JAIL SUICIDE/MENTAL HEALTH UPDATE
(A joint project of the National Center on Institutions and Alternatives and the National Institute of Corrections, U.S. Department of Justice)

Summer 2005

Volume 14 • Number 1

MODEL SUICIDE PREVENTION PROGRAMS
PART 1

I

n Missouri, a 43-year-old woman was sent to a county jail for
failing to complete the community service conditions of her
the probation following a driving while intoxicated conviction.
Within hours of her confinement, she was observed to be confused
and disoriented — crawling on the floor and talking to herself.
She was placed on suicide precautions and required to be
observed at 15-minute intervals. A few days later, she was dead.
The autopsy showed she died from an intestinal hemorrhage due
to alcoholism. A subsequent investigation indicated that a jail
sergeant falsified the observation log. Following her death, the
county attorney referred to the incident as a “very unexpected
event.” The sheriff stated that “I think it is a unique, isolated
incident…not everything is preventable.”
In California, a 27-year-old man was arrested for public
intoxication and a parole violation. He was transported to the
county jail and placed in an observation cell. He hanged himself
several hours later, the second suicide in the facility in less than
a month. According to the jail commander, “We have 1,000 inmates
in custody on any given day and 35 staff on duty. So, even under
the best of circumstances, there is going to be a window of
opportunity to try (suicide) if they’re determined to do it.” The
facility averages two suicides per year. A county supervisor was
not convinced, suggesting that even if jail staff followed policy
“we need to take a close look at what happened and try to
implement some corrective procedures. Maybe we should look
at the type of assessment we do at intake to possibly identify
inmates with suicidal tendencies.”
In Pennsylvania, a 49-year-old man was transported to the county
jail following his arrest for driving while intoxicated. Apparently
despondent after both his parents and wife had died within the
past 16 months, the inmate first attempted suicide by jumping
head first off an upper bunk in an attempt to break his neck. He
was placed on suicide precautions and observed at 15-minute
intervals. He then attempted to hang himself with a bed sheet,
but officers intervened and prevented any further serious injury.
A few days later, the inmate lodged pieces of orange peel and
paper in his throat and nose, as well as bound his hands behind
his back so he could not involuntarily free his air passage when
he started to choke. He then placed a sheet over himself so that
the officer conducting rounds would assume that he was sleeping
in the bunk. The inmate was eventually found unresponsive in
his bunk and pronounced dead.

psychotropic medication. The judge stated it was not the first
time her court orders for medication had not been followed at
the jail: “Oftentimes they do not get the medications as
prescribed. Either they don’t get the medications or they don’t
get the prescribed medication because they’re not on the prison
healthcare services formulary.” The coroner concluded that “If
it hadn’t been for the inaction of other people, the inmate would
still be alive.”
In Texas, two inmates committed suicide in the same housing unit
within a three-day span. Although both inmates had histories of
mental illness, the suicides appeared unrelated. The warden
appeared disinterested: “Our concern is more if we suspect foul
play...we always go back and review our policies and procedures
to see if there’s anything we could do to prevent it.” He then
added, “I have no idea why they do it. If I ever did, I could probably
do a better job of preventing it.”
Why do some jail systems experience an inordinate number of
inmate suicides or deaths attributed to obvious deficiencies while
others of comparable size are spared the tragedy? Some
observers would call it good fortune, while others believe that
“attitude” and comprehensive policies and procedures are the
keys to suicide prevention in correctional facilities (Hayes, 2005).
The Update has continually stressed that negative attitudes (e.g.,
“If someone really wants to kill themselves, there’s generally
nothing you can do about it”) impede meaningful jail suicide
prevention efforts.
Our most loyal readers will recall that the Update profiled model
jail suicide prevention programs several years ago (Volumes 7

In South Carolina, a coroner’s inquest jury found that the suicide
of an inmate was the result of medical neglect at the county jail.
The victim had a long history of mental illness. During his eight
days of confinement, he never received his court-ordered
—1—

INSIDE. . .


Model Suicide Prevention Programs: Part I



We’re Still Looking for a Few Good Programs



Tax Would Help Keep Mentally Ill Out of Jail



Now Available: Special Issue of Psychiatric
Services



Stripping Inmates Naked in the Name of Suicide
Prevention



News From Around the Country



Jail Mental Health Services Initiative from the
National Institute of Corrections (Jails Division)

and 8 in 1998). Beginning with this issue, we will revisit the
topic by examining several model suicide prevention programs
operating in jail systems of varying sizes throughout the country.
Programs have been evaluated (and on-site case studies
conducted) according to the following criteria:

♦

Intake screening to detect both current and prior
suicidal behavior, as well as further and periodic
assessment of suicide risk by mental health staff;

♦

Suicide prevention training for correctional,
medical, and mental health staff;

♦

Levels of communication between outside agencies,
among facility staff, and with the suicidal inmate;

♦

Suicide-resistant, protrusion-free housing of
suicidal inmates;

♦

Levels of supervision for suicidal inmates;

♦

Timely emergency intervention by correctional and
medical personnel following a suicide attempt;

♦

Provision of critical incident stress debriefing to
affected staff and inmates, as well as completion of
a multidisciplinary mortality review following an
inmate suicide and/or serious suicide attempt; and

♦

According to David J. Kelley, Ph.D., coordinator of Adult Forensic
Services at the Albany County Correctional Facility, the deaths of
Messrs. George and Richardson also resulted in an internal review
of mental health services provided to inmates at the facility. The
general consensus was there were too few staff and too few
programs for the rising mentally ill population. Regarding suicide
prevention, “we needed to go back to the basics,” according to
Dr. Kelley.
The “basics” were a previously initiated statewide program
designed to reduce jail suicides. Launched in 1985, the Local
Forensic Suicide Prevention Crisis Service Model was developed
through the cooperative efforts of the state Office of Mental Health,
Commission of Correction, Ulster County Department of Mental
Health, and a statewide task force. The Crisis Service Model was
a multifaceted initiative designed to facilitate the identification,
referral and treatment of inmates who were suicidal and/or seriously
mentally ill. The program was specifically designed to establish
administrative and direct service linkages among county jails,
police lockups and local mental health programs. It also clearly
defined the roles and responsibilities of mental health and local
correctional agencies in the identification and management of highrisk inmates. In essence, jail suicide prevention became the joint
responsibility of local jails and mental health programs.
Although refined over the years, the Crisis Service Model currently
contains the following major components (Cox and Morschauser,
1997, pp. 180-181):

A low rate of inmate suicides for an extended period
of time.

We begin our special series by highlighting the suicide prevention
program currently operating within the Albany County
Correctional Facility in Albany, New York.
Albany County Correctional Facility

O

riginally constructed in 1931 and renovated as recently as
1993, the Albany County Correctional Facility in Albany,
New York is located northwest of the state capitol and adjacent to
the county airport. James L. Campbell is the Sheriff. With a rated
capacity for 1,035 beds, the Albany County Correctional Facility
is the fifth largest county jail in the state. On the day of our visit in
April 2005, the count stood at 767, with pretrial inmates representing
the vast majority (about 70%) of the population. During the past
year, over 7,000 inmates were admitted into the facility and the
average daily population was 787.
Sabu George, 28-years-old, entered the Albany County Correctional
Facility on October 28, 1998. Charged with violation of probation
stemming from a driving while intoxicated charge, he was assigned
to the mental health housing unit and observed at 15-minute
intervals. On November 2, he was dead, a victim of suicide by
hanging. Less than a year later on June 28, 1999, Gregory Lee
Richardson died in restraints in the facility. The 42-year-old inmate
had a long history mental illness, including schizophrenia. These
two deaths were very controversial, resulting in significant media
coverage and investigations by several outside agencies, including
the New York State Commission of Correction.
—2—

♦ Policy and procedure guidelines to clarify roles of
county jail, police department lockup, and mental
health agency personnel. These guidelines
promoted shared mental health and local jail
responsibility for inmates, coordination among
departments, and minimum services.
♦ Screening of detainees by trained jail/police officers.
A basic principle of this program was that officers
were valued as “first responders” and persons most
likely to first identify signs of suicidal behavior by
inmates. It was also recognized that suicide is a rare
event and that most of the upstate jail facilities were
too small to financially justify full-time medical or
mental health staff. Therefore, reliance on jail staff
to perform the pre-cell assignment and on-going
suicide risk screening functions was essential. The
screening required use of a structured suicide
prevention screening guideline at intake to identify
high risk inmates as well as observation for risk
indicators during routine rounds and at times of high
stress.
♦ Supervision. Establishment of more rigorous levels
of supervision for high risk inmates was required to
ensure safety. After the initial assessment at booking,
provisions for continuous observation for signs of
suicide risk were required to identify high risk
inmates during the remainder of their incarceration.
Although this requirement appears obvious, it was
not routinely performed prior to program

implementation. In fact, a protocol had not been
established in all jails to formally identify inmates as
high risk to communicate such information across
shifts, and to continue the more intensive
supervision until another risk decision was made.

others. Communication was the foundation for
accomplishment of both the suicide prevention and
service enrichment goals of this project.
♦ Investigation and monitoring of inmate deaths. Careful
investigation, including psychological autopsies,

♦ Mental health observation housing. As an adjunct to
the levels of inmate supervision, special units or cells
with varying levels of mental health and medical
supervision were required for the management of
high risk inmates. In small jails, this often resulted in
a cell located in close proximity to the officer’s post
being designated as an increased observation area
for high risk inmates.

WE’RE STILL LOOKING FOR A FEW
GOOD PROGRAMS

F

uture issues of the Jail Suicide/Mental Health
Update will be devoted to exemplary suicide
prevention programs operating within correctional
facilities throughout the country. Does your facility’s
suicide prevention policy contain, and do your practices
reflect, the following critical elements?

♦ Scheduled mental health treatment. In order to
manage inmates identified as high risk either at
booking or later in their incarceration, timely mental
health treatment (e.g., medication, crisis
intervention, case management and release planning)
was required. The goals of these services were shortterm and focused on suicide prevention, stabilization
of acute psychiatric symptoms, reduction in the risk
of clinical decompensation, and continuity of care
at jail admissions and release.
♦ Crisis intervention. Provision for timely emergency
mental health and medical backup was required to
respond to suicide attempts and other mental health
crises. These services were arranged through onsite staff, on-call procedures, and/or agreements with
local emergency rooms.
♦ External hospitalization. Provision for short-term
psychiatric in-patient treatment was required for
persons with serious mental illness or persons who
were severely suicidal to the extent that stabilization
was not possible within the jail setting. In the state
of New York, this short-term hospitalization was
provided through transfer to state or locally operated
forensic hospitals or with security guard
arrangements to civil hospitals operated by the
locality or the state.
♦ Training for both jail and mental health staff. In 1985,
an eight-hour crisis intervention/ suicide prevention
training curriculum was developed for local jail and
mental health/medical staff. This training component
was revised and expanded in 1990, again in 2000,
and now also includes a four-hour refresher training
curriculum (New York State Office of Mental Health,
Commission of Correction, and Ulster County
Department of Mental Health, 2000).

♦

Intake screening to detect both current and
prior suicidal behavior, as well as further
and periodic assessment of suicide risk by
mental health staff;

♦

Suicide prevention training for correctional,
medical, and mental health staff;

♦

Levels of communication between outside
agencies, among facility staff, and with the
suicidal inmate;

♦

Suicide-resistant, protrusion-free housing
of suicidal inmates;

♦

Levels of supervision for suicidal inmates;

♦

Timely emergency intervention by
correctional and medical personnel
following a suicide attempt;

♦

Provision of critical incident stress
debriefing to affected staff and inmates, as
well as completion of a multidisciplinary
mortality review following an inmate
suicide and/or serious suicide attempt; and

♦

A low rate of inmate suicides for an
extended period of time.

