Love, Spirituality, and Regret: Thematic Analysis of Last Statements from Death Row, Texas (2006–2011)
========================================================================================================

* Brendan D. Kelly
* Sharon R. Foley

## Abstract

Individuals awaiting execution have high rates of mental illness and psychological problems. We examined themes and psychological factors in last statements before execution in Texas between December 2006 and July 2011 (*n* = 79) and compared them to our previous research on last statements between April 2002 and November 2006 (*n* = 100). We used the Thematic Guide for Suicide Prediction to examine the state of mind of the prisoners facing imminent death. The most common themes in last statements were love (82%), spirituality (52%), and regret (39%). The most common psychological factors were indirect expressions (43%), identification-egression (i.e., identification with a lost or rejecting person or with any lost ideal) (40%), rejection-aggression (38%), and unbearable psychological pain (37%). These features were constant over time. Evidence of deteriorating mental health, unbearable psychological pain, and increased suicide risk suggests an ethics-related medical duty for psychiatrists to object to the death sentence.

In 2011, at least 20 countries carried out legal executions or judicial killings in the context of capital punishment.1 This is a substantial reduction from 10 years earlier, when 31 countries conducted executions.1 It is a small reduction from 2010, when 23 countries performed executions.

The number of executions has risen, however: in 2010 there were 527 reported executions worldwide, increasing to 676 in 2011. The rise was chiefly attributable to more executions in Iran, Iraq, and Saudi Arabia. The statistics do not include the number of executions in China, which Amnesty International estimates to be in the thousands.1

The United States is one of the few Western countries that still practices capital punishment: in 2011, there were 43 executions in 13 of the 34 U.S. states that still have the death sentence, a substantial decrease from 2005, when there were 60 executions.1,–,3

Little is known about the state of mind of individuals immediately before execution. The U.S. state of Texas provides a valuable opportunity to study this topic, because the last statements of executed prisoners are published on the website of the Texas Department of Criminal Justice.4 These statements were made by prisoners immediately before execution after all avenues of appeal had been exhausted and the sentence was about to be carried out. The statements were generally brief, and the prisoners were aware they would be made public. The statements are transcribed immediately, but are not recorded.

In a study of prisoners executed in Texas between April 1, 2002, and November 30, 2006,5,6 we found that the most common themes were love (70%) and spirituality (56%). The most common psychological factors were identification-egression (i.e., identification with a lost or rejecting person or any lost ideal; e.g., health, freedom, and employment) (62%), unbearable psychological pain (53%), and rejection-aggression (42%).

Since our initial papers appeared in 2007,5,6 the United States has been slowly moving away from the death penalty,1 with particular change occurring in 2007, when Illinois and New Jersey abolished it. Even in Texas, traditionally the U.S. state with the most executions, the number of executions fell from 19 in 20053 to 13 in 2011.1 Nonetheless, Texas still accounts for 30 percent of all U.S. executions, despite having just 8 percent of the population.

On this basis, and especially given the decline in capital punishment since our original work, we again studied last statements from Texas, to identify any evidence of change in theme or content, between the two periods studied (April 2002–November 2006 and December 2006–July 2011). Did the decline in capital punishment produce any alteration in themes and psychological factors in the last statements of the diminishing number of individuals executed? Or did the key themes and psychological constructs remain constant over time, despite such trends? Are there any therapeutic lessons to be drawn from thematic shifts, if any, over time?

