systems typically respond to suicidal and acute psychiatric crises using suicide watch practices that rely on isolation, restricted property, limited stimulation, and brief risk-focused clinical contacts. Although intended to prevent immediate danger, these practices may undermine key mechanisms associated with effective crisis intervention. This article critiques the continued use of isolation-based suicide watch in correctional environments and argues that such practices may discourage honest disclosure, intensify distress, and increase longer-term risk for incarcerated individuals, the staff, and institutions. Drawing on principles from community psychiatric care, safety planning, crisis response planning, and research on special observation, the authors propose a less restrictive crisis intervention model that emphasizes engagement, therapeutic activity, peer and family connection, individualized observation, and out-of-cell clinical support. The article also acknowledges operational barriers, including staffing, physical plant limitations, and security concerns, while encouraging gradual implementation through stepwise reductions in isolation. Reframing suicide watch as an active, treatment-centered intervention rather than a restrictive containment strategy may better align correctional mental health care with evidence-informed crisis standards and the ethical obligation to reduce harm.
Keywords: suicide watch, correctional mental health, crisis intervention, psychiatric observation, incarcerated patients
Re-Thinking Suicide Watch: Engaging Solutions for Crisis Care
Correctional settings overwhelmingly use isolation and restricted property for prolonged periods of time in response to individuals experiencing a self-reported or objectively obvious mental health crisis. This practice is commonly known as “suicide watch.” For decades, the authors have struggled with this practice and in turn, endeavored to find a means by which correctional environments can balance safety risks associated with mental health crises, security concerns regarding the improper use of crisis housing, and the need for autonomy and support for the individual who is experiencing the crisis. While we continue to research this topic and explore alternatives available in other settings and across current carceral systems, we hope to use the current forum to expand our thoughts and spark a movement away from isolation and restriction as the default intervention for crises in carceral settings.
Any mental health professional and most non-clinicians will affirm that contact with supportive friends or family, time spent outdoors in nature, and hobbies or activities to distract oneself are crucial for anyone experiencing psychiatric distress. Individual and group psychotherapy help people process and resolve emotional distress and develop skills for relapse prevention. Specific to suicidal crises, safety and crisis response planning have proven to be effective immediate interventions to reduce risk. The efficacy of safety planning and crisis response planning have been attributed to seven factors, including providing distraction, increasing connection, fostering autonomy, building competence, reducing engagement with impulsive urges, increasing the difficulty of suicidal behavior, and managing cognitive load (Rogers, et al., 2022). The only one of the mechanisms served by placing an individual in isolation during a suicidal crisis is increasing the difficulty of engaging in suicidal behavior. Several of the other risk factors addressed by safety planning and crisis response planning are actually exacerbated by the use of traditional suicide watch including lack of distraction, absence of connection, limited autonomy, no opportunities for building competence, no support in reducing engagement with urges, and no skill development in managing cognitive load.
When a community member has an acute crisis that rises to the level of risk of harm to self or others, the individual is often hospitalized in a psychiatric unit where contact with family and friends is encouraged. Leisure or recreational activities as well as psychotherapy are expected and provided in the least restrictive environment possible. Connection with clinical staff and peers is encouraged, autonomy and choice are supported, competence in increased, and cognitive load is reduced.
In contrast, incarcerated individuals experiencing an acute psychiatric crisis are typically isolated in a locked cell, away from peers or any stimulation. They may be given heavy smocks to wear; shoes and undergarments are rarely provided. Access to television, leisure/recreational activities, time outside or visits with supportive family and friends is unlikely. In contrast to community standards and research on the management of suicidal patients, clinical contacts are often limited to brief daily risk assessments (often at the cell door) with limited targeted treatment interventions being provided.
In our experience, many individuals experience the conditions of suicide watch as a disincentive for engaging in genuine clinical interactions and will often recant suicidal ideation or other symptoms with the goal of being removed from suicide watch. Even for individuals who have not experienced suicide watch directly, the fear of isolation and humiliation along with the belief that their distress will be exacerbated by the conditions of suicide watch creates resistance to seeking help during a crisis. Thus, the data gleaned from clinical assessments of individuals in crisis used to determine if suicide watch is initiated, continued, or discontinued, are limited in utility and not likely be reliable.