If you believe your correctional facility operates an
exemplary suicide prevention program, and would like it
to be considered as a possible case study in an upcoming
issue of the Update, please send copies of your suicide
prevention policy, screening/assessment forms utilized
to identify suicidal inmates, and total number of suicides
and your facility’s average daily population for each year
from 1995 thru 2004 to:
Lindsay M. Hayes, Project Director
Jail Suicide/Mental Health Update
40 Lantern Lane
Mansfield, MA 02048
(508) 337-8806
Lhayesta@msn.com

♦ Communication. The training, policy and procedure
aspects of this program emphasized the necessity
for clearly defined communication across all levels
of correctional, medical and mental health staff, as
well as communication with detainees and, when
possible, communication with families and significant
—3—

was also critical to the success of the program. An
investigation of completed suicides in local jails
provided valuable information which could be utilized
to prevent future suicides. Results of such
investigations were utilized to develop the original
suicide prevention project and are continuously
utilized in local training and statewide conferences
for alerting staff to particular trends or even new
information critical to suicide prevention.

Albany County was not the first jurisdiction to adopt the Crisis
Service Model, but it was not far behind. And its success in
preventing inmate suicides parallels other jails in the state. As
seen by Table 2, since Mr. George’s death in October 1998, the
Albany County Correctional Facility (ACCF) has not had any
further suicides through May 2005 — a period of almost seven
years and 50,000 admissions. It also has established a suicide rate
that is far below the statewide average.

♦ Staff debriefing. Suicides and serious suicide attempts
have an impact on the staff members involved in the
crisis response. The program’s guidelines strongly
encouraged the development of a structured
debriefing which was routinely required for staff who
were involved in incidents of suicide. The training
materials encouraged staff to be aware of the
potential negative impact and to seek help.

Suicide prevention efforts at the ACCF are patterned after seven
principles: 1) Identify suicidal inmates with serious mental health
problems and to manage them in a timely manner; 2) Minimize the
incidence of suicide among persons incarcerated within the Albany
County Correctional Facility; 3) Stabilize acutely mentally ill and/
or suicidal inmates and to provide facility safety; 4) Prevent
decompensation among locally incarcerated inmates with a history
of mental illness; 5) Provide all seriously mentally ill inmates access
to mental health care within a reasonable amount of time; 6)
Facilitate continuity of care for all seriously mentally ill inmates
upon their release from jail; and 7) Foster cooperative working
relationships between the jail and local medical/mental health
service providers.

During a three-year period of 1985 through 1987, technical
assistance was offered to interested New York State counties in
the development and maintenance of the Crisis Service Model. All
57 upstate counties, including Albany County, and most police
departments participated in the process. To date, the results are
very impressive. In 1984, county jails and police department
lockups (including New York City) experienced 32 inmate suicides.
In 2004, these same facilities experienced only 15 suicides. This
decline is even more dramatic when viewed in the context of the
inmate population size. From 1984 through 2004, the average daily
population increased over 10,000 inmates from 18,113 to 29,977.
However, the jail suicide rate was significantly reduced from 177
deaths per 100,000 inmates in 1984 to 50 deaths per 100,000 inmates
in 2004. As shown in Table 1, the number and rate of jail suicides in
the state of New York has remained stable during the most recent
10-year period.

These seven principles are accomplished through adherence to
the state’s Crisis Service Model that was tailored to the needs of
the ACCF. For example, all staff, including correctional, medical
and mental health personnel (as well as individuals working in
maintenance, kitchen, education, etc.) are required to complete
the 8-hour suicide prevention training program and 4-hour refresher
course. A suicide prevention screening form is administered to all
arrestees upon intake and booking. Mental health and medical
services are available 24-hours a day, and include an Adult Forensic
Unit of both full-time weekday and partial weekend on-site coverage
from two staff psychologists (including Dr. Kelley, the coordinator),

Table 1
SUICIDE RATES IN JAILS WITHIN NEW YORK STATE*
1995 TO 2004**
YEAR

AVERAGE DAILY
POPULATION

SUICIDES

RATE
(Per 100,000)

1995
1996
1997
1998
1999
2000
2001
2002
2003
2004

32,248
34,075
33,058
33,868
29,876
29,700
28,789
29,420
30,237
29,977

15
17
18
22
14
12
13
16
19
15

46.5
49.8
52.8
65.3
46.8
40.4
45.1
54.3
62.8
50.0

1995-2004

312,248

161

51.5

*Includes New York City Department of Corrections
** Source: New York State Commission of Correction

—4—

Table 2
ALBANY COUNTY CORRECTIONAL FACILITY
AVERAGE DAILY POPULATION AND INMATE SUICIDES
1995 to 2004*
YEAR

AVERAGE DAILY
POPULATION

SUICIDES

RATE
(Per 100,000)

1995
1996
1997
1998
1999
2000
2001
2002
2003
2004

693
726
739
721
770
719
760
832
900
877

0
0
1
1
0
0
0
0
0
0

0
0
135.3
138.6
0
0
0
0
0
0

1995-2004

7,737

2

25.8

*Source: Albany County Sheriff’s Department

3 licensed clinical social workers, a psychiatric nurse, mental health
assistant, and 25 hours per week on-site from a psychiatrist. The
Adult Forensic Unit is staffed by the Albany County Department
of Mental Health. A 48-bed-Special Housing Unit for acutely
mentally ill was designed with input from the mental health
coordinator. And although the ACCF has implemented all of the
necessary procedures to run a model suicide prevention program,
four key areas — intake screening, constant supervision,
identification of risk following court proceedings, and inter-agency
cooperation — form the backbone of the program.
Intake Screening

U

pon entry into the ACCF and prior to initial cell assignment,
all inmates are screened by booking deputies. The screening
includes: 1) Obtaining verbal reports from any person regarding
the inmate’s behavior and/or statements; 2) Determining whether
the inmate attempted suicide and/or received mental health services
during prior incarceration in the facility; and 3) Administering the
Suicide Prevention Screening Guidelines form.
The Guidelines form, developed in conjunction with the state’s
Crisis Service Model and appearing on page 6, is divided into four
sections: observations of the arresting/transporting officer;
personal data; behavior/appearance; and action. Following
completion of the form, the tour commander is notified of the results
whenever the inmate expresses extreme embarrassment, shame, or
feelings of humiliation as a result of the charge or confinement;
threatens suicide; has attempted suicide within the past month;
expresses feelings of hopelessness; is intoxicated, incoherent or
showing signs of withdrawal or mental illness; refuses to answer
any questions; the arresting/transporting officer believes the
inmate is a suicide risk, or the inmate has scored “8” or more on the
Guidelines form. The tour commander will review the form, place
the inmate in a holding cell and immediately contact the Adult
Forensic Unit. Critical to the comprehensiveness of intake

screening process, ACCF policy states that “the Booking officer
also has discretion to refer inmates to Mental Health even if the
above criteria are not met. It is preferable that too many inmates are
referred rather than overlook the one inmate who may be suicidal.”
The Suicide Prevention Screening Guidelines form is unique for
several reasons. Normally taking less than five minutes to complete,
the form is administered separately from the medical intake form. It
is exclusively devoted to identifying suicidal behavior in arrestees,
and encourages communication between the arresting/
transporting officer and the booking deputy regarding the
arrestee’s mental health status. Since the arresting officer can
frequently provide insight into both the arrestee’s behavior and
emotional state, as well as the circumstances of arrest that may
not be apparent or are hidden from the booking deputy, their
observations are critical from the standpoint of suicide prevention.
In addition to the screening process during booking, inmates are
screened separately by medical staff and classification personnel.
The medical screening form includes the following lines inquiry:
“Have you ever been hospitalized or treated for psychiatric
problems?” “Have you ever considered or attempted suicide?”
“Are you feeling depressed or extremely sad?” “Do you want to
hurt yourself or someone else.” In addition, ACCF has recently
enacted a policy in which classification staff are required to consult
the facility’s automated inmate management system to determine
whether the newly arrived inmate was a suicide risk during a prior
ACCF confinement. Following these processes, correctional staff
are instructed that if they hear an inmate verbalizing a desire to
commit suicide, observe an inmate acting despondent or making a
suicidal gesture, or otherwise believe an inmate is at risk for suicide,
immediate steps are taken to ensure that the inmate is continuously
observed until mental health, medical or supervisory assistance is
obtained. According to Dr. Kelley, “No one in the ACCF is shy
about referring an inmate to mental health staff or placing an inmate
on suicide precautions.”

—5—

_...__ ...."

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—6—

-

Constant Supervision

I

n November 1999, the state Commission of Correction (SCOC),
an agency that provides both oversight and assistance to state
and local correctional facilities, issued a memorandum regarding
the supervision provided to suicidal inmates. Following an
investigation of several inmate suicides, the SCOC’s Medical
Review Board had determined that “a supervisory interval of 15
minutes is not adequate as a suicide prevention precaution.” The
SCOC then revised its interpretation of the state’s minimum
correctional standards by requiring all suicidal inmates to be
observed under “constant observation.” According to the SCOC
interpretation of constant observation:

in itself (e.g., temperature, embarrassment). Thus, the smock
should be used only in cases of active suicidal ideation in which
the clinician believes the client is at risk. It should not be used for
disciplinary or behavior management reasons. Also, the safety
smock should be used as a temporary measure, not a permanent
solution, and the time a client is ‘stripped’ should be limited.”
Correctional and mental health officials see little reason to remove
clothing from an inmate that is under constant supervision. “For
us to go beyond constant watch and deprive inmates of both their
clothing and the little dignity they may be holding onto, they have
to be actively trying to hurt themselves,” Dr. Kelley said.
Identification of Risk Following Court Proceedings

C

“The required elements include uninterrupted personal
visual observation from a post that affords a continuous
clear view of those under supervision, and sufficient
proximity to afford the ability to immediately and directly
intervene in any situation that threatens health or safety.
In some settings, this requires the assignment of a
correctional officer to each inmate under constant
supervision (commonly referred to as one-on-one
supervision). In others, the physical plant configuration
may allow more than one inmate to be constantly
supervised by a single officer. Video surveillance is not
sufficient to satisfy these requirements. There are
conditions, illnesses and injuries for which a supervisory
interval reduced to 15 minutes is entirely adequate and
appropriate, but suicide attempt is not one of them.”

ourt appearances also can be a particularly stressful event
for an inmate. The Albany County Correctional Facility
sustained three inmate suicides during the summer of 1989. All
three victims had appeared in court within a few days of their
deaths. In response to these suicides, the ACCF instituted a policy
in which all inmates on the mental health caseload who return
from court are temporarily placed on suicide precautions (i.e.,
constant supervision) until they can be assessed by mental health
staff. The mental health caseload includes inmates who are deemed
seriously and/or persistently mentally ill, chronically mentally ill,
have a history of suicidal behavior, or are currently taking
psychotropic medication. While there was some initial resistance
to this second layer of assessment, all staff quickly realized the
benefit of the practice.

