Editor’s note: This story discusses suicide, which some people may find disturbing. If you or someone you know is struggling with thoughts of suicide, you can call the National Suicide Prevention Lifeline by dialing 988 or 1-800-273-8255. Those in New York City with mental health struggles can contact NYC Well at 1-888-NYC-WELL.

Around this time last fall, a delegation of state and local lawmakers visited Rikers Island, New York City’s 400-acre jails complex in the East River. More than a year into the COVID-19 pandemic, amid a spike in violent incidents and chronic absenteeism among staff, elected officials had come to see for themselves what had been described as an unrelenting crisis.

Some of them ended up seeing something unimaginable: an attempted suicide. “I had never witnessed something like that before,” state Sen. Jessica Ramos told City & State recently. “It was truly disheartening to see someone feel so hopeless that they really only saw that as their way out.”

Just over a year later, with a new mayor and a new commissioner leading the Department of Correction, New York City is still dealing with this crisis. Sixteen people have died after being held in custody so far this year, and five of those deaths were suicides or suspected suicides. New York City isn’t alone here. Between 2000 and 2019, suicides were the leading cause of deaths in jails – facilities that hold individuals still awaiting their day in court, or some people serving short sentences.

But New York faces the challenge of stemming this crisis at a massive scale. Rikers Island is one of the largest psychiatric care providers in the country, and it is the largest psychiatric provider in New York City. Half of Rikers’ population in the previous fiscal year had a mental health diagnosis – about 2,780 people – and 16% had a serious mental health diagnosis. In the face of the immense responsibility of caring for those people in custody, some lawmakers and criminal justice advocates said the city was flat out failing. “New York City jails often lack adequate mental health services, which has contributed to unsafe conditions for detainees and staff working within the jail complex,” Reps. Carolyn Maloney and Alexandria Ocasio-Cortez wrote in an April letter to Mayor Eric Adams.

The New York City Board of Correction has recommended policy and management changes to improve access to mental health care on Rikers, including having medical staff conducting more regular rounds of the intake areas and improving mental health treatment training for correction officers, while others have called for expanding the number of dedicated psychiatric units in the jails system.

But some advocates and progressive lawmakers argued that the best solution to these problems was a much bigger undertaking: diverting many more mentally ill people involved in the criminal justice system to treatment programs, rather than jailing them. “It’s important to recognize that lots of these folks shouldn’t be in jail,” New York City Council Member Tiffany Cabán said. “They should be in their communities receiving the kind of mental health care that they need and deserve.”

Problems starting at intake

An individual’s access to mental health care on Rikers often starts during the intake process. A mental health screening is supposed to happen for every person in custody within 24 hours of their arrival. The same window applies for general medical intake screening. But in practice, some criminal justice advocates said, people sometimes have to wait several days for those screenings. “I think the problems often start there,” said Julia Solomons, a senior policy social worker at Bronx Defenders, a public defender nonprofit.

Brandon Rodriguez, a 25-year-old man who died by suicide on Rikers in August 2021 after just a few days in custody, had a recorded history of mental illness during a previous detention at Rikers. But last year, Rodriguez was held in an intake area of the Otis Bantum Correctional Center – one of eight facilities on Rikers – for more than two days before receiving his initial mental health assessment, according to a recent report by the Board of Correction. Rodriguez’s mother has since filed a lawsuit against the city, alleging numerous violations in how Rodriguez was treated, including the delay in his initial assessment.

If a person is flagged as having a mental health issue or is in need of further evaluation during the initial screening, they will then be referred for a more comprehensive mental health assessment. Mental health staff at Correctional Health Services – the division of New York City Health + Hospitals responsible for health care on Rikers – could determine whether the person needed to be hospitalized at Bellevue Hospital’s psychiatric ward or possibly be housed in one Rikers’ specialized units that offer more direct access to psychiatric services and closer observation. Correctional Health Services staff could also determine at this point whether a person should be placed under suicide watch.

In June, 82% of the 371 referrals that were made for mental health services took place within 72 hours.

Fewer barriers to care in specialized units

The level of psychiatric care that a person in custody has access to largely depends on where the person is housed. Most people on Rikers – including those with mental illnesses – will be housed in the general population across the island, and they’re meant to receive access to individual counseling and medication treatment through Correctional Health Services. But a smaller number of incarcerated people with serious mental health issues will be placed in specialized units meant to offer more regular observation and access to treatment.