This article has three purposes. First, we explore the role of psychiatrists in relation to the death penalty. Second, we provide an overview of literature relating to the psychiatric and psychological health of death row prisoners. Third, we review the themes and psychological factors in last statements in Texas from December 2006 through July 2011 and compare them to those in our previous study (April 2002– November 2006).5

## The Role of Psychiatrists in Relation to the Death Penalty

The Universal Declaration of Human Rights states that “everyone has the right to life, liberty, and security of person” (Ref. 7, article 3) and “no one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment” (Ref. 7, article 5). In 1966, the International Covenant on Civil and Political Rights stated that “no one shall be arbitrarily deprived of his life” (Ref. 8, article 6.1) and limited the death penalty to “the most serious crimes” (Ref. 8, article 6.2). In 2011, only 18 of the 193 member states of the United Nations conducted executions, and the United States was the only G8 country to do so.1

In 1992, the American Medical Association restated its prohibition on physician participation in capital punishment.9 The U.S. Code of Ethics of the Society of Correctional Physicians states that “the health professional shall…not be involved in any aspect of execution of the death penalty.”10 Nonetheless, Gawande11 reports that 17 U.S. states still require physician participation in executions. Owing to the conflict between this requirement and various declarations of medical ethics, many states offer legal immunity and anonymity for participating physicians.

For psychiatrists, involvement with death row inmates may involve treating mental illness, evaluating competency, treatment to restore competency, and prediction of future dangerousness.12 The ethics position for psychiatrists in these roles is complex, owing to both the ethics-based prohibition on being “involved in any aspect of execution of the death penalty”10,13 and the requirement, in the Code of Ethics of the Society of Correctional Physicians, that “the correctional health professional…shall render medical treatment…when it is justified by an accepted medical diagnosis.”10

The psychiatric literature on death row populations clearly indicates a strong need for such treatment, based on the high rates of neurologic deficit, mental illness,14,15 and substantial psychological pain.5 There are, however, significant complexities inherent in such treatment. Outside the death row context, for example, psychological and psychiatric care often aim to reduce feelings of helplessness, increase hope for the future, and promote social integration. All of these tasks become more complex when one's patient may never leave prison and ultimately will die there.

This difficulty is rendered more acute by established links between homicidal and suicidal states of mind,16 both of which are found in many prisoners on death row. The population distribution of homicide-suicide resembles the distributions of both suicide and homicide in certain respects.17 At the individual level as well, homicidal behavior is strongly associated with suicidal ideation and suicide attempts:18 86 percent of psychiatric patients who report homicidal ideation also report suicidal ideation.19 Consistent with this, suicidality is common among death row prisoners, most of whom have engaged in homicide.5,20 These findings highlight both the need for mental health care among death row prisoners and its inherent complexity.

## Psychiatric and Psychological Health of Death Row Prisoners

Mental illness and psychological problems are common on death row.14,15 Lewis *et al*.21 presented results of clinical evaluations of 15 death row prisoners (13 men and 2 women) in five U.S. states. These 15 individuals were selected because they had all exhausted their final legal appeals, and public defenders sought to establish any clinical factors that might inform clemency appeals to state governors. All 15 had histories of severe head injury, as evidenced by scars, indentations of the cranium, neurologic deficits, abnormal brain imaging results, or histories verified by hospital records or families. Five had major neurologic impairment and seven had less serious neurologic signs. Six had schizophreniform psychosis preceding incarceration and two had bipolar affective disorder.

In a thematically similar but methodologically contrasting study, Freedman and Hemenway22 used a multisource, cross-validation approach to study the social and family histories of 16 men sentenced to death in California. They assessed patterns of impairment, injury, and deficit at four levels: family, individual, community, and social. These men demonstrated numerous risk factors and few of the resiliency factors associated with violence. In all cases, there was a history of family violence, 14 had posttraumatic stress disorder, 13 had severe depression, and 12 had histories of traumatic brain injury.

In addition to this high level of pathology before incarceration, there is evidence that prisoners develop further psychological symptoms while on death row.14,23 Johnson24 interviewed 35 of 37 death-sentenced prisoners in Alabama and reported high rates of fluctuating mood, recurrent depression, and deterioration of mental capabilities while on death row. The suicide rate is up to five times higher than that of the general U.S. male population.20

There are, however, significant methodological problems with this field of research. Samples in studies tend to be low, and there is substantial variation in methodology: For example, whereas Lewis *et al*.21 presented individual clinical evaluations of 15 prisoners, Freedman and Hemenway22 presented a qualitative, multisource study performed at the family, individual, community, and social levels. These methodological divergences reduce comparability across studies. There is also substantial geographical bias, with most of the literature emanating from the United States.15

Notwithstanding these complexities and deficits in the literature, it is reasonable to conclude that death row prisoners have high rates of head injury and severe mental illness before incarceration and that being on death row is associated with further deterioration in mental health. In 2007, we sought to add a new dimension to the literature by studying the mental state of death row prisoners immediately before execution.