Given these new regulations, correctional facilities (including
Albany County) began to revise their supervision policies. Within
the Albany County Correctional Facility, two levels of supervision
are now afforded to suicidal inmates: 1) constant observation is
reserved for inmates “who voice suicidal thoughts without a clear
plan or intent to hurt themselves, or who are intoxicated, psychotic
or disorganized to such a degree that staff believe them to be at
risk for self-harm.” One officer may supervise up to four inmates
under this observation level, and mental health staff provide
assessments of these inmates on a daily basis; and 2) one-to-one
supervision is reserved for inmates “who are found to actively
attempting to harm themselves or are voicing immediate intent to
do so, as well as with inmates who are unable to control their
behaviors to such a degree that they place themselves at imminent
risk for harm.” One officer is assigned to maintain direct visual
observation of the inmate on a continuous basis, and mental health
staff provide daily assessments.
While there traditionally has been a reluctance to use constant
supervision in many jails throughout the country, it has never
been an issue in the ACCF or any other facility in the state of New
York (even before the advent of the new SCOC regulation).
Correctional officers are specifically assigned the responsibility
to observe suicidal inmates and the use of overtime is generally
not an issue. According to Dr. Kelley, “when we place inmates on
constant supervision, we’re telling them — ‘you’re safe. We’re
not going to let you or anyone else harm you.’ We take that
responsibility very seriously.” In addition, very few suicidal inmates
are stripped of their clothing and issued either safety smocks or
paper gowns. ACCF policy warns that “being ‘stripped’ is stressful

Perhaps the case of Jason Wick (a pseudonym) best exemplifies
the need for this additional layer of assessment. On January 20,
2004, he entered the ACCF on a charge of 2nd degree murder. Mr.
Wick expressed suicidal ideation during intake and was placed on
suicide precautions. He was then seen daily by mental health staff
until February 1, when he was cleared from constant observation
and transferred to the mental health unit. Mr. Wicks was then seen
on daily rounds and weekly counseling sessions by mental health
staff. Facing a bail reduction hearing on May 28, he expressed
mild suicidal ideation but denied any intent or plan to mental health
staff. On June 1, Mr. Wick returned to the ACCF from the court
hearing and was automatically placed on suicide precautions
pending an assessment. He was then seen by mental health staff
and appeared anxious about the unknown outcome of his bail
hearing. Mr. Wick expressed suicidal ideation and remained on
suicide precautions. Two days later on June 3, he was informed by
his attorney that his bail had been reduced. Mr. Wick was able to
talk with his sister and was informed that his family remained
supportive and would try to raise funds to post his bail. He was
then reassessed by mental health staff and, relieved at the support
from his family and reduction in bond, denied any further suicidal
ideation and was cleared again from suicide precautions. Mr. Wick
remains on the mental health caseload and is seen on a regular
basis.
Inter-Agency Cooperation

T

he success of a suicide prevention program is often determined
by the relationship that exists between correctional, mental
health, and medical staff. Many preventable suicides result from
poor communication amongst these three disciplines. Cooperation

—7—

and communication problems are often caused by lack of respect,
personality conflicts, and other boundary issues. Simply stated,
facilities that maintain a multidisciplinary approach avoid
preventable suicides. The ACCF enjoys a solid relationship
between the three disciplines, particularly amongst correctional
and mental health staff. According to Dr. Kelley, “It’s never us
versus them.” There are monthly medical advisory committee
meetings (comprising the first deputy superintendent, medical
administrator, and mental health coordinator), as well as a separate
medical-mental health management meeting. Mental health staff
are in the housing units on a regular basis, interacting with both
inmates and correctional staff. They make daily rounds of both
the mental health and segregation units — going cell-to-cell.
Nursing staff also make daily rounds of the segregation unit.
Mental health staff also automatically assesses each inmate
transferred to segregation to ensure that an inmate’s mental health
is not contraindicated by the placement. They work with
correctional staff in devising behavior management plans for
inmates deemed to be manipulative. And an integrated health care
record better ensures effective communication between medical
and mental health staff.
Inter-agency cooperation is not limited to inside the walls of the
ACCF. For example, concerned about how to address the needs of
an increasing number of individuals with mental illness becoming
involved with the criminal justice system, several county agencies
(including the Albany County Correctional Facility, Albany County
Department of Mental Health, and Office of the Public Defender
for Albany County) formed an multidisciplinary committee to
address the issue. Coined the Options Committee, the group soon
grew to 20 members. Its mission included managing the integration
of existing health, mental health, substance abuse and social service
systems to match client needs with available services. As a result
of the Options Committee’s work, various programs and services
have been implemented, including improvements in mental health
services in the ACCF and opportunities for pre-trial diversion.
The case of Barbara Griffin (also a pseudonym) is indicative of
both inter-agency cooperation within the Albany County
Correctional Facility, as well as overall jail suicide prevention
efforts. Ms. Griffin, 50-years-old and a native of Nigeria, was
arrested by Albany police officers on a charge of grand larceny
and booked into the ACCF on the afternoon of April 12, 2005. She
was administered the Suicide Prevention Screening Guidelines
form and positive responses were received regarding the arresting/
transporting officer’s belief that she was a suicide risk (Question
No. 1), she was concerned about her children (Question No. 4),
and she was thinking about killing herself (Question No. 9). Ms.
Griffin was placed on constant observation and assessed by mental
health staff less than an hour later. She self-reported a significant
mental health history, including prior suicidal behavior. Although
subsequently denying suicidal ideation to mental health staff, she
remained on constant observation due to her unstable behavior
and history.
Following the assessment, staff at the ACCF’s Adult Forensic
Unit requested and received copies Ms. Griffin’s community mental
health records from the Albany County Department of Mental
Health. The records revealed that her suicidal ideation was chronic
and exacerbated, in part, by a continuing threat of deportation.

She was very concerned about her children, including a disabled
adult son for which she provided full-time care. Her history was
very troubled; it included physical abuse from her husband and a
prior conviction for submitting a false birth certificate to obtain
social services for her disabled son.
Ms. Griffin was seen the following day (April 13) by mental health
staff. She was given supportive counseling and appeared much
more stable. The clinician reviewed the mental health records with
her client and subsequently decided to clear Mr. Griffin from
constant observation. She was placed in the mental health unit
and scheduled to see the psychiatrist.
On April 19, Ms. Griffin wrote a “kite” suggesting that “I am very
depressed. I need to talk to someone who cares.” The mental
health referral was given to Adult Forensic Unit staff by a
correctional officer. When seen by her clinician, she appeared
anxious but not suicidal. She was again given supportive
counseling. Ms. Griffin attended a court hearing the following day
(April 20) and, upon her return, was automatically placed on suicide
precautions and referred to mental health staff for assessment.
She was cleared from suicide precautions following the assessment,
and subsequently seen by the psychiatrist who prescribed
psychotropic medication. She remained on the mental health unit
and was provide with regular follow-up mental health services.
Conclusion

I

n conclusion, it should be noted that the Albany County
Correctional Facility’s success is not limited to suicide
prevention. The facility is accredited by both the New York State
Sheriff’s Association and the National Commission on Correctional
Health Care. Its mental health housing unit is one of the few in the
state to be certified as a “clinical treatment program satellite” by
the state Office of Mental Health.
Developing a model suicide prevention program is more than simply
having a policy containing all the required components — it is
ensuring that staff have knowledge of, and implement, the
components. Suicide prevention is also more than management
personnel attending regular monthly meetings — it is
demonstrating that the collaborative group has an intuitive sense
as to when a particular inmate may be most at risk for suicide and
positioning themselves for appropriate intervention. In the end, it
comes down to people like Barbara Griffin, who just wanted to talk
with “someone who cares” — and received such attention from
each of the ACCF staff with whom she interacted. The Albany
County Correctional Facility exemplifies the best in suicide
prevention programming.
For more information on suicide prevention efforts at the Albany
County Correctional Facility, contact David J. Kelley, Ph.D.,
Coordinator, Adult Forensic Unit, Albany County Correctional Facility,
840 Albany Shaker Road, Albany, New York 12211, (518/869-2683;
518/869-2704-Fax), or e-mail: DKelley@albanycounty.com
EDITOR’S POSTSCRIPT: Even model jail suicide prevention
programs are not immune from inmate suicide. On June14, 2005,
a few months after our visit, the Albany County Correctional
Facility suffered its first suicide in almost seven years when a 21-

—8—

year-old man committed suicide by hanging. The State
Commission of Correction is currently investigating the death.

Identifying the Need

C

References
Cox, J. F. & Morschauser, P. C. (1997), “A Solution to the Problem
of Jail Suicide,” Crisis: The Journal of Crisis Intervention
and Suicide Prevention, 18 (4): 178-184.
Hayes, L. M. (2005). “Suicide Prevention in Correctional Facilities,”
in Handbook of Correctional Mental Health, edited by C.L.
Scott and J.B. Gerbasi, American Psychiatric Publishing, 6988.
New York State Office of Mental Health, Commission of Correction,
and Ulster County Department of Mental Health (2000),
Suicide Prevention and Crisis Intervention in County Jails
and Police Lockups: Basic Program Trainer’s Manual,
Albany, NY: Authors.
‰

TAX WOULD HELP KEEP
MENTALLY ILL OUT OF JAIL

W

ashtenaw County, through its jail millage request, is asking
voters to make the largest mental-health spending decision
in county history. The proposal’s plan to improve services and
treatment for mentally ill offenders would cost $84 million over 20
years —- more than 25 percent of the $314 million that would be
generated by the levy. The proposal would provide more
assessment, more treatment, more beds outside the jail and more
support to help mentally ill inmates once they’ve left jail than the
county has ever offered.
“It is unprecedented,” said Donna Sabourin, executive director of
the county’s Community Support and Treatment Services, formerly
known as Community Mental Health. Sabourin said her
counterparts in other counties are “amazed and impressed…..
Washtenaw County is way ahead of the curve on this.” The
concept is known as mental health diversion —- keeping mentally
ill people who are not violent offenders and whose crimes often
result from untreated mental illness from being incarcerated.
Many county groups serving mentally ill people, including the
Washtenaw County chapter of the National Alliance for the
Mentally Ill and the St. Joseph Mercy Health System, have endorsed
the proposal, but critics of the millage ask whether the money would
be put in the right places and what would happen after the levy ends
in 20 years. “We should not be passing bond issues of this magnitude
that are basically operating costs unless we have some plan of what
we’ll do when the bond issue is finished,” said Rosemary Sarri,
professor emeritus from the University of Michigan and an active
researcher with U-M’s Institute for Social Research. “I think the mistake
that was made was to put all of this into one issue.” Sarri said she
favors the mental health aspects of the proposal, “but the solution
isn’t just to build jail beds. We need to think about how this will be
paid for afterwards, since it’s mostly operating costs.”