The least intensive level is known as mental observation, of which there are currently 15 units, many of them in the Anna M. Kross Center, the largest jail on Rikers Island. Mental observation units are intended to house people with more serious mental illnesses who might require closer clinical evaluation or are on suicide watch. Mental health staff are assigned to work in these units, and according to Correctional Health Services, the units involve group therapy, individual counseling, medication management and community-building activities. Still, some advocates said these units only amount to slightly modified general population housing. Cabán said she consistently hears that people in mental observation units feel that they’re not getting enough attention or care, but she added that she has heard some positive reports: “There were a couple of units we walked through where they did report that they regularly saw and had a (health) practitioner available to them in their unit.”

A newer specialized housing program, known as the Program to Accelerate Clinical Effectiveness, houses people with serious mental health issues and is more akin to inpatient psychiatric care, people familiar with the system said. These units were modeled on the existing Clinical Alternative to Punitive Segregation program, an intensive inpatient alternative to punitive segregation for those with serious mental illnesses.

According to the Department of Correction’s website, PACE units are meant to offer intensive treatment to those who “struggle to function adequately while incarcerated due to chronic mental illness, risk of acute psychiatric decompensation, and/or behavioral disruption.” A step up from mental observation units, PACE units include dedicated staff from medicine, nursing and mental health services, as well as correction officers with some additional training.

“When you go into those units, you’ll find that things do tend to be a little bit calmer in those spaces,” Cabán said of her visits to PACE units. “It’s clear that people are also, for better or worse, heavily medicated.”

One benefit that both kinds of units share is a more direct access to medication than individuals in custody usually receive when they’re in the general population. For the most part, people in PACE and mental observation units can receive their medication in their unit, while those in general population usually need to be escorted by a correction officer to retrieve their medication. “For the people that have to be escorted down to get their medications, things like alarms, things like insufficient DOC escorts, will hinder that availability of medications,” said S. Lucas Marquez, associate director of civil rights and law reform at Brooklyn Defender Services. “Someone might be labeled as ‘not treatment compliant,’ but it actually just turns out that they haven’t had the opportunity to be given their medication, as opposed to a refusal (of it).”

Still, some report problems accessing medication even in these specialized units. “My clients tell me that even on the PACE unit, the thing that they don’t like is they have to be awake when someone comes around to dispense the medication,” said Katherine Bajuk, a mental health specialist at New York County Defender Services. “At 5:30, when someone comes to their housing cell and says, ‘Come take this morning medication,’ sometimes they’re just sleeping, and they miss it that way.” Bajuk said this can hurt her clients when courts look into a person’s compliance with medication when considering treatment alternatives to incarceration.

The Department of Correction has reported that individuals who have been housed in PACE or CAPS units are involved in fewer use-of-force incidents and lower rates of self-harm. Solomons argued that there weren’t enough of the specialized PACE units for the number of people who could benefit from being housed there. “It’s not that people are not sick enough for those beds, it’s that they have to triage and pick only the absolute sickest people who can be in those units,” she said. “And they move people off of those units fairly quickly if they show signs of improvement, which is also often a bad situation for folks – once they get stable and they go back to the general population and they decompensate again.” Plans to expand the PACE units, which started under former Mayor Bill de Blasio, have stalled under Mayor Eric Adams’ administration. There are currently 12 PACE units on Rikers, according to the Department of Correction, which added that it is open to the possibility of expanding these units.

Although individuals in PACE units or even under mental observation can face fewer barriers to accessing mental health care than those in general population, it doesn’t guarantee a person’s safety.

In August, Michael Nieves, a 40-year-old man who was housed in a PACE unit in the Anna M. Kross Center, died after slitting his throat in front of two correction officers and a captain who failed to respond for 10 minutes, The New York Times reported. The officers and captain were suspended pending an investigation.

Triage conditions

Incarcerated people housed in the general population require correction officers to escort them to clinic visits with Correctional Health Services. The Department of Correction pointed to data showing that roughly half of missed clinic appointments were due not to a lack of available escorts, but to people in custody refusing to go. A department spokesperson said that the lack of an officer escort accounted for 0.5% of missed medical appointments. But the recently released Mayor’s Management Report acknowledged that the department’s staffing problems played a role in missed appointments in the previous fiscal year. “Although the Department aims to produce as many individuals to the clinic as possible, staffing shortages contributed to an increase in overall non-production numbers during Fiscal 2022,” the report read.

“Our medical non-productions, which are published on our site, show that non-production in June and July declined by approximately 40% when compared to June and July of 2021 – a substantial improvement,” a department spokesperson wrote in an email. The department has also assigned additional staff in each facility to be available for escorting individuals to the clinic. At the Rose M. Singer Center, which houses women in custody, “low classification” individuals no longer require an escort to the clinic.

Department of Correction Commissioner Louis Molina, who is on the clock to institute reforms at Rikers to avoid a judge installing a federal receivership, said the department’s staffing problems have improved since he took over in January. The city comptroller’s office reported, however, that the share of uniformed staffers out each day was still far above pre-pandemic levels.

In June, the most recent month for which data on mental health services was available, Correctional Health Services reported completing 63% of 13,759 scheduled mental health services across the jails, while 31% – or 4,246 services – were missed because the person was not brought there. This data didn’t specify why the person wasn’t brought to the visit.

When a health issue arises – for example a new mental health problem that wasn’t present during intake or a need to adjust or be prescribed medication – a person in custody can ask to be escorted to the clinic by a correction officer or call a Correctional Health Services hotline. But when those visits aren’t completed for whatever reason, it can take advocates on the outside to follow through. “It’ll often take two or three emails (to Correctional Health Services) in combination with the client asking and trying to get seen, for them to see the psychiatrist,” Solomons said. “I often wonder what it looks like for people in custody who don’t have advocates that are pushing on the other side for them.”

Cabán, who worked as a public defender before joining the City Council this year, said individuals in custody have resorted to desperate actions to be seen by doctors. “There are folks that will resort to self-harm in order to be able to get to see a doctor, or resort to self-harm to get on suicide watch and then be able to see a psychiatrist or other mental health facility on the island,” Cabán said.

Wilson Diaz-Guzman, a 30-year-old man who died by suicide after being held in custody last year, was seen by mental health staff on Rikers after he reported making “superficial scratches” on his arm several days before his death because he was afraid for his safety and “wanted someone to pay attention to him,” according to a Board of Correction report.

Several people City & State spoke to complimented the efforts of Correctional Health Services staff to treat people on Rikers, but said that because of the crisis conditions in the jails system and the level of care people need, incarcerated individuals often need to be their own best advocates. “When they do access care and are sitting down with a clinical professional, I think at least some of the time that’s a productive visit. But I do think it requires a lot of advocacy on the part of the client and being forthcoming about what’s going on with them,” Solomons said. “Everyone is moving quickly and just trying to triage.”

Persistence – from individuals themselves or from advocates on the outside – was sometimes needed to secure a suicide watch status too. Solomons said it recently took two weeks for a client to be moved to a unit where they could be placed on suicide watch. “For someone that’s experiencing suicidal ideation, those two weeks are pretty critical,” she said.

The department spokesperson said in a statement: “The department is also committed to suicide prevention, and we provide our recruit correction officers with extensive training in suicide prevention during their onboarding.” After vetting and training, people in custody can also be hired as suicide prevention aides to assist correction officers in observing people deemed at higher risk for suicide or self-harm. A recent Board of Correction report recommended significantly raising wages for these aides, who are currently paid $1.45 an hour, to incentivize more participation.

Staff at Correctional Health Services make the determination for when a person should be placed on or removed from suicide watch, but Department of Correction staff are responsible for monitoring someone on suicide watch. Health staff also conduct rounds to those individuals to determine if clinical intervention is needed, but it’s unclear how often those rounds are made. Suicide watch requires a person to be under constant supervision by correction officers – not just with surveillance cameras but “uninterrupted personal visual observation,” according to the department’s rules.

In their recent report, the Board of Correction noted that several of the people who died by suicide in 2021 had been placed on suicide watch and then taken off after a couple days. In Javier Velasco’s case, Correctional Health Services discontinued his suicide watch after 30 hours, which followed Velasco’s attempted suicide and disclosing previous attempts while in custody. The state Commission of Correction identified the decision to remove Velasco from suicide watch as premature, and the commission’s Medical Review Board stated that his death was “preventable had his suicidal ideation been properly identified and treated.” 

The Board of Correction further found insufficient staffing to be a “persistent problem,” citing it as an issue in several of the deaths by suicide on Rikers in 2021. “Suicides in jail are preventable,” Dr. Robert Cohen, a member of the Board of Correction, wrote in an email. “Rates of suicide in New York City’s jails are skyrocketing because people are housed where no floor officers are present. If DOC cannot provide adequate supervision, it should decrease the population in its jails.”

Treatment not jails

State Sen. Jessica Ramos and Assembly Member Phara Souffrant Forrest sponsored a bill in the state Legislature to reduce the number of people with mental illnesses on Rikers. The Treatment Not Jails bill would expand eligibility for mental health diversion programs in the justice system, with the goal of keeping people with mental illnesses out of Rikers in the first place. If the blowback to the state’s bail reforms was any indication, the bill, first introduced in 2020, could face a rocky path in the Legislature. But Forrest and Ramos both said they hope to advance it in the upcoming session. “In the budget dance last cycle, I felt like I did make good headway in helping so many people understand what the bill really does,” Ramos said. “I think a lot of people are starting to better understand the legalese, if you will, instead of succumbing to knee-jerk reactions.”