happened in
the case under review and what can be learned to help
prevent future incidents. The team should carefully review
what was done in the particular case, what precautions were
taken and what procedures were followed. The clinical
review team can interview other appropriate staff members
or inmates (should interview victim of attempted suicide if
available) or request or review written reports prepared by
other staff relative to the incident. Any additional
information relative to a particular case should be explored
fully.

D)

Meetings of the clinical review team will be scheduled within
five working days after the incident has occurred. A
designated team member will take the responsibility for
making sure that the central file, treatment file, medical file,
incident reports etc., are available to the team at the time of
the review. The team will be advised in advance of the date,
time, and place of the review meeting.

E)

In determining whether or not to request a clinical review of
an attempted suicide, the superintendent may request a joint
evaluation by the inmate’s counselor and the institutional
psychologist as to the seriousness of the attempt. Based on
this report and the incident report, the superintendent
can decide if he/she wants a review of the attempted
suicide.

F)

At the conclusion of the review, the chairperson of the clinical
review team will make a written confidential report to the
superintendent of their findings and any recommendations
the team may have concerning changes in procedures. The
team will also gather information that can help to sensitize all
staff members to the cues and situations that are
present before such incidents occur. The aim is to help all
staff become more proficient at detecting potential suicidal
incidents before their occurrence. Appropriate information,
not the confidential report, will be shared with the institutional
training coordinator, who in turn will present an annual in108

service training seminar for all staff on recognition
and prevention of suicide based on information gathered by
the clinical review team.
G)

VII.

The superintendent will forward a copy of the confidential
staff report with his/her comments to the appropriate
regional deputy. The report should have appended a copy of
the Critical Incident Report, Classification Summary entries on
the DC-14 Cumulative Adjustment Record for the 30 day
period prior to the suicide or attempted suicide and any other
reports considered pertinent to the incident.

SUSPENSION DURING EMERGENCY
In an emergency situation or extended disruption of normal
institutional operation, any provision or section of this policy may
be suspended by the commissioner or his/her designee for a
specific period of time.

109

VIII. RIGHTS UNDER THIS POLICY
This policy does not create rights in any person nor should it be
interpreted or applied in such a manner as to abridge the rights of any
individual. This policy should be interpreted to have sufficient flexibility
so as to be consistent with law and to permit the accomplishment of the
purpose of the policies of the Department of Corrections.
IX.

SUPERSEDED POLICY AND CROSS-REFERENCE
This policy supersedes all previous policy on this subject (OM107.05, memorandum dated April 18, 1990).
Policy Manual Cross-Reference: 7.3.1. SCAN Policy
ACA Cross-Reference:

3-4364

110