Jail Suicides in Massachusetts Point to National Crisis: Part 1

That heightened risk is also a component of the racism endemic to our criminal justice system, given the overrepresentation of people of color in carceral settings. And as people with mental health issues are also overrepresented in these settings, failure to enact suicide prevention measures constitutes disability discrimination.

Reducing our reliance on incarceration and punishment is essential to reducing jail suicide. This can be achieved through sentencing reform, good time credit, parole, and compassionate release. Government budgets should be redirected toward mental health and substance abuse treatment and rehabilitation services.

Another urgent reform: the pursuit of legislation targeted specifically at reducing suicide risks. While suicide is a concern in all types of carceral settings, county jails have particularly high rates. This article focuses on the problem in Massachusetts, but it is germane to county jails across the country.

Failed Mental Health Treatment

Jail suicide must be seen within the larger context of a failed carceral mental health treatment system. Suicides are the symptom of that system’s failure. Over the past 30 years, as prison and jail conditions have worsened, including all types of health care, the rate of suicide has predictably been climbing.

Suicides are for the most part preventable, but the overall indifference to the health and safety of prisoners’ lives and well-being make that all but impossible. Many people think that because suicide is a volitional act it can’t be stopped, but we know that is not true. Indeed, some mid-size prison systems go years with no suicides.

Most counties have one or more jails. They hold pretrial detainees and convicted prisoners who are serving shorter sentences than their counterparts in state facilities. (This article uses the term “prisoner” to refer to all persons held in county jails and the term “jail” to encompass houses of correction.) County jails are typically run by local sheriffs, who are elected or, less commonly, appointed. In Massachusetts, elected sheriffs run the county jails and the state Department of Correction (DOC) operates state prisons.

While their roles vary from state to state, county sheriffs generally have a degree of operational autonomy that administrators of other carceral facilities do not. This results in differences and, potentially, deficiencies in services and quality of care from jail to jail, including mental health services and suicide prevention.

A corresponding lack of significant external oversight makes it difficult to identify and remedy deficiencies. It is essential to do so to confront the problem of jail suicide.

Suicides and suicide attempts continue year to year in Massachusetts county jails with devastating consequences for prisoners and their families. Despite what we now know about how to prevent suicides, this information has not led to the elimination of such risks. Advocates must press for comprehensive and detailed Suicide Prevention Programs (SPPs) at all county jails. To ensure that Massachusetts jails adopt such SPPs, and to ensure that remedies exist when jails fail to do so, the state Legislature should enact statutory mandates applicable to all facilities.

Prisoners in any setting are at high risk of suicide and those in Massachusetts jails are at higher than average risk.

In the United States, suicide rates are higher in jails than among the general population and also than in prisons. In 2019, an investigation by the Associated Press and the University of Maryland’s Capital News Service found that the suicide rate in U.S. jails peaked in 2014, with 50 deaths for every 100,000 prisoners. That rate was 2.5 times the rate in state prisons and over three times the rate in the general population. The reporters compiled a database of more than 135 suicides and 30 suicide attempts in local jails over the previous five years.

In 2020, the federal Bureau of Justice Statistics (BJS) issued a report regarding suicides in local jails from 2000 to 2016. It also found that suicide deaths had peaked in 2014 but remained high after that date.

Massachusetts data are consistent with the national trend. Between 2006 and 2016, 62 prisoners died by suicide in Massachusetts county jails. The largest number, 11, took place in 2009. Only three jail suicides occurred in 2018, according to data compiled by the New England Center for Investigative Reporting (NECIR). NECIR concluded that the 2018 decline could be at least partially explained by a 9% decrease in the number of county jail prisoners that year.

While there has been no official publication of Massachusetts jail suicide data for 2019 and 2020, at least three have occurred. Media accounts reported two suicides in Bristol County facilities in 2019; both were pretrial detainees: Mark Trafton in May 2019 at the Ash Street Jail and Cierra Brin in July 2019 at the House of Correction. In November 2020, a man hanged himself in the Nashua Street Jail. There were at least 11 other deaths of pretrial detainees in Massachusetts jails in 2019, though it is unclear if any were suicides.

Lack of information about jail suicides is compounded by the fact that the BJS is slow to release data. The most recent figures regarding suicide in jails on the BJS website are from 2016. Even if newer data were added, the figures would be at least two years old. The BJS explains that it takes time to ensure full year data and to conduct analysis. There also is some evidence that BJS data releases are slowing down. These delays make it difficult to assess the suicide risk to prisoners.