## Last Statements Before Execution, Texas

We previously studied the last statements made by all death row prisoners executed in Texas between April 1, 2002, and November 30, 2006 in order to explore the themes and psychological factors evident immediately before execution.5 These statements are published on the website of the Texas Department of Criminal Justice soon after each execution.4

Texas has published all last statements of executed prisoners since it began executing by lethal injection in 1982.25 As a result, the initial last statement published on the website of the Texas Department of Criminal Justice is that of Charlie Brooks, Jr, executed on July 12, 1982: “I, at this very moment, have absolutely no fear of what may happen to this body. My fear is for Allah, God only, who has at this moment the only power to determine if I should live or die… .”4

During the 56-month period in our first study, 116 prisoners were executed (25 per year), of whom 100 made last statements.5,6 In both that study and the present one, we used the Thematic Guide for Suicide Prediction (TGSP) to analyze themes and psychological factors in these statements (see Methods).26,27

In our first study, we found that, between April 2002 and November 2006, all executed prisoners were male, 46.6 percent were black, and all offenses involved killing.5 As mentioned earlier, the most common themes in last statements were love (in 70% of last statements) and spirituality (56%) (Table 1). The most common psychological factors were identification-egression (62%), unbearable psychological pain (53%), and rejection-aggression (42%) (Table 2).

View this table:
[Table 1](http://jaapl.org/content/41/4/540/T1)

Table 1 
Frequency of Themes in Last Statements from Death Row, Texas: April 1, 2002 to November 30, 2006, and December 1, 2006 to July 31, 2011

View this table:
[Table 2](http://jaapl.org/content/41/4/540/T2)

Table 2 
Psychological Factors Evident in Last Statements from Death Row, Texas: April 1, 2002 to November 30, 2006, and December 1, 2006 to July 31, 2011

In light of the high level of interest in our work,5 the paucity of literature, and decline in capital punishment in the U.S. (including Texas) since our first study, we decided to study more recent last statements from death row, Texas, to identify any changes in theme or content, comparing the last statements of recent years with those in our original study.

## Methods

### Study Sample

We studied the last statements made by all death row prisoners executed in Texas between December 1, 2006, and July 31, 2011. These last statements are published on the website of the Texas Department of Criminal Justice.4 To optimize comparability with our previous study, which spanned a 56-month period (April 1, 2002–November 30, 2006),5 we studied the next 56-month period. During this period, 93 death row prisoners were executed, of whom 79 made last statements. We again limited our study to Texas, owing to the ready availability of data and a desire to optimize comparability with our earlier study.

### Assessment of Last Statements

We recorded the following baseline characteristics for each prisoner from the website of the Texas Department of Criminal Justice: the prisoner's race (black, white, Hispanic, or Asian); the number of years the prisoner had spent in education, the prisoner's age at the time of the offense, the prisoner's age at the time of execution, the number of months spent on death row, the number of victims involved in the offense (one or more than one), whether the offense involved a child victim (yes/no), and whether the offense involved sexual assault (yes/no).

A single assessor (S.R.F.) reviewed all last statements and recorded whether the following themes were present: spirituality (references of a religious nature; e.g., quotations from scripture, mentions of God), regret for the offense, request for forgiveness, literary references (including poems by the prisoner), love (i.e., the use of the word love), apology to the victim's family, apology to the prisoner's own family, anger (e.g., hostile comments to attendees at the execution), and denial of the offense.