ounty mental health officials estimate that 25 percent of jail
inmates have some sort of mental illness, primarily depression,
bipolar disorder and schizophrenia. That percentage represents
only those who are being seen by a psychiatrist or are on prescribed
medication. “Certainly there are additional people in jail showing
depression, anxiety. If it’s being managed through counseling,
those people aren’t counted,” Sabourin said. “There’s a significant
gap in our society as a whole and in our community in having a full
range of mental health services available for all citizens..... There
is no identifiable funding stream to serve the population we have
targeted.”
Screening for mental illness among jail inmates is limited to a brief
interview by corrections officers, with more comprehensive
assessments done only for those already on psychotropic medicine
or those being treated through county services.
Yet county psychologist Daniel Ing, who works with and assesses
jail inmates, said he sees a need to assess everyone, something
that would happen if the millage passes. “People are committing
the petty crime side of things and they’re suffering from illness,”
Ing said. “We have people who come here (to the jail) who need
treatment but don’t have it and go back into the community untreated,
and then end up back here.” Ing, who also has worked in county
mental health outside the jail, said inmates are far more motivated to
adhere to a treatment program than mentally ill clients who are
struggling with basic food and shelter issues. “Having the stability
the jail provides in relation to everyday needs, then people are able to
look at issues they are dealing with,” he said. And, he said, providing
an entire assessment for everyone who becomes incarcerated would
help the community as well as the inmates. “Taxpayers would benefit
just as a whole with fewer individuals going around untreated,” Ing
said.
Diane Davidson said she believes her 27-year-old son could have
avoided going to prison if the provisions in the Feb. 22 millage request
were in effect during the past decade. She said her son, John, who
suffers from mental illness and substance abuse, underwent years of
repeated arrests and jail time. When first arrested, he wasn’t in the
mental health system, so he didn’t get a mental assessment and the
pattern continued. “It was a vicious revolving door,” Davidson said,
adding that her son was imprisoned for three years after repeated
stints in the Washtenaw County Jail and then a Charlevoix County
facility before he was caught stealing a car. “I’m convinced that if
we’d had mental health assessment capability in jail here, his earlier
experiences in jail before he ended up north could have been avoided.
We’d have had a more intensive treatment program for him,” said
Davidson, the executive director of the Washtenaw Housing Alliance,
which has endorsed the jail proposal. Davidson, who has participated
in the county’s mental health diversion subcommittee, has for years
spoken openly about her son’s illness and convictions. She said the
mental health initiatives under the millage would provide better care
for mentally ill people. “Over the long haul, the recidivism rate would
go down, and we’ll do a better job across the board,” she said.
Gloria VanAlstine, a Scio Township mother of a son with mental
illness and substance abuse problems, also sees hope in the
proposal. She said the new, 96-bed jail pod that would house

—9—

inmates with medical and special needs, as well as general
population inmates, would have greatly helped her son. “When
he ended up in jail due to stealing to get these drugs, what he
really needed was drug rehabilitation,” VanAlstine said. “One of
the problems is that once someone like my son has been in jail,
then it’s not as easy to get into drug rehabilitation because he
basically detoxed in jail.”
Outlining the Costs

W

hile the three-quarter mill property tax levy would be in
effect, cost projections show that the mental health part of
the $314 million plan would steadily increase, due to inflation and
rising numbers of people using the services. During most of those
years, mental health diversion would cost at least half as much as
the overall, additional jail operating expense. For example, in 2015,
additional jail operating costs covered by the millage would be an
estimated $9.4 million and mental health diversion would be $4.8
million. By 2024, additional operating costs would be $13.4 million
and mental health diversion would be $7.2 million.
The mental health money would be spent in several ways. For
starters, there would be more training for law enforcement officers
in recognizing and working with mentally ill people. The county
also would provide better assessment of the mental status of an
inmate; build three new six-bed crisis residential facilities, one of
which would help those with both mental illness and substance
abuse problems; and put in place long-term referral and treatment
services tailored to those diverted from the jail.
The price tag would be steep. The crisis residential services alone,
for the 24 people who could be housed at one time, would cost
$7,200 a day, or $2 million a year. Each client would use those
services for very short-term periods, from eight to 30 days, Sabourin

UPDATE
ON THE INTERNET
Recent issues of the Jail Suicide/Mental Health Update are
now available on the Internet at:
www.ncianet.org/cjjsl.cfm

Check us out on the Web!
www.ncianet.org/cjjsl.cfm

Other jail/juvenile suicide prevention and jail mental health
resources, including several recent articles by Lindsay M.
Hayes, can be found at the following web sites:
www.hhpub.com/journals/crisis/1997
www.nicic.org/jails/defrault.aspx
www.ojp.usdoj.gov/managingoffenders/mentalhealth.htm
www.ncjrs.org/html/ojjdp/jjjnl_2000_4/sui.html
www.pbstandards.org/resources.aspx
www.gainsctr.com

said. Yet the cost is half what it would be to hospitalize such
mentally ill offenders, she said. The long-term treatment services
in the plan would cost $10,507 a year for each client, for an estimated
$1 million a year for nearly 100 clients. Yet that cost is less than
half of what incarceration costs a year, Sabourin said.
Staffing is another issue. Nearly 60 new employees would be
needed, either through direct county hires or contracted
services, to make the millage proposal work, Sabourin said.
The critics of the costs include those who want the county to
consider the front end first —- providing social and mental services
that would prevent people, including those with mental illnesses,
from going to jail in the first place. “We recognize the community
needs jails but so much research shows that if you invest in kids
early on there is less juvenile delinquency, less crime, less jail
service to teenagers and young adults,” said Susan Miller, a
community member and co-chair of the Zero to Five Action Group,
which focuses on early childhood issues. The group has made
that recommendation to the county. “Wouldn’t it be wonderful if
the community would look at both ends,” Miller said. “Yes, we
need improvements in the jail..... but we’d like to talk about social
and emotional health for kids.”
The movement to deinstitutionalize mentally ill people began
in the late 1970s, Sabourin said, and accelerated in Michigan in
the 1990s, during former Gov. John Engler’s administration.
“Over the years there had been a whole series of hospital
closures..... There had been promises made that the money
would follow people into the community (through community
mental health boards). But there was a strong sense (under
Engler) that fewer funds were transferred during his
administration than previously,” Sabourin said.
Over time, the percentage of mentally ill jail inmates rose.
Sabourin said there is a direct correlation between the hospital
closures and the larger mentally ill jail population today. “If the
(state) money had followed people as we’d understood it would
when we started this, and had been maintained instead of being
decreased, putting more people at risk, we wouldn’t see as
high a number of mentally ill inmates,” Sabourin said.
The National Institute of Corrections estimates that the trend
to deinstitutionalize reduced the number of mentally ill patients
in state hospitals from nearly 600,000 nationwide in 1959 to
about 70,000 in the late 1990s. And, by 1998, an estimated 283,000
mentally ill adults were in prison and jail nationwide; another
547,800 were on probation. Locally, no historical records exist
of mental illness and inmates at the jail, sheriff’s Cmdr. Dave
Egeler said.
But mental health advocates and correctional facility leaders
have been working —- on a limited basis —- to keep those who
are mentally ill, but not violent offenders, out of the jail. In 2001, a
jail diversion agreement was worked out among the county’s
criminal justice, public safety and mental health systems. Sabourin
said it came about after the state Department of Community Health
issued a policy statement setting expectations for community
mental health to negotiate such agreements in each county.
However, there was no money attached to the policy.

—10—

The Long-Term Results

W

hat would county residents get for their investment? Local
mental health community advocates say this proposal
might be the best hope mentally ill people have had in years to
counter the long-term effects of the hospital closings in the
early 1990s. Both the National Alliance for the Mentally Ill of
Washtenaw County and the Shelter Association of Washtenaw
County have endorsed the proposal. Ellen Schulmeister,
executive director of the Delonis Center, Ann Arbor’s homeless
shelter, sees the proposal for mental health diversion as another
example of how the community has come together to help
disadvantaged populations. “If people are appropriately
assessed and given treatment, then maybe fewer would be here,
down the road,” she said, referring to the homeless shelter. “I
see it as an appropriate tool that may help prevent
homelessness and keep people out of jail..... In the long run, it
could save the community money.”

♦

The local NAMI also supports the millage, particularly the
mental health aspects. “It’s good because it’s not just about
adding jail space. There’s lots of programs that will benefit
these people without them just being incarcerated,” said Chuck
Hughes, president of NAMI of Washtenaw County. “We feel a
lot of people are being incarcerated who have mental illness
problems. This way they can receive the treatment they need
and should get,” Hughes said. “It’s too bad we don’t have the
resources to do it without a millage.”
The above article — “Tax Would Help Keep Mentally Ill Out
Of Jail” — was written by Lisa Klionsky, a staff writer for The
Ann Arbor News, and appeared in the February 13, 2005
edition of the newspaper. Copyright 2005, The Ann Arbor
News. All rights reserved. Used with permission.
‰

♦

“Clinical Outcomes of Defendants in Mental
Health Court,” in which Roger A. Boothroyd, PhD
and his co-authors report on outcomes of 116
clients of a mental health court in Broward County,
Florida compared with 110 defendants from a
regular magistrate court;

♦

“Rediversion in Two Postbooking Jail Diversion
Programs in Florida,” in which Marcus T.
Boccaccini, PhD and colleagues examined
rediversion patterns in two post-booking jail
diversion programs in Florida to assess the extent
to which the programs served repeat clients;

♦

“Incarceration Associated with Homelessness,
Mental Disorder, and Co-Occurring Substance
Abuse,” in which Dale E. McNiel, PhD and coauthors assessed relationships between
homelessness, mental illness, and incarceration in
a large sample of inmates of the San Francisco
County Jail system;

♦

“Relationship Between Criminal Arrest and
Community Treatment History Among Patients
with Bipolar Disorder,” in which Cameron D.
Quanbeck, MD and associates studied the
relationship between criminal arrest and gender,
substance abuse disorder, and use of community
mental health services among inmates in the Los
Angeles County Jail who had a diagnosis of
bipolar I disorder and a history of psychiatric
hospitalization; and

♦

“Rearrest and Linkage to Mental Health Services
Among Clients of the Clark County Mental Health
Court Program,” in which Heidi A. Herinckx, MA
and her co-authors present the results of their
study of rearrest and linkage to mental health
services in a sample of 368 misdemeanants with
severe and persistent mental illness who were
served by the mental health court in Clark County,
Washington.

NOW AVAILABLE: SPECIAL ISSUE OF
PSYCHIATRIC SERVICES

T

he July 2005 issue of Psychiatric Services (a monthly
journal published by the American Psychiatric Association)
is devoted to mental health and the law. Articles include:
♦

♦

“An Actuarial Model of Violence Risk Assessment
for Persons with Mental Disorders,” in which John
Monahan, PhD and his co-authors describe their
study of the validity of the multiple iterative
classification tree model in distinguishing between
patients with high and low risk of violence in the
community after discharge from a psychiatric
facility;
“Validation of the Brief Jail Mental Health Screen,”
in which Henry J. Steadman, PhD and associates
report on a study they conducted to validate the

Brief Jail Mental Health Screen—a revision of the
Referral Decision Scale—in a large sample from
four jails in Maryland and New York;
“Major Mental Disorders, Substance Use
Disorders, Comorbidity, and HIV-AIDS Risk
Behaviors in Juvenile Detainees,” in which Linda
A. Teplin, PhD and her colleagues determined the
prevalence of 20 HIV-AIDS risk behaviors among
juvenile detainees with and without mental
disorders or substance use disorders;

For more information regarding the availability of Psychiatric
Services (Volume 56, Number 7, July 2005), contact the American
Psychiatric Publishing, Inc., 1000 Wilson Boulevard, Suite 1825,
Arlington, VA 22209, (800/368-5777) or e-mail at
appi@psych.org, website: www.appi.org.
—11—

STRIPPING INMATES NAKED IN THE
NAME OF SUICIDE PREVENTION

“any inmate placed into these cells would be placed into them
without clothes.” Inmates would remain naked in the cells until
such time that he or she no longer posed a threat to him/herself,
others, or the secure operations of the jail.

n March 2005, the American Civil Liberties Union (ACLU) of
Michigan announced that it would join in three lawsuits that
had been filed against the Saginaw County Jail in Saginaw for
allowing jail personnel to strip inmates and house them naked in
segregation. The three lawsuits, Rose v. Saginaw County, Whittum
v. Saginaw County, and Brabant v. Saginaw County, were filed in
the United States District Court, Eastern District, Northern Division,
and assigned to Judge David M. Lawson. In January 2005, Judge
Lawson found in Rose that the practice of holding detainees naked
in segregation was unconstitutional, but he has yet to rule on
damages in that case.