Essentially, suicide watch, the practice that is used to ensure safety, increases overall risk. In the mental health field beyond carceral settings, the approach to treatment is least restrictive intervention with the least risk for harm. In the correctional environment, the current default is overly restrictive which causes the highest form of emotional suffering and unnecessary harm for some patients. The authors can recall numerous patients who have shared that the circumstances of the suicide watch exacerbated old traumas or created new traumas, leading patients to wholeheartedly say, “I’m not telling anyone I’m suicidal again,” thus increasing the risk to the individual, staff and the correctional environment. In addition to the conditions and isolation of suicide watch, with the focus on monitoring and restriction of access to items that can cause harm, there is a lack of targeted treatment despite the overwhelming need.
An Alternative Model
The authors propose consideration of a crisis intervention model which balances autonomy and safety within the least restrictive setting; ultimately discontinuing the use of isolation to manage individuals in crisis.
The authors propose a model that is parallel to that available to community psychiatric patients where the patient can interact freely with staff and peers while under increased monitoring. The patient would remain in the standard correctional uniform. Level of observation would be implemented as clinically indicated based on the assessed level of risk. Ray, Perkins, and Meijer (2011) explored the use of observation for individuals in crisis in psychiatric hospitals. They found that while constant visual observation could reduce the incidence of self-injury when staff were able to intervene and stop the behavior, there were few other positive benefits. In fact, they noted that constant observation could result in adverse patient reactions including increased agitation and verbalized despair. The authors noted that engagement along with having a staff member within proximity to the patient and available to provide support and discuss the patient’s urges without restricting the patient’s movements or freedom served to increase the patient’s trust of staff and their own ability to control their impulses, thus reducing short and long-term risk. In correctional settings, increased observation could occur in the patient’s current housing unit or a specialized mental health treatment unit. Instead of the patient remaining in the cell while under observation, we propose that the observer accompany the patient to a myriad of individualized out-of-cell therapeutic activities including group therapy and recreational activities. Out-of-cell time would also include meals, visits, and phone calls unless clinically contra-indicated. When the patient wants to be in the cell, the cell door should be open to allow for engagement with peers and support for autonomy. As noted earlier, an effective model of crisis intervention should provide distraction, increase connection, foster autonomy, build competence, reduce engagement with impulsive urges, increase the difficulty of suicidal behavior, and support the individual in managing their cognitive load (Rogers, et al., 2022).
This model may seem too drastic from current practices. An alternative approach would be to transition the current system of isolation to a stepwise process of decreasing isolation. This slower process will likely be more acceptable to staff and patients. As a first step, we suggest increasing out-of-cell time as much as possible for individuals under psychiatric observation or on suicide watch. This includes access to recreational activities, outdoor space (where possible), and clinical interventions in private offices.
The authors recognize that there are various barriers to transition from total isolation/seclusion. To name a few, barriers such as physical plant (e.g., lack of private therapeutic space, lack of outdoor space), increased staffing needs, and security concerns/resistance are real. Resistance from both clinical and custodial staff may stem from perceptions that the incarcerated person is feigning or exaggerating symptoms or falsely reporting suicidal ideation to secure a housing change or gain access to privileges, female staff, peers, or more freedom. The perception may be that increasing engagement with others and decreasing isolation/seclusion will act as a reinforcement for individuals looking to obtain these “secondary gains” by feigning a crisis. The authors fully believe the benefits outweigh the costs. In this case, the benefits include the provision of evidence-based interventions in keeping with community standards and saving lives, while the costs include preventable death, unnecessary suffering, unsafe environments, and staff burnout. Another cost may be that individuals who are not in acute crisis gain access to increased clinical contacts. This is not a negative outcome. Close consultation between custody and clinical staff with these individuals can help determine which interventions and/or consequences will best support the individual in making more adaptive choices and decreasing violence toward themselves and others. While there may be some growing pains and resistance, the time is long overdue to improve the provision of treatment to incarcerated patients in crisis who need suicide watch or psychiatric observation. As Socrates has famously stated, “The secret of change is to focus all of your energy not on fighting the old, but on building the new.”
As we work to develop our model, we would love to hear your thoughts regarding improvement of mental health care for our most acute patients. We can be reached at sharen@sharenbarboza.com or maria@drmariamasotta.com.
References
Ray, R., Perkins, E., & Meijer, B. (2011). The evolution of practice changes in the use of special observations. Archives of Psychiatric Nursing, 25(2), 90–100.
Rogers, M. L., Gai, A. R., Lieberman, A., Schafer, K. M., & Joiner, T. (2022). Why does safety planning prevent suicidal behavior? Professional Psychology: Research and Practice, 53(1), 33–41.