For the analysis of psychological constructs we used our adaptation of the TGSP,26,–,29 which we used in our earlier study.5 The author of the TGSP describes it as an inferential guide to suicidal thoughts, developed from extensive study of suicide notes and last communications, spoken or written, from individuals who subsequently died by suicide.26 The aim of the TGSP is to assist in risk assessment of suicidal individuals by identifying in written or verbal communications the presence or absence of psychological constructs listed in the tool. There are two sections, one devoted to intrapsychic and one to interpersonal themes, divided into eight subsections. These subsections contain protocol statements against which the communication being examined is compared. The subsections are as follows.

### Intrapsychic Themes

#### Unbearable Psychological Pain

There are six statements in this subsection, two of which are not applicable on death row, because of the lack of control over the death. The four remaining statements refer to the idea that death stops painful tension, relieves intolerable pain, and provides flight from psychological and environmental traumas.

#### Cognitive Constriction

There are three statements in this subsection, examining whether the individual appears overwhelmed by emotion and has constricted logic or perception. There may be poverty of thought, with a focus only on grief.

#### Indirect Expressions

There are three statements in this subsection, two of which are applicable on death row. These seek evidence of contradictory feelings and attitudes in the communication or that the prisoner appears ambivalent or unclear about the situation in which he finds himself (facing death).

#### Inability to Adjust

There are three statements in this subsection, seeking to establish whether the individual seems to reject everything, wanting to escape life. There may be evidence of mental disorder (e.g., mania, psychosis, or major depression).

#### Ego

There are three statements in this subsection, two of which are applicable on death row. These statements seek evidence of weakness in the capacity for constructive tendencies such as attachment and love, or other factors relating to ego strength. There may also be evidence of unresolved problems in the communication (e.g., feeling unjustly accused).

### Interpersonal Themes

#### Personal Relationships

There are six statements in this subsection, four of which are applicable to death row. These seek evidence of difficult or unresolved problems in relationships. The individual may describe stress or frustration around relationships or there may be evidence of pathologic or unhealthful attachments.

#### Rejection-Aggression

There are eight statements in this subsection, six of which are applicable on death row. These seek evidence of disgust or rejection of either oneself or others or preoccupation with a rejecting or lost other. There may be evidence of vengeful or destructive thoughts or impulses, or the individual may hope that his death will have a negative effect on others.

#### Identification-Egression

There are three statements in this subsection, seeking to establish whether the individual identifies with a lost or rejecting other or ideal. This loss allows the individual to desire death as an escape from hurt. As a result, the individual may want to flee from the situation and may come to regard death as a form of escape from undesired circumstances (such as the present one) rather than as an end to life.

Each of these eight factors is examined by verifying whether the specific protocol statements in the tool correspond to the contents of the last statement. For each protocol statement the researcher records whether there is evidence of the sentiment in the last statement (yes/no).

Finally, we selected extracts from last statements for inclusion in the results. These extracts were purposely selected to provide examples of the content of some of the last statements.

### Statistical Analysis

We used the Statistical Package for the Social Sciences to analyze the data.30 For univariate analyses, we used Student's *t* test, Pearson chi square, and the Mann-Whitney *U* test. For multivariate analyses, we generated binary logistic regression models for the four most common psychological factors in last statements: in each model the dependent variable was presence or absence of the psychological factor, and the independent variables were baseline characteristics (e.g., race) and observed themes (e.g., spirituality).

### Ethics

This study used existing data that are publicly available and was thus exempt from full research ethics review under the guidelines of the University College Dublin ([http://www.ucd.ie/researchethics/apply/exemptions](http://www.ucd.ie/researchethics/apply/exemptions)).

## Results

### Quantitative Results

During the 56-month period studied, 93 death row prisoners were executed (20 executions per year). All were male. Thirty-nine (41.9%) identified as black, 32 (34.4%) as white, and 22 (23.7%) as Hispanic. The mean number of years of education was 10.10 (SD 1.77). Median age at the offense was 23 years (range, 18–45). Median age at execution was 38 years (range, 27–59).