According to Saginaw County Sheriff Charles Brown, “it’s taking
away the chance that the person may hurt themselves or somebody
else, and once they sober up or once they become cognizant of
what they’re doing, you may have saved that person from
tremendous injury.” Although the county’s main justification for
stripping inmates naked and placing them in administrative
segregation was the prevention of suicide, Sheriff Brown gave
additional reasons at his deposition: “Inmates can obviously stuff
(their clothes) down their throat, they can obviously hang
themselves, they urinate on their clothing and throw it at the
deputies, defecate on it and throw it at the deputies, which has
been done many times, they could actually use the clothing to, if
the guard got close enough, to wrap it around his neck.”

I

In all three cases, those arrested were misdemeanor, pre-trial
detainees held for minor offenses. In both Rose and Brabant, the
jail policy allowed jail personnel to remove all clothing from
detainees and house them in segregation if they were perceived
as uncooperative. As a result, naked detainees could be viewed
by both jail personnel and other inmates of the opposite gender.
The Whittum case challenges the jail’s strip search policies as
violating a state law that limits strip searches to inmates who were
arrested for a felony or were suspected of having drugs, weapons,
or contraband.
One of the plaintiffs in the lawsuits, Amanda White, then 21-yearsold, was in the jail after being beaten by her boyfriend and released
from an emergency room. It was Ms. White’s first offense for
intoxication. According to the lawsuit, in spite of the fact that she
had stitches in her head and broken ribs, jail officers, some of
whom were men, forcibly stripped her after she begged to use a
bathroom and then left her in “the hole.” In the process, one of the
stitches was dislodged and the medical appliance to support her
broken ribs was withheld.
Linda Rose, 36-years-old, was being detained on a misdemeanor
when she was put in “the hole” after repeatedly asking if she
could call her parents for help. “I knew what they were doing to me
was wrong,” said Ms. Rose. “I squatted in a corner with my arms
crossed over me for three hours trying to stay out of the camera’s
view because I knew that strangers were watching me naked. I
never want this to happen to anyone again.”

The sheriff’s argument was bolstered by reports from two expert
witnesses for the county who believed that “placing a detainee
for a limited duration under close supervision, in the nude, in an
administrative segregation cell, is a reasonable alternative
legitimately related to detention objectives,” and that “by removing
their clothing, a greater degree of protection was provided to the
inmates.”
Yet, according to Christopher Pianto, the Flint lawyer who initially
filed the lawsuit on behalf of the 22 Rose plaintiffs in 2001, the
placement of inmates without clothing into segregation cells
subjected them to unreasonable and illegal conditions of
confinement. Therefore, the Saginaw County Jail policy was
unconstitutional. He cited the case of a former inmate who
provided a statement alleging that trustees would vie for the
job of emptying the trash cans near the closed circuit television
monitor in order to view the naked pre-trial detainees in the
segregation cells. “How is it possible for the sheriff to testify
that ‘there is absolutely nothing wrong with what we did?”’
asked Mr. Pianto.
After hearing all the arguments, Judge Lawson ruled, in part,
that:

According to Saginaw County, the policy of stripping inmates
naked and housing them in segregation was initiated in August
1996 following an incident that ended in the suicide of a detainee
who had been placed in administrative segregation. The detainee,
dressed in a standard-issued orange jail jumpsuit, was placed in
the segregation cell and left unobserved for several hours. He
then wedged his jail uniform between the cell door and the door
frame and hanged himself. Approximately three months later,
another inmate vandalized one of the direct observation cells and
rendered it unusable.
As a result, jail officials formulated a policy that called for disruptive
detainees to be placed in segregation cells and mandated that
‰
—12—

“the question in this case does not focus on the
reasonableness of placing uncooperative and
disruptive detainees in administrative segregation.
Rather, the issue is whether the regulation requiring
removal of all of the detainees’ clothes violates the
Constitution. Courts in this Circuit have recognized
that prisoners have a liberty and privacy interest in
shielding their naked bodies from view by others,
especially members of the opposite gender.
The Court finds, however, that confining such
detainees with no clothing whatsoever is an
exaggerated response to the articulated security and
safety concerns of the defendants in light of the
importance of the right described in this Circuit’s
precedents and the availability of reasonable
alternatives. First, there is a rational connection

between the interest of jail security and confining
unruly prisoners in segregation, but that alone does
not justify removing all their clothes. One of the
defendants’ experts states that the practice amounts
to ‘behavior modification,’ but that purpose suggests
a punitive rationale that is not permissible under the
Due Process Clause. The defendants also argue that
obstreperous detainees could use their clothes to
assault guards, but once the detainee is in the
segregation cell, that concern dissipates. Finally, the
defendants offer suicide prevention as a rationale, but
none of these plaintiffs were screened for suicidal
tendencies, and the intake papers indicate that they
were not suicide risks. Moreover, according to the
defendants’ expert, the “operational system” in place
included both voice and visual “officer monitoring . . .
documenting security checks every 15 minutes, [and]
monitoring by medical personnel.” There is no
indication that these measures were in place in 1996
when an inmate committed suicide, and they appear to
be quite adequate to ensure that a detainee is not using
clothing to harm him/herself. Further, the Saginaw
County jail has a ‘suicide cell’ available for those
prisoners who truly are suicide risks.

Kalamazoo, 124 F. Supp. 2d at 1104, 1106; providing
paper suicide gowns, Wilson v. City of Kalamazoo, 124 F.
Supp. 2d at 858; and restricting access by jail personnel
of the other gender, Kent v. Johnson, 821 F.2d at 1222;
Everson v. Michigan Department of Corrections, 391 F.3d
at 756. As mentioned above, the guards also could make
use of the jail’s suicide observation cell. Given the
magnitude of the right to privacy in one’s own body
described by the cases, these rather rudimentary
alternatives demonstrate the unreasonableness of the
defendants’ regulation and a violation of the Due Process
Clause. The policy requiring confinement in the nude
also is unreasonable under the Fourth Amendment. The
scope of the intrusion is substantial. The manner in which
clothes are removed depends on the degree of vehemence
exhibited by the detainee, but at times will include the
forced removal of clothes by guards of the other gender.
The justification for the extraordinary measure does not
withstand scrutiny for reasons stated earlier. And the
removal of clothing at times occurred in view of other jail
personnel. Although the record demonstrates that
isolating many of these plaintiffs was justified as a
legitimate security measure because of their outrageous
conduct, the Court is persuaded that society recognizes as
legitimate an inmate’s subjective expectation that he or she
may not be required to forfeit all clothing and covering,
even for a brief time, when he or she has been detained for
relatively minor violations, there is no individualized
suspicion of drug, weapon, contraband possession, and
there is no indication that he or she is suicidal.

Second, the plaintiffs had no alternative means of
exercising their right to privacy. Once their clothes were
removed, they were exposed to all who could view them
in the segregation cell by video monitoring device or
through the slot in the door. The record indicates that
some of the plaintiffs were observed naked by members
of the opposite gender. They had no way to protect
that ‘special sense of privacy in their genitals’ or avoid
the ‘especially demeaning and humiliating’ experience
and ‘degradation’ resulting from the ‘involuntary
exposure of them in the presence of people of the other
sex.’
Third, the defendants argue that allowing the detainees
in the segregation cells to maintain some vestige of
their modesty will result in substantially increased
administrative costs. They contend that keeping
disruptive and violent detainees in cells with other
detainees would impact guards and other detainees;
other detainees would be subject to the disruptive and
violent conduct of one detainee; jail staff would be
forced to focus their attention on one detainee who is
violating the security and orderly operation of the jail
to the necessary detriment of other detainees and to
their other responsibilities; and posting one officer
outside the segregation cell while one detainee is
housed in the cell with his or her clothing on would
place a serious strain on the resources of the jail. Most
of these arguments, however, address the practice of
placing disruptive prisoners in isolation to begin with,
a practice not challenged here.
The alternatives to naked confinement include those
discussed in the cases cited above, such as allowing
detainees to wear underwear, Johnson v. City of

The Court finds, therefore, that the plaintiffs have shown
that the defendants’ policy of taking all the clothing from
detainees confined in administrative segregation
violates the Fourth and Fourteenth Amendments of the
Constitution based on the undisputed facts. They are
entitled to partial summary judgment on their Section 1983
claim against the County of Saginaw.
Judge David M. Lawson’s full opinion in Rose v. Saginaw County
[353 F. Supp. 2d 900 (E.D. Mich. 2005)] can be found at: http://
w w w. m i e d . u s c o u r t s . g o v / _ o p i n i o n s / L a w s o n p d f / 0 1 10337DML.pdf.
In the midst of this litigation, Saginaw County officials told Judge
Lawson that they had discontinued the practice of stripping
inmates naked in segregation. In May 2005, however, the ACLU of
Michigan filed a motion challenging the Sheriff’ Brown’s assertion
that the practice had ceased. The civil rights group alleged that
“evidence indicates that even after the practice was allegedly
stopped in December 2001, inmates were routinely stripped of
their clothing by force and placed in ‘the hole.’ The policy of
providing isolation cell detainees with paper gowns is not uniformly
followed and the paper gowns, which tear easily, are inadequate
to cover private body parts. In addition, prisoners are forced to
use the gowns either as toilet paper or to remove the mace that is
sprayed in their face when the guards strip them of their clothes.”
The U.S. Justice Department is said to be investigating the ACLU’s
most recent allegations.
‰
—13—

being held in segregation. “Two weeks ago I got four injections
in my back,” he wrote to his mother. “They helped somewhat, but
other than that, I’ve received no health care, in spite of numerous
requests. There is still chronic pain, which has recently been
exacerbated because it’s cold and rainy and there is no heat
whatsoever.”

NEWS FROM AROUND THE COUNTRY

O

ffered below are brief stories regarding inmate suicide, offenders
with mental illness, and other related topics that have recently
occurred and/or been reported throughout the country.
Vermont

I

n March 2005, the state agreed to pay $750,000 to settle a lawsuit
filed by the family of an inmate who committed suicide in a
Department of Corrections (DOC) facility during 2003. The family
stated that they planned to use most of the money to help other
state inmates fight grievances over their treatment in custody.
James Quigley, 52-years-old, committed suicide by hanging at
the Northwest State Correctional Facility in St. Albans on
October 7, 2003. “I feel it’s the beginning of greater changes for
the penal institution,” the decedent’s mother, Claire Quigley,
told the Burlington Free Press. Her lawyer, David Sleigh, said
most of the money will be used to establish a fund to provide
legal representation for inmates who, like Mr. Quigley, contest
their treatment in prison. Mr. Sleigh said he will determine the
best way to invest the money to keep the fund going.
An independent investigation commissioned by the state and
released in March 2004 found the state was at least partly
responsible for the death of Mr. Quigley. In 1980, he began
serving a life sentence for murder in Florida and was transferred
to Vermont in 2001 as part of an interstate compact agreement
According to investigators, during the next two years, Mr.
Quigley prepared many grievances of his own and assisted a
number of other inmates in preparing legal grievances and
lawsuits against the Northern State Correctional Facility (NSCF)
in Newport — and later the Northwest State Correctional Facility
(NWSCF) in St. Albans. As a result, the NSCF superintendent
recommended that Mr. Quigley be kept in solitary confinement
until he could be sent back to Florida because he was considered
“an escape risk.” In the interim, it was recommended that he be
transferred to the NWSCF — known as the state’s most secure
facility. Although Mr. Quigley kept out of trouble, he suffered
various forms of mistreatment, including the withholding
privileges such as showers, recreational time and personal items.
By September 2003, lawyers were investigating whether his civil
rights were violated by being held in segregation without
sufficient cause.
The investigators concluded that “the placement of James
Quigley…..(into solitary confinement) …..for 118 days was not
adequately supported and likely reflected retaliation against
the inmate for filing grievances and lawsuits.” As a result of
Mr. Quigley’s treatment, several employees, including two
prison superintendents, were suspended.
In the last two days of his life, James Quigley wrote letters to
both his attorneys and mother that expressed frustration at

Robert Hofmann, the current DOC Commissioner, said litigating
the Quigley case for several years would not have been in the
state’s interests. Meanwhile, he said, the death was one of the
catalysts for changes within the department, including a
comprehensive assessment and subsequent revamping of both
suicide prevention and mental health services. As Ed Paquin,
executive director of Vermont Protection & Advocacy, Inc., told the
Free Press, Mr. Quigley was a “classic jailhouse lawyer….He brought
a lot of attention to issues that were not paid attention to.”
Texas

S

ince state budget cuts affecting almost every public entity
that deals with mental health, getting an individual with
mental illness into treatment can be challenging. The head of
the mental health services division of the Galveston County
Sheriff’s Office appears up to the challenge. In March 2005,
Lieutenant Jaime Castro told the Galveston County Daily News
that he was preparing a pitch to county commissioners and to
University of Texas-Medical Branch (UTMB) officials for a
mobile mental health unit. “Everybody’s downsizing their
services or programs,” he said. “It seems like everybody’s
closing down but me.”
Lieutenant Castro’s plan is to take a doctor, nurse, social worker
and medication to the scenes of people in urgent need of
treatment. The only two places in the county for urgent mental
health treatment are the acute in-patient psychiatric beds at
the UTMB and any bed at the Galveston County Jail.
Harris County started a similar program more than two years
ago, which now consists of six vehicles with doctors, nurses
and social workers to treat the mentally ill wherever they are
when they need assistance. “Our commissioner’s court
increased spending on it, which they certainly wouldn’t have
done if weren’t successful,” said Tom Mitchell, director of the
Harris County program. Diana Villareal, a psychiatrist with the
Harris County program who previously worked with the
mentally ill in Galveston County, said treatment that did not
involve jail was also more effective. “Once the legal system
gets involved, a patient is much more resistant to treatment,
because criminal law is much more adversarial than treatment,”
she told the Daily News. “This program has also allowed us to
help people in a way that preserves their dignity, which is
important.”
The Harris County program costs approximately $1.7 million a
year. Lieutenant Castro said a van and salaries for the
professionals necessary to staff it would cost Galveston
County less than a third of that. County Judge Jim Yarbrough
said that the county’s budget was tight, and that a program
costing six figures would likely require sacrifices to other
programs or county functions. “I don’t think anyone would

—14—

argue that we’re spending a lot of money on mental health
under the current system,” he said. “And it seems apparent
that, over time, we’ll save the county taxpayers’ money, but
that is hard to prove, going into something. Like we’ll be doing
with other departments when budget time comes, the question
we’ll ask is, what are your higher priorities?” Lieutenant Castro
said the county would more than make its money back, in the
long run. “It’s just cheaper to be able to deal with people at
their homes than in a hospital, or the jail,” he said. “Almost
every day, I answer a call because someone stopped taking his
medication and is acting up, to the point they’re a danger to
themselves or to someone else. If we can treat them, or provide
the medication they need on the spot, we’ll save a lot, because
right now, jail and UTMB are our only options for those people.”
Judge Yarbrough said that approximately 15 percent of county
jail inmates had mental health issues. “If you use the estimate
we’ve been given, that it costs about $40 a day to keep someone
incarcerated here, multiply that by 120, which would be 15
percent of 800, which I’d call a very conservative estimate of
our jail population,” he said.
That math worked out to a cost of $1.7 million a year to house
people with histories of mental health problems in the jail.
“Obviously, even if there were a way to treat some of these
people in a way that kept them out of jail, we still wouldn’t be
saving that entire amount,” he said. “But this mental health
issue is going to do nothing but get more widespread. One
thing it isn’t going to do is go away.”
County Probate Judge Gladys Burwell, who presides over civil
commitment proceedings, also said starting such a program
here would create long-term savings. “For every person who
could be treated like that, taxpayers will save the cost of having
that person hospitalized, or jailed,” she said. “Of course, it
would also be a more humane way of dealing with those people.”

which have caused inmates to hallucinate, rip chunks of flesh
from their bodies, rub feces on themselves and attempt suicide.
“A disproportionately high number of mentally ill prisoners are
transferred to the SHU because they are often misidentified as
trouble-makers in prison,” said David C. Fathi, an attorney with
the ACLU’s National Prison Project. “If mentally ill prisoners receive
inadequate mental health care or their disease worsens because of
the extreme deprivation within the SHU, it is likely they will find it
difficult to obey prison rules and will remain stuck at the facility
indefinitely.”
Inmates only leave their cells at the SHU to shower or for solitary
recreation in a small walled compound, but recreation is often
canceled because of bad weather. The cells remain illuminated at
night and the unit is extremely noisy, as the inmates, who cannot
see each other, shout in order to communicate. Inmates are also
restricted in their ability to keep books, letters, family photographs
or other personal items in their cells. There is no limit on how long
an inmate can spend in the SHU, and many remain there for several
years.
According to the ACLU, little has changed in the SHU since Human
Rights Watch detailed many of the abuses faced by mentally ill
inmates in a 1997 report entitled Cold Storage: Super-Maximum
Security Confinement in Indiana. “Warehousing severely ill and
psychotic individuals under conditions that increase their
suffering by exacerbating their symptoms, and in facilities that
lack adequate mental health services, can only be characterized as
cruel,” the report conditioned.
The lawsuit, Mast v. Donahue, was filed in U.S. District Court in
the Southern District of Indiana and seeks a ban on placing mentally
ill inmates in the SHU. No monetary damages are sought. It can be
found at: http://www.aclu.org/Prisons/Prisons.cfm?ID=
17412&c=121.
California

Lieutenant Castro told the Galveston County Daily News that
he hoped to have a proposal that would allow for the launch of
a mobile mental health unit by the end of this year.
Indiana

A

ccording to the American Civil Liberties Union (ACLU),
the extreme isolation and sensory deprivation found in
the state’s Secured Housing Unit at the Wabash Valley
Correctional Facility in Carlisle caused four suicides and
numerous self-mutilations by mentally ill inmates since 2000. In
February 2005, the ACLU’s National Prison Project and Indiana
Civil Liberties Union filed a class-action lawsuit alleging that
inmates with mental illness are confined in the facility’s Secured
Housing Unit (SHU) under brutal conditions. “Locking up
prisoners with mental illness in small windowless cells is
psychological torture,” said Ken Falk, Legal Director of the
Indiana Civil Liberties Union. “Confinement for lengthy periods
of time in 24-hour isolation would compromise even a healthy
person’s sanity.”
The ACLU charges that the inmates’ mental illness is
exacerbated by the unbearable conditions in the 288-bed SHU,

A

licensed vocational nurse who worked for a correctional health
services contractor committed suicide shortly after being
booked into the Solano County jail in Fairfield on June 18, 2005.
Marrisa Honda, 32-years-old, was booked into the jail at 4:29
am and found unresponsive exactly 31 minutes later, apparently
after strangling herself with a 10-inch long telephone cord in
the holding cell. “This is a terrible, terrible tragedy,” Sheriff
Gary R. Stanton told the Daily Republic. “Our thoughts and
prayers are with her family and loved ones at this time.”
The series of events that led to Ms. Honda’s suicide began
during the early morning hours of June 18 while she and her
sister were traveling together on the highway. Sheriff’s
department investigators said that Ms. Honda and her sister
were in the midst of a heated argument when at some point Ms.
Honda is believed to have grabbed the car’s steering wheel,
causing it veer across several lanes. The erratic movement of
the car caught the attention of a state Highway Patrol officer
who pulled the car over. It was at that point that Ms. Honda
was suspected of being under the influence of alcohol and
arrested. She was then transported to the Solano County jail
for booking.

—15—

Sheriff Stanton stated that Ms. Honda was cooperative and
answered all the intake screening questions, including one where is
she was asked if she had thought about hurting herself. “She
responded initially ‘Yes,’” the sheriff told the Daily Republic. “When
we followed up with another, more direct question about whether she
was actually feeling suicidal, she told our staff ‘Yes, I have thought
about hurting myself, but not right now.’” Sheriff stated Ms. Honda
displayed no other behaviors that would prompt the jail staff to place
her on suicide precautions “While our investigation is on-going, it
appears this case was handled by the book. I don’t believe there was
anything we could have done to anticipate her actions,” the sheriff
said.

New Hampshire

A

pproximately two hours passed before any Manchester
Police Department employee realized that a suicidal man
had succeeded in killing himself in a holding cell at the station,
according to an investigative report released in February 2005.
Before hanging himself with his shirt on January 20, 2005, Julian
Wisz, 43-years-old, made the sign of the cross on his chest, a
movement captured on closed circuit television (CCTV). An
inmate in another cell reported hearing him pray — “Jesus
forgive me, I can’t do it anymore….Jesus, forgive me, I can’t
take it,” Mr. Wisz was also heard to be crying.

The suicide of Marrisa Honda follows the February 2004 death of The 70-page investigative report, completed by Detective Sergeant
Roberto Soto who also utilized a telephone cord to commit suicide in Nick Willard and obtained by The Union Leader, concluded that a
the Solano County Jail. Following Mr. Soto’s death, the cords were lack of communication was responsible for the suicidal inmate not
shortened from 12 to 10 inches. Sheriff Stanton said his agency was being observed on suicide precautions. Although booking officer
in a quandary over what to do. On one hand, he believes state law Anna Marie Martin told Sergeant Willard that she had problems
requires that intake cells within jail facilities have telephones, and that night getting the CCTV monitor to work, she was not informed
that inmates be afforded a certain degree of privacy to conduct on a that Mr. Wisz was suicidal.
conversation with their
attorneys, bail bond agents or
Captain Mark Putney said he did not have Mr.
family members. On the other
Wisz’s cell locked into any of his monitors
hand, the corded telephones —
because he had not been told the inmate was
“Everybody’s downsizing their
even at 10 inches in length —
suicidal, nor that the CCTV monitor in the
services or programs. It seems
continue to offer an opportunity
booking area was not working. The captain
like everybody’s closing down
for suicidal inmates to hurt
told Sergeant Willard that although he was
themselves. The sheriff said jail
aware the inmate’s girlfriend (Patricia Gouin)
but me.”
was en route to the police station to fill out a
staff have considered and
“prayer” statement for involuntary
largely rejected “speaker”
telephones because their use cannot guarantee an inmate’s privacy. emergency hospitalization, the woman had not arrived prior to
Likewise, telephones with “breakaway” cords have been rejected out the end of his shift.
of concern that the loose handset could be used as a weapon. “There’s
got to be some kind of telephone technology out there that will provide The investigation found, however, that the Manchester
Police Department was clearly aware of Mr. Wisz’s risk for
us an answer,” he told the Daily Republic.
suicide. Ms. Gouin had called the police that day when he
EDITOR’S NOTE: It should be noted that state law in California had threatened to hang himself or throw himself off a bridge.
does not require or mandate that telephones be placed inside of When police arrived at her house, Mr. Wisz was observed
holding cells, only the inmates have reasonable access to a to be intoxicated and unstable. He was arrested for criminal
telephone during confinement. In fact, state jail standards in trespass, simple assault and criminal threatening. Upon
California caution jail officials of the hazards inherent in corded intake at the police station at approximately 7:00pm, his
telephones placed within cells. Title 24: Minimum Standards booking sheet indicated that Mr. Wisz was brought in for
for Local Detention Facilities states, in part, that “Telephone protective custody (as being at risk for suicide). Ms. Gouin
cords provide a mechanism for suicide attempts and consideration arrived at the police station a few hours later and filled out
of telephone placement should be given in the design of a facility. a “prayer” statement indicating that her boyfriend had
Telephones should be placed in locations where they can be threatened to commit suicide and needed to be involuntarily
observed by staff. Because inmates have used telephone cords in hospitalized. In addition, Mr. Wisz’s psychologist called the
suicides and suicide attempts, a short receiver cord should be station to inform police that her patient was suicidal. Finally,
considered and there are alternative telephone designs that the Greater Manchester Mental Health Center was contacted
eliminate the cord entirely.”
by the police department to conduct a mental health
evaluation of Mr. Wisz.
We have spoken about the hazards of placing wall-mounted
telephones with metal cords of varying length inside cells on many According to a CCTV videotape recording of the death, Mr.
occasions (e.g., Jail Suicide/Mental Health Update, Volume 12, Wisz hanged himself approximately nine minutes after Officer
Number 3, Fall 2003; Jail Suicide/Mental Health Update, Volume Martin checked his cell at 10:50pm. Officer Robert Powers,
11, Number 4, Winter 2003). Given the known inherent danger of who relieved her shortly after 11:00pm, never conducted
placing corded telephones within cells, correctional officials are any rounds in the 10-cell facility. At approximately 1:00am
faced with two options — relocating the corded telephones to a on January 20, Mr. Wisz was found hanging in his cell by a
common area (e.g. dayroom) that is regularly observed by staff or detective who happened to be in the cellblock to interview
replacing the corded telephones with cordless systems.
another inmate.
—16—

Police Chief John A. Jaskolka said his department realizes the
seriousness of Mr. Wisz’s death. “I wish to assure all members
of the community that every effort will be made to prevent this
type of incident from happening again,” he said in a prepared
statement that was published in The Union Leader. “Any
violation of policies or procedures made by Manchester Police
Department personnel that might be identified during these
investigations will be addressed, and appropriate action will be
taken,” he added.
New York

I

n January 2005, the state Commission of Correction (SCOC)
found that the former medical director at the Saratoga County
Jail in Ballston Spa was “directly implicated” in the May 2004
suicide of inmate James Pecor for cutting his dosage of
psychotropic medication. The SCOC report also charged that
the doctor “negligently ordered medications for inmates
without any physical assessment” as a common practice. The
state oversight board recommended disciplinary action before
the state Department of Health.
Dr. Russell Peacock retired in October 2004 (of his own accord)
while the SCOC investigation was still under way. “After 34
years and at my age, I thought it was time,” he told The
Saratogian. Although the doctor refused to discuss the
investigation, Saratoga County Sheriff James Bowen told the
newspaper that “They raked him for this….Dr. Peacock was the
doctor here for over 30 years. He did a good job for us.”
James Pecor, 25-years-old, had a long history of mental illness
and multiple hospitalizations. On April 3, 2004, he was arrested
for domestic violence and transported to the Saratoga County
Jail. For reasons that remain unknown, Dr. Peacock cut the
dosage of his psychotropic medication. On May 8, Mr. Pecor
was placed in segregation after tobacco was found in his cell.
He was then found hanging by a bed sheet attached to the
ceiling light at approximately 10:30pm. Officers initiated
cardiopulmonary resuscitation, but he was subsequently
pronounced dead at the local hospital.
According to the SCOC report, “Dr. Peacock willfully withheld
Pecor’s appropriate treatment….Dr. Peacock also negligently
ordered medications for inmates without any physical
assessment, which commission investigators found to be
common practice for Dr. Peacock. These same negligent
practices repeated themselves in each of Pecor’s incarcerations.
This gross negligence and incompetence on the part of Dr.
Peacock was directly implicated in Mr. Pecor’s death.” The
report also found that Mr. Pecor was self-medicating himself
with another inmate’s psychotropic medication. Although
Sheriff Bowen defended the doctor by stating that he had the
right under state corrections law to change inmate prescriptions,
SCOC investigators determined that Dr. Peacock should have
consulted with the jail psychiatrist before changing the dosage
of Mr. Pecor’s medication.
The SCOC also concluded that Dr. Peacock was illegally running
a pharmacy at the Saratoga County Jail. He had a bulk stock of
medication, including controlled substances, and a bulk stock

of homeopathic remedies. According to the report, Sheriff Bowen
had previously told the doctor to stop this practice in 2003.
The SCOC said that doctors are allowed to run a pharmacy in
their own offices, but the county jail is not a doctor’s office and
was not licensed to store controlled substances.
In addition to the recommendation for disciplinary action against
Dr. Peacock, the SCOC recommended numerous corrective
actions in the delivery of mental health services at the Saratoga
County Jail.
Michigan

G

etting inmates with mental illness out of jail cells and into
residential or out-patient treatment while they are awaiting
trial could help ease overcrowding in county jails throughout the
state. That was one recommendation from a task force report
released in March 2005. The task force was examining ways to
open beds in the state’s overcrowded jail and prison system
without spending new dollars on construction.
Inmates with mental illness often wait weeks or months for
examinations to see if they are competent to stand trial, said Marge
Bossenbery, a sentencing guidelines specialist for the Department
of Corrections. “If we could divert them pre-trial and get them into
treatment, it would free up space,” she told a Lansing newspaper.
But Terry Jungel, executive director of the Michigan Sheriffs’
Association, said there were too few programs available to tap for
that assistance. “It’s a great concept, it just doesn’t work in practice
because we have no place to take them,” he said. Mr. Jungel, a
member of the Michigan Task Force on Jail and Prison
Overcrowding, said better mental health services is the “silver
bullet” that can curb overcrowding in the state’s 81 county jails.
The 19-member Task Force was formed in June 2004 after sheriffs
and county officials protested Governor Jennifer Granholm’s plan
to tighten sentencing guidelines and lock out more offenders from
the state 50,000-bed prison system. Local officials said that would
simply shift the high cost of incarceration down to the 19,000-bed
county jail system. Governor Granholm, who created the task force,
has since also proposed that $4 million be offered in grants next
year to create alternative community programs such as additional
residential treatment for the mentally ill. The Task Force concluded
that the closing of 10 state psychiatric hospitals from 1992 to 2001
funneled many of the seriously mentally ill into the county jails.
The Task Force report also encouraged communities to expand
pretrial diversion options for persons charged with nonviolent
crimes who cannot afford to post bonds prior to trial. Kent County,
for example, experienced a significant decrease in its nonviolent
pretrial population following the initiation of a pretrial diversion
program. Other recommendations included using fines and
community service in lieu of jail time for nonviolent offenders;
allowing probation officers to waive low-level probation violations
instead of arresting probationers for technical offenses;
encouraging state probation officers, responsible for writing presentencing reports for judges, to process the most serious prisonbound felons first in order to expedite their transfer from jail to
prison; training police officers to recognize signs of mental illness
so offenders can be taken to emergency treatment centers instead
of jail.

—17—

The Michigan Task Force on Jail and Prison Overcrowding:
Final Report can be found at: http://www.michigan.gov/
documents/report_119595_7.pdf
Iowa

G

ary Maynard, director of the state Department of Corrections,
recently announced that steady progress was being made to
improve living conditions and treatment programs at the Clinical
Care Unit of the Iowa State Penitentiary in Fort Madison where
four inmates have committed suicide during the past two years
(see Jail Suicide/Mental Health Update, Volume 13, Number 3,
Winter 2004, page 17). “I think eventually we will have a very good
system” of providing care for mentally ill prisoners, he told the
Des Moines Register in June 2005. “I think it will be one of the
better systems, relative to the rest of the country. Nobody has it
solved. I can guarantee you it is a big, big problem everywhere.”
The 140-bed Clinical Care Unit was the focus of a critical report in
February 2005 by a consultant for the National Institute of
Corrections. The unit has been without an administrator for over a
year, and the report faulted state officials for poor management
and inadequate mental health staffing. In addition, the consultant
found that, although inmates in the unit had individual treatment
plans, the only beneficial treatment they were receiving was their
psychotropic medication. There was also a problem of excessive
lockdown due to a lack of programming.
According to Larry Brimeyer, DOC Deputy Director, efforts are
now being made to encourage inmates to get out of their cells and
engaged in a wider variety of activities. “We have changed that
tremendously. These inmates now have access to many services
inside the penitentiary compound” that were not previously
available, Mr. Brimeyer told the Des Moines Register. “There is
the dining hall, the gym, the yard” and other areas where mentally
ill offenders are permitted when other inmates are engaged in other
activities. The agency has also hired treatment staff to work in the
evening, thus allowing mentally ill inmates to be more involved in
recreational and social activities after 4:00pm.
Dr. Edward O’Brien, DOC Medical Director, said an effort was also
underway to change the culture within the unit to benefit mentally
ill inmates. “This is not something that you will see in any reports,
but we are having officers take an inmate to lunch just because he
doesn’t get along well in a group setting,” Dr. O’Brien said. “Instead
of leaving him in his cell, they will assign somebody to take him to
lunch. I think the sensitivity of the staff to these individuals has
grown exponentially.”
With regard to mental health staffing, Director Maynard had
previously expressed frustration that the state’s entire prison
system of approximately 8,600 inmates was served by only one
psychiatrist. That has since changed with the hiring of two more
full-time psychiatrists, a part-time contract psychiatrist and a
psychiatric nurse-practitioner. The department recently opened a
24-bed psychiatric housing unit at the Medical and Classification
Center in Oakdale which will allow for more treatment of inmates
with acute mental health and/or chronic behavioral issues in a less
restrictive setting. The state legislature has provided funds to hire
29 additional mental health staff.

Finally, construction is under way on a 180-bed special needs unit
at the Oakdale facility which will open in early 2007. “There is such
a spectrum of these men. Some of them are socially inept. Some of
them are mentally retarded….A fair number are psychotic. There
seems to be an increasing number of those who are finding their
way to us, and one wonders if the Department of Corrections isn’t
becoming the safety net for those kinds of persons,” Dr. O’Brien
said.
State Ombudsman Bill Angrick, who has been monitoring treatment
of mentally ill offenders, said it was too early to judge the
department’s response to problems in the Clinical Care Unit. “We
are keeping on top of that and asking questions,” he told the Des
Moines Register. Sylvia Piper, executive director of Iowa Protection
and Advocacy Services, a nonprofit disability rights group,
complimented Director Maynard. She said that he has been
responsive to concerns raised by advocates for mentally ill
offenders and that he is making progress. “It’s nice to be in a
position where we are actually seeing some movement and change,
and we are excited about it,” Ms. Piper said.
Missouri

I

n a unanimous opinion, a three-judge state Court of Appeals
panel ruled in April 2005 that an officer at a county juvenile
detention facility “never physically assisted” in rescuing a
teenager found hanging in a room, resulting in neglectful conduct.
According to the ruling, Michael Vaughn was hired by the St.
Louis County’s Juvenile Court in 1988 and was working as an
officer at the county’s Juvenile Detention Center June 9, 2002. He
was assigned to Unit G which housed six youth. Four of those
youth —- including the 15-year-old boy who attempted suicide —
- were locked in their rooms at approximately 1:45pm when that
youth managed to tie his arms behind his back and tried hanging
himself with clothing wrapped around a Bible and a hardcover
book he jammed into his window. Mr. Vaughn was returning another
boy to his room when they walked past the suicidal youth’s room
and saw him hanging. Mr. Vaughn opened the door and ordered
the other boy to free the hanging victim. The youth tried, but
could not rescue the victim on his own. Mr. Vaughn then left the
area and called the front desk for help, then waited for two other
officers to arrive before returning to the victim’s room, where the
other officers cut the youth down. The youth survived the suicide
attempt and was hospitalized for nine days before being returned
to the detention facility.
A subsequent investigation by the state’s Division of Family
Services (DFS) concluded there was probable cause to find that
Mr. Vaughn neglected the suicidal youth. In February 2003, he
petitioned the St. Louis County Circuit to review the matter and,
following a trial, a judge later affirmed the DFS finding. His bid for
a new trial or other relief was also rejected.
Upon appeal to the state Court of Appeals for the Eastern District,
Mr. Vaughn argued that the lower circuit court had erred, insisting
that he had followed the facility’s “check, call, and care” procedure
and provided the necessary care during the emergency. John
Snipes, the assistant superintendent at the detention facility, had
previously testified at trial that in such medical emergencies,

—18—

officers were trained to “check the scene making sure there are no
other incumbent dangers, call for help and then go to assist until
help arrives.”
Although Mr. Vaughn claimed he followed the correct protocol in
handling the crisis, the appellate court found otherwise. The court
wrote there was evidence that when Mr. Vaughn first checked on
the youth, he threw water on the boy’s face and then remarked,
“See, there’s nothing wrong with him. He’s OK.” He then left the
room, leaving an undersized youth to try to save the suicidal
youngster’s life. In addition, Mr. Vaughn carried a personal alarm
that, if triggered, was designed to activate a loud siren indicating
an emergency. He never used the alarm and instead went to a
nearby office and called the front desk to report the emergency,
then waited roughly two minutes for other officers to arrive before
they went to assist the youth. Even then, the court wrote, “there is
evidence indicating that Vaughn never physically assisted” the
other officers in rescuing the teenager.”

The lawsuit does not seek monetary damages on behalf of inmates.
One of the state’s most powerful law firms, Nelson Mullins Riley
& Scarborough — which often defends businesses in lawsuits —
is representing the inmates (pro bono). The lawsuit was filed by
the state’s Protection and Advocacy for People with Disabilities
agency on behalf of three mentally ill inmates and other affected
inmates. The lawsuit gives graphic details of the three inmates’
allegations:

The Court of Appeals concluded on April 19 that “Taking all of
this evidence into consideration, we find that the circuit court’s
finding of probable cause of neglect by Vaughn was supported by
substantial evidence.” The full opinion in Vaughn v. Missouri
Department of Social Services (ED84172) can be found at: http://
www.osca.state.mo.us

♦

A male inmate suffering from paranoid schizophrenia
and who has a “history of bizarre behavior, including
drinking his own urine,” has been kept for most of
his 14 years in prison in a segregation cell at least
23 hours a day instead of being treated at a
psychiatric hospital;

♦

A female inmate, who suffers from schizophrenia
and who is mentally retarded, set herself on fire with
a cigarette lighter after being without her medication
for two days. The department failed to forward her
medication after she was discharged from an inpatient psychiatric facility; she saw a psychiatrist
twice while she was in segregation for 37 days.

♦

A male inmate with a history of self-mutilation was
confined in a restraint chair for 16 hours after
cutting himself on his arms and re-opening his
wounds after he was treated. He cut himself twice
the next day after being left naked in his cell; eight
months passed before he saw a psychiatrist.

Michael Vaughn was never criminal charged in the case and his
attorney, citing privacy concerns, has declined to disclose his
client’s current employment status.

South Carolina

I

n the first lawsuit of its kind in the state, prisoners and an
advocacy group contend the state Department of Corrections
(DOC) has failed to adequately treat mentally ill inmates for several
years. The lawsuit, filed in June 2005, seeks class-action status on
behalf of all mentally ill inmates in the state’s 29 prisons. The exact
number of affected inmates is not known, although the lawsuit
alleged that as of 2004, the DOC had diagnosed 2,146 inmates —
approximately 9 percent of the state’s approximate 24,000 inmate
population — as being mentally ill. The lawsuit requested that a
judge order the DOC and the state General Assembly — also named
as a defendant — to “design, maintain, fund and provide resources
for a reasonable and adequate system” for treating mentally ill
inmates.
Gloria Prevost, executive director of Protection and Advocacy for
People with Disabilities Inc., a plaintiff in the lawsuit, said she and
others met privately earlier this year with DOC Director Jon Ozmint
and his staff to “possibly see if a lawsuit could be avoided….We
could not agree on the next steps to do that,” she told The State.
State Representative Bill Cotty, a member of the House Ways and
Means Committee, said he could not predict whether the Legislature
would find extra money next year for mentally ill inmates. Asked
by The State whether he thought those inmates receive inadequate
treatment, Mr. Cotty, a lawyer, replied, “I’ve seen cases where
people allege that, and I’ve seen little proof where that is the
truth.”

DOC Director Jon Ozmint confirmed that he had met with
plaintiffs counsel earlier in the year regarding treatment of
mentally ill inmates in the prison system. “I wanted them to tell
us what the problems were,” he told the Associated Press. “We
would be glad to work with them to address them, but they
never once volunteered to help us…or identified any inmates’
needs that we’re not meeting.”
According to the lawsuit, however, three separate studies since
1999 have found problems with the delivery of mental health
services in the prison system, including a lack of staffing and
proper training. “The need has been clearly articulated,” said Dave
Almeida, director of the state chapter of the National Alliance for
the Mentally Ill. “What else is there (except a lawsuit) when you
have three studies, and you can’t get the job done?”
Kansas

A

policy of examining deaths of inmates in state and local
custody is getting credit for helping to keep jails and prisons
safe for both the prisoners and the officers supervising them. One
state official said because of the 13-month-old law, inmate
suicides are a more visible issue, which could change how some
officers are trained. Others contend jails and prisons are now
more accountable. “The initiative seems to be working,” Sonny
Scroggins, a Topeka human rights activist who pushed for the
law, told the Associated Press in August 2005. “We need checks
and balances and we can’t have accountability without a
mechanism like this.”

—19—

The law took effect on July 1, 2004, and last year the Kansas
Bureau of Investigation (KBI) reviewed 42 deaths in custody.
Most of the deaths (i.e., 29) were from natural causes, but 10 were
suicides, while two resulted from accidents, and one from a hunger
strike.
Change, however, did not come without a modification of
the law. Earlier this year, legislators revised the law to make
sure the KBI focused on deaths involving suspicious
circumstances or suicide, rather than natural causes. “When
we don’t do our job, bad things are going to happen,” Coffey
County Sheriff Randy Rogers told the Associated Press.
“The KBI can use it as a tool to make sure we’re dotting Is
and crossing Ts.”
Before the law was enacted, the KBI typically investigated
between 5 and 10 inmate deaths a year, most of which
involved suspicious circumstances (and not all suicides),
said Kyle Smith, KBI Deputy Director. But Mr. Scroggins
and others were concerned that deaths were not being fully
reviewed by officials; or information about them, disclosed
to the public. Legislators enacted the law, requiring the KBI
to investigate all deaths of inmates in city, county or state
custody. But in the month after the law took effect, the KBI
was swamped with investigations, including two suicides
in one week at the Sedgwick County Jail in Wichita. KBI
officials asked legislators to modify the law this year. They
did, deciding the KBI did not have to investigate if an
autopsy, preliminary autopsy report or death certificate,
determined the death was from natural causes, or if the
inmate had received regular care from a licensed physician.
KBI Deputy Director Smith said investigating deaths from
natural causes strained the KBI, citing a case in which the
family of a terminally ill prisoner decided to end life support.
But he said investigations still determine whether there were
any unusual circumstances, such as manslaughter or murder,
so county prosecutors can be notified. “It doesn’t eliminate
the civil aspects of the case, whether there was negligence or if
someone should have been on suicide watch and wasn’t,” he
added.
In addition, the KBI reports on its completed investigations
to the chairmen of the House and Senate committees that
handle crime legislation every three months. State
Representative Ward Loyd, chairman of the House panel,
said it was important for the public to know about such
incidents. “The question I have from the suicide standpoint
is if they have satisfied themselves that everything was
done to avoid the suicide,” Representative Loyd said.
Sheriff Rogers is also president of the state Sheriffs’
Association and said the KBI investigations will give law
enforcement agencies data they can share among themselves
or in training. And KBI Deputy Director Smith said agency
officials may use the data in training law enforcement
officers so they too can, for example, better identify inmates
who are suicide risks. “I think it’s done a lot to elevate the
suicide issue. I think a lot of sheriffs have taken it to heart,” he
‰
said.
—20—

JAIL SUICIDE/MENTAL HEALTH UPDATE

T

his technical update, published quarterly, is part of
the National Center on Institutions and Alternatives
(NCIA)’s continuing efforts to keep state and local
officials, individual correctional staff, mental health/
medical personnel, and interested others aware of
developments in the field of jail suicide prevention and
jail mental health services. Please contact us if you are
not on our mailing list. Readers are encouraged to offer
opinions and/or submit pertinent materials for inclusion
into future issues.
This publication is supported by Cooperative Agreement
Award Number 04J34GJD9 from the National Institute of
Corrections (NIC), U.S. Department of Justice. Points of
view or opinions stated in this document do not
necessarily represent the official position or policies of
the U.S. Department of Justice.
Unless otherwise noted, all articles appearing in this
newsletter are written by Lindsay M. Hayes, Editor/Project
Director.

AVAILABLE JAIL/PRISON/JUVENILE
SUICIDE PREVENTION MATERIALS
And Darkness Closes In...National Study of Jail Suicides
(1981)
National Study of Jail Suicides: Seven Years Later (1988)
Training Curriculum on Suicide Detection and
Prevention in Jails and Lockups—Second Edition
(1995)
Curriculum Transparencies—Second Edition (1995)
Prison Suicide: An Overview and Guide to Prevention (1995)
Juvenile Suicide in Confinement: A National Survey (2004)
Jail Suicide/Mental Health Update (Volumes 1-13)
For more information regarding the availability and cost
of the above publications, contact either:
Lindsay M. Hayes, Editor/Project Director
National Center on Institutions and Alternatives
40 Lantern Lane
Mansfield, Massachusetts 02048
(508) 337-8806 • (508) 337-3083 (fax)
Web Site: www.ncianet.org/cjjsl.cfm
E-Mail: Lhayesta@msn.com
or
NIC Information Center
1860 Industrial Circle, Suite A
Longmont, Colorado 80501
(800) 877-1461 • (303) 682-0558 (fax)
Web Site: www.nicic.org