Neither the state nor counties regularly report jail suicide data. There is no information about jail suicides on the Massachusetts DOC website, although the DOC’s enabling statute requires the agency to “establish and maintain programs of research, statistics and planning, and conduct studies relating to correctional programs and responsibilities of the department.” Similarly, there is no information on the Massachusetts Sheriffs’ Association (MSA) website, although the association is responsible for “evaluating research and data on matters of mutual interest and concern.”

Rod Miller, president of Community Resource Services, which consults with carceral departments, wrote in a February 27, 2020, memo to the Massachusetts Correctional Funding Commission: “There is no source of information that describes how each jail is working, in terms of outcomes such as injuries, deaths, assaults on staff or inmates, escapes, program completion … and other indicators of the effectiveness of jail operations … Even if the baseline information about jail facilities and operations were available, there is no way to determine the quality and effectiveness of operations.”

The only reason that jail suicide data is publicly available for 2017 and 2018 is that NECIR and other media outlets have been tenaciously following the issue of carceral suicides. Their success in gathering this data is not accidental: the Poynter Institute, the Vera Institute of Justice, The Marshall Project and the MacArthur Foundation united to train journalists on how to aggressively cover local jails.

The lack of transparency in Massachusetts is a longstanding and well-recognized concern. To reduce recidivism, contain carceral spending, and increase public safety, Massachusetts officials began working with the Council of State Governments (CSG) Justice Center and others in 2015 to study the state’s criminal justice system and develop reform legislation. One of the group’s major findings, after discussions in 2015 and 2016 with major stakeholders, including the Massachusetts DOC and county sheriffs’ offices, was that Massachusetts had insufficient data collection regarding “key criminal justice system trends and outcomes” due to a “lack of standardization in existing criminal justice agency data systems and minimal quality assurance.”

Researchers Can Identify Individual and External Risk Factors for Suicide

While the reporting of suicide data is lackluster, progress has been made in understanding how to prevent prisoner suicides. Researchers have identified individual and environmental risk factors in carceral settings.

A 2016 BJS study found that suicide rates in prisons and jails differed by race, length of stay, and housing unit. In 2014, the overall suicide rate for prisoners in jails was 45 per 100,000, but the rate for white prisoners was 95, compared to 19 for Black prisoners and 23 for Hispanic prisoners. On average, a prisoner who committed suicide had been in jail for nine days. 47% of suicides occurred in general population housing areas, while about 20% occurred in solitary or other special housing units.

A 2010 U.S. Department of Justice (DOJ) study of prisoner suicides found that most were carried out by white males with an average age of 35. Forty-two percent were single, 43% were held on a personal and/or violent charge, 47% had a history of substance abuse, 28% had a history of medical problems, 38% had a history of mental illness, 20% had a history of taking psychotropic medication, and 34% had a history of suicidal behavior.

Other studies have identified additional risk factors. The Associated Press and the University of Maryland’s Capital News Service investigation of 165 jail suicides found that 80% of those prisoners were pretrial and about one-third had not received their prescription medication for mental illness.

The 2010 DOJ study also identified environmental risks: 23% occurred within the first 24 hours of the prisoner’s confinement; 27% occurred between two and 14 days; and 20% between one and four months of the onset of incarceration. Twenty percent of the victims were intoxicated at the time of death. In addition, 38% were held in isolation at time of death and 8% were on suicide watch.

Prisoners frequently use clothing, bedsheets, or shower curtains to hang themselves, the most common method of suicide. Many of those who died were not checked regularly (i.e., every 15 to 30 minutes), often because of staffing shortages or inadequate training. However, 15-minute checks are not a panacea. One study of hospital suicides found that one-third occurred while patients were on 15-minute checks.

Researchers also have explored why jail suicide rates are higher than prison rates. Reasons include features of the jail experience: the prisoner’s shock of confinement, staff’s lack of information about prisoners, the higher rate of drug or alcohol intoxication and less robust intake protocols.

All these factors are rendered more dangerous given what we know about suicidal ideation. As Jill Harvay-Friedman of the American Foundation for Suicide Prevention notes, the impetus to take one’s life can come on suddenly: “Research shows that suicidal behavior often emerges quickly with as little as five to 10 minutes between the thought and the action.” She warns that screeners cannot simply rely on self-reports but also must look carefully at all potential risk factors.

Press reports of Massachusetts jail suicides suggest that several of the above-mentioned risk factors have been present in recent cases. Media accounts describe suicides that occur early in jail stays are caused by hanging, and coincide with the individual’s withdrawal from drugs or alcohol or both. In some cases, deaths follow jailed persons’ unheeded reports of suicidality.

We Know What Suicide Prevention Measures Work

Researchers have identified effective SPPs and stress the importance of interventions that go beyond suicide prevention itself and seek to improve mental health care in jails more broadly. Many successful SPPs have features in common.

The authors of a 2014 meta-analysis of 12 studies of prison suicide prevention activities, including six SPPs, concluded that the most effective suicide prevention measures were multi-factored and each:

• ran from intake until discharge;
• encompassed a broad range of activities, including enhanced screening and assessment of prisoners on intake, improved staff training, post-intake observation for suicide risk, monitoring and psychological treatment of suicidal prisoners, limited use of isolation and increased social support, and adequate and safe housing facilities for at-risk individuals; and
• required actions after a suicide or suicide attempt, such as internal and external review processes and staff debriefing and support. Additionally, programs that used prisoners to provide support and observation to troubled prisoners were beneficial. To be effective, prison officials must carefully select, train, and oversee the observers. (Emily Barker et al., Management of Suicidal and Self-Harming Behaviors in Prisons: Systematic Literature Review of Evidence-Based Activities, Archives of Suicide Research, 2014).

More recently, the nonprofit National Commission on Correctional Health Care (NCCHC) published a 2019 “Suicide Prevention Resource Guide.” It urged consideration of the connection between self-injury and suicide: “Some patients who initially engage in [non-suicidal self-injury] may miscalculate the lethality of the behavior, while others who chronically self-injure can become suicidal over time.”

To prevent suicide, we need to focus on delivery of mental health care!

Preventing jail suicides requires not only SPPs, but also a broader reform of prisoner mental health services. Unfortunately, to the extent that officials have tried to curtail suicides, they often focus more on stopping suicides than on preventing the deterioration of prisoner mental health in the first place. As Jessa Irene DeGroote observes in Weighing the Eighth Amendment: Finding the Balance Between Treating and Mistreating Suicidal Prisoners:

Beyond the moral compunctions, the treatment of suicidal prisoners is of particular concern given the rise in lawsuits against prison officials for failing to prevent inmate suicide. In order to preemptively avoid many of these cases, officials have taken measures to make prisoner suicide nearly impossible. These measures are too often aimed not at providing mental health services, but rather at “preventing the attempt from succeeding.”

The tendency to rely upon restrictions rather than on providing expanded mental health services for people in crisis continues in Massachusetts, with poor outcomes. For example, in its 2020 report on Massachusetts DOC facilities, the U.S. DOJ found that prisoners on mental health watch were observed by carceral officers who neglected them and even encouraged self-injury: “During a time when prisoners are most in need of treatment, MDOC fails to properly treat suicidal prisoners and prisoners who self-harm.” Yet the DOJ limited its own potential for addressing the problem of suicide in DOC facilities by focusing its investigation on problems related to mental health watch.

The tendency to treat people only at the moment of mental health crisis is not unique to carceral settings. In her book, Rational Suicide, Irrational Laws, attorney Susan Stefan has made the same observation with respect to how we typically address suicide in the larger community: “The majority of our suicide prevention resources seem concentrated on identifying a potential suicide and restraining that person, rather than preventing the buildup of desperation or healing the underlying wounds.”

Instead, Stefan suggests, suicide prevention should be about countering “powerless or hopelessness of changing circumstances” and “should focus on supporting and increasing feelings of power, agency, control, and hope.” Surveying people who attempted suicide, Stefan found that the most common suggestion her subjects would make to policymakers was to listen to the voices of those in emotional distress.

In a similar vein, carceral suicide prevention expert Lindsay Hayes stresses that reforms must be systemic rather than targeted to those prisoners already identified as presenting a suicide risk. In other words, reformers must meet the needs of prisoners not only while on suicide precautions, but while off them as well. Facilities should offer a comprehensive array of programming that identifies prisoners who might not openly present as suicidal, ensures their safety on suicide precautions, and provides a continuity of care throughout confinement.

In fact, focusing solely on restrictions as a means to combat suicide risk is misdirected and, in its worst forms, dangerous. As DeGroote notes, describing harsh restrictive measures that lack clinical involvement, such responses are neither appropriate nor helpful:

Such measures range from placing the inmate in administrative segregation with heightened supervision to prisoners being stripped naked and restrained to a chair. Prison officials, who tend to select suicide prevention methods most convenient to the staff rather than require extensive observation and treatment, will often physically isolate or even restrain the individual. The literature, however, recognizes that inmates should only be stripped naked and physically restrained as an absolute last resort. Furthermore, isolation and deprivation of human contact are also disfavored; housing assignments are more effective in protecting inmates when based on interaction and observation of the inmate.

There is evidence that improving overall mental health care and services in carceral settings can reduce the risk of suicide. For example, when the Louisiana State Prison system shifted its focus to engage prisoners in educational and social programming, the prison system went seven years without a suicide, and violence dropped substantially.”