All offenses involved killing. Thirty-three (35.5%) offenses involved more than one victim and 17 (18.3%) involved at least one child. Twenty-one (22.6%) offenses involved sexual assault. None of these parameters differed from those in our earlier study5 (*p* > .05 for all comparisons). In the present study, the median number of months spent on death row before execution (127; range, 14–380) was longer than that in our earlier study (109; range, 25–254)5 (mean rank in the present study, 115.77; mean rank in our earlier study, 96.36; Mann-Whitney *U* test = 6396; *p* = .02).

In the current study, there was no difference between prisoners who made last statements (*n* = 79) and those who did not (*n* = 14) in terms of race (Pearson χ2 = 1.93; *p* = .38), years of education (*t* = 1.01; *p* = .07), age at offense (Mann-Whitney *U* test = 509, *p* = .64), months on death row (Mann-Whitney *U* test = 367.00; *p* = .07), proportion of offenses involving more than one victim (Pearson χ2 = 0.00; *p* >. 99), proportion of offenses involving at least one child victim (Pearson χ2= 1.17; *p* = .28), and proportion of offenses involving sexual assault (Pearson χ2 = .01; *p* > .99). Prisoners who made last statements were slightly younger at the time of execution (median, 37 years) compared with those who did not make last statements (42 years) (mean rank of prisoners who made last statements, 44.61; mean rank of prisoners who did not make last statements, 64.46; Mann-Whitney *U* test = 7364.50; *p* = .04).

Love and spirituality were the most common themes, appearing in 82 and 52 percent of last statements, respectively; these were also the most common themes in our earlier study5 (Table 1). Regret for the offense was the next most common theme (39%), and quotations from poetry or literature were the least common in both this study (8%) and our previous one (12%).5 There were no statistically significant differences in the frequency of themes between our two studies, although there was a trend for the theme of love to be more common in the present study (*p* = .08).

In the present study, the most common psychological factors in last statements were indirect expressions (43%), identification-egression (40%), rejection-aggression (38%), and unbearable psychological pain (37%) (Table 2). Compared with our previous study,5 one psychological factor was more common in the present study (indirect expression), and four were less common (interpersonal relations, identification-egression, inability to adjust, and unbearable psychological pain) (*p* < .05 in all cases).

Prisoners whose last statements contained indirect expressions were younger at the time of the offense (β = −0.35; *p* = .03) and had spent shorter periods on death row (β = −0.04; *p* = .02) (overall *r*2 for the model = 0.39). Prisoners whose last statements contained identification-egression were less likely to have been convicted of sexual assault (β = −3.18; *p* < .01), more likely to include a spiritual theme (β = 2.45; *p* < .01) and less likely to apologize to their own families (β = −3.17; *p* = .03) (*r*2 = 0.54). Prisoners whose last statements contained rejection-aggression were more likely to express anger (β = 6.58; *p* < .01; *r*2 = 0.79). Prisoners whose last statements contained unbearable psychological pain were more likely to apologize to their own families (β = 3.35; *p* = .03) and the victim's family (β = 3.76; *p* = .02; *r*2 = 0.58).

### Examples of Last Statements

Spirituality and love were two of the most common themes in last statements in both this study and our previous one (Table 1).5 Examples from the present study include: 

*   Jesus receive my spirit. I love you Edgardo; I appreciate your hard work. Thank you. Okay. Receive my spirit. Thanks sir.

*   I love you. May the Lord be with you. Peace, I'm done.

*   Don't cry, it's my situation. I got it. Hold tight, It's going to shine on the golden child. Hold tight. I love you.

Expressions of love are sometimes combined with regret: 

*   If I can go back and change the past I would, there's nothing I can do. I'm sorry. I love you Adonya. That's it.

The theme of apology is evident in certain last statements, sometimes in combination with spirituality: 

*   First of all I would like to tell my Uncle Kyle that I am sorry. I have been sorry for the last 10 years for what I did. I wish you could accept my apology. I know you can't accept my apology; I know you can't give your forgiveness; it's okay and I understand. I have done what I could to heal the rest of the family. I wish that someday you could come to terms and understand. I know I was wrong; I accept responsibility as a man. I take this penalty as a man. This doesn't solve anything, 'cause it hurts others that love me. I am sorry.

*   Yes sir, I would like to ask forgiveness of the family. I have no reason for why I did it, I don't understand why I did it. I hope that you can live the rest of your lives without hate. I pray the Lord grant me forgiveness. All powerful and almighty Lord I commit myself to thee, Amen.

By way of contrast, other last statements present themes of anger and denial, sometimes in combination with denial of the offense and rejection-aggression: 

*   I know y'alls' pain, believe me I shed plenty of tears behind Carlos. Carlos was my friend. I didn't murder him. This what is happening right now is an injustice. This doesn't solve anything. This will not bring back Carlos. Y'all fought real hard here to prove my innocence. This is only the beginning. I love each and everyone dearly. Dre My queen. I love you. Yaws, Junie I love y'all. Stay strong, continue to fight. They are fixing to pump my veins with a lethal drug the American Veterinary Association won't even allow to be used on dogs. I say I am worse off than a dog. They want to kill me for this; I am not the man that did this. Fight on. I will see y'all again.

Some last statements present complex combinations of themes and psychological factors. The following example demonstrates themes of spirituality and anger; psychological factors, including unbearable psychological pain and inability to adjust; specific comments about the Allan B. Polunsky Unit, a facility operated by the Texas Department of Criminal Justice; and a plea for the abolition of capital punishment: 

*   The Polunsky dungeon should be compared with the death row community as existing not living. Why do I say this, the death row is full of isolated hearts and suppressed minds. We are filled with love looking for affection and a way to understand. I am a death row resident of the Polunsky dungeon. Why does my heart ache? We want pleasure love and satisfaction. It… The walls of darkness crushed in on me. Life without meaning is life without purpose. But the solace within the Polunsky dungeon, the unforgiveness within society, the church pastors and Christians. It is terrifying. Does anyone care or who I am? Can you feel me people? The Polunsky dungeon is what I call the pit of hopelessness. The terrifying thing is the U.S. is the only place, country that is the only civilized country that is free that says it will stop murder and enable justice. I ask each of you to lift up your voices to demand an end to the death penalty. If we live, we live to the Lord. If we die we die to the Lord. Christ rose again, in Jesus name. Bye Aunt Helen, Luise, Joanna and to all the rest of y'all. You may proceed Warden. (began singing).

Finally, while some prisoners chose not to make any last statements, others made exceedingly brief statements: 

*   Yes, ain't no way fo' fo', I love all y'all.

*   Blessed are they that mourn, for they shall be comforted. It is finished.

*   Bye, I'm ready.

## Discussion

The rate of execution in Texas declined by 20 percent from 25 executions per year between April 2002 and November 2006 to 20 per year between December 2006 and July 2011. In the latter period, last statements of prisoners most often demonstrated themes of love (82%), spirituality (52%), and regret (39%). The most common psychological factors were indirect expressions (43%), identification-egression (40%), rejection-aggression (38%), and unbearable psychological pain (37%). The similarity of findings over the two periods demonstrates consistent distress in this population over time.

This study has several strengths. It and our previous one focused on an important topic that is relatively neglected in the literature: the mental state of death row prisoners immediately before execution.5 The completeness of the sample is another strength: we included all prisoners executed in Texas between December 1, 2006, and July 31, 2011. Although 14 prisoners of the 93 executed did not make last statements, those prisoners did not differ in age, race, education, and ages at offense and execution, from those who made last statements.

Limitations include the fact that we used the TGSP, which was developed for the study of suicide notes rather than last statements from death row.26,–,29 However, although there are significant differences between individuals who write suicide notes and prisoners on death row (e.g., the element of perceived choice), there are also similarities: both have high rates of mood disorder15,29,31 and both face imminent death. Moreover, there is no gold standard with which to compare the TGSP for the analysis of last statements. Our adaptation of the TGSP has face validity (i.e., measures relevant criteria such as unbearable psychological pain) and content validity (i.e., covers the required domains). In addition, we had used this tool previously, to informative effect.5

Other potential limitations of the present study include limits on the generalizability of findings beyond death row in Texas. The literature relating to the mental health of prisoners on death row throughout other U.S. states, however, is notably consistent: Cunningham and Vigen15 summarized studies from a range of states, including New York, North Carolina, Florida, Alabama, Mississippi, and California, and these studies indicated consistently high levels of psychological and psychiatric morbidity in death row prisoners across these states. This consistency suggests that our findings may have significant generalizability within the United States, beyond Texas.

### Last Statements and Mental Health

Our studies of last statements are strongly consistent with the broader literature that has demonstrated increased rates of psychological problems and mental illness on death row.14,15,21,22 We showed that the psychological factors most commonly in last statements (2002–2006) are very similar to those in suicide notes (e.g., identification-egression in 62% of last statements5 and 80% of suicide notes29). Similarly, the psychological constructs least common in last statements are generally least common in suicide notes (e.g., ego in 28% of last statements5 and in 36% of suicide notes29).

This finding holds true for the present study (2006–2011), in which the most notable difference between last statements and suicide notes is the low prevalence of cognitive constriction in last statements (32%) compared with that in suicide notes (87%).29 This may reflect the particular association between cognitive constriction and depression in individuals who die by suicide.

The similarity between the themes and psychological constructs in last statements from death row and suicide notes may point to a convergence of psychological concerns immediately before death, with a notable focus on love, spirituality, and regret. This area merits further study, possibly involving comparison with other forms of communication immediately before death (e.g., last statements in hospice settings).

### Subgroups of Death Row Prisoners According to Last Statements

Our earlier study of last statements demonstrated identifiable subgroups of prisoners on death row. Those whose last statements contained identification-egression were more likely to be convicted of a nonsexual offense, admit to the offense, and express love.5 Prisoners whose last statements revealed unbearable psychological pain were younger at the time of the offense and had spent shorter periods on death row. Prisoners whose last statements demonstrated rejection-aggression were more likely to be convicted of a sexual offense, to make spiritual references, and to express anger, but were less likely to express regret.

The models that emerged in the present study are broadly consistent with these subgroups. In particular, the present study shows that prisoners whose last statements contain identification-egression were more likely to have been convicted of a nonsexual offense (as in the previous study) and to include themes of spirituality and apology to their own families in their last statements. Our earlier study found that love was the most common theme in this subgroup. The present study also demonstrates associations between the psychological construct of rejection-aggression and the theme of anger (as in our previous study), and the psychological construct of unbearable psychological pain and the theme of apology to one's own and the victim's family.

Unlike our previous study, the present study found that the psychological factor most common in last statements between December 2006 and July 2011 is indirect expression, present in 43 percent of last statements during this period. On multivariate testing, this type of expression is associated with younger age at offense and having spent a shorter period on death row before execution. This finding may reflect the use of less explicit figures of speech among younger prisoners who have had a shorter period to adjust to their situation and are, as a result, less direct in their cognitive and communication styles.

This finding is interesting, because it adds a new dimension to the existing knowledge about the effects of death row on mental health. These effects can vary significantly between individuals. For some individuals, time spent on death row involves intense psychological change, which may, for example, result in an altered pattern of religious practice and spiritual awareness.32 These changes may account for the fact that themes of love, spirituality, and regret are common in last statements (Table 1), despite the distressing nature of the offenses for which many of these prisoners were convicted.

For many prisoners, time spent on death row involves very substantial psychological suffering and pain.33 Consistent with this, the present study demonstrated high rates of intense suffering and unbearable psychological pain immediately before execution. The broader literature, too, plainly documents substantial deterioration in mental health on death row.14,23,24 Lester and Tartaro20 studied death row suicide rates in the United States between 1976 and 1999 and found a rate of 113 per 100,000 per year, five times higher than the rate in the U.S. male population. Of interest, the statistic for young U.S. army veterans lies somewhere between these two rates.34,35

Overall, the present study, along with the broader literature, provides strong evidence that being on death row is associated with notable psychological change, substantial psychological pain, and considerable psychiatric morbidity. There remain, however, significant gaps in knowledge regarding certain aspects of psychological adjustment on death row. For example, little is known about the moment when a death row prisoner realizes that, while he may have successfully delayed execution for many years, he has, at a certain point, exhausted virtually all options for living, save for a very rare last-minute reprieve. Does the psychological uncertainty and intense suffering associated with this process mean that being on death row constitutes “torture” or “cruel, inhuman or degrading treatment or punishment” as outlined in the Universal Declaration of Human Rights?7

The intense psychological pain demonstrated in our studies of last statements, along with the broader literature, poses profound questions about precisely which goals of justice are served by sending a prisoner to death row. Our studies, along with the literature, suggest that a sentence of death really means “death preceded by many years of intense psychological pain and suffering.” Although a lengthy period on death row may be necessary to exhaust appeals mechanisms, it remains the case that, for most of these prisoners, execution is likely to be preceded by years of intense psychological suffering. Is this consistent with societal preferences in relation to capital punishment, or does it support the view that the death penalty is deeply flawed, both morally and as a public policy? Finally, what does this situation mean for psychiatrists and psychologists working on death row?

### Dilemmas Faced by Psychiatrists and Psychologists Working on Death Row

A further dimension of the present work relates to its implications for treatment of psychological and psychiatric symptoms on death row, and the ethics-based dilemmas faced by psychiatrists and psychologists working in these settings. In the first instance, our studies demonstrate consistent evidence across time that prisoners on death row in Texas resemble suicidal individuals in certain important respects. Most important, they have high levels of psychological pain and mental illness, requiring treatment.

Ethically, psychiatrists and other mental health professionals working in these settings can and should provide such care.9 Care may also be provided by others, such as religious professionals, but it is important to note that death row prisoners have the right to expect mental health care, the same as individuals who are not in prison.36

In terms of the precise care required, the study of last statements, combined with the broader literature, certainly demonstrates substantial need for both psychiatric and psychological care. To probe more deeply into the therapeutic implications of last statements, further study of last statements by using narrative or ethnographic approaches would allow for more in-depth analysis and help establish directions for treatments specific to this population. Such studies may also provide rich information about the psychological effects of a sentence of death and its precise nature as a punishment, especially in the years before execution.

Once effective care is provided, psychiatrists and psychologists face the possibility that the prisoner may be deemed competent to be executed and then killed.12 Notwithstanding this possible outcome, it still appears unethical to deny treatment to any individual, including a prisoner on death row.36 This position clearly poses difficulties for psychiatrists and psychologists, but the difficulty stems not from the ethics-based duty of psychiatrists to treat, but from the peculiar concept of competence to be executed and society's decision to retain the death penalty in the first place.12

Finally, there are clear ethics-related implications in the finding that being on death row is associated with a significant deterioration in mental health,14,23,24 increased risk of suicide,20 and unbearable psychological pain (as demonstrated in our studies).5,6 Whether this constitutes torture or cruel, inhuman or degrading treatment or punishment7 from a legal perspective is not clear. From a medical ethics perspective, however, these findings create an ethics-based duty for psychiatrists to object to the sending of individuals to death row, on the grounds that being on death row has an adverse effect on mental health, quite apart from the ultimate execution.

In relation to future research, there is a clear need to look beyond last statements such as those in the present study. These last statements are brief and time specific, and are not overall statements from the death row prisoner about his situation. Further information may be available from other sources, such as criminal records, courtroom transcripts, prison documents, evaluations by various professionals before and after imprisonment, and unofficial last statements left in prison cells, given to religious ministers, or posted to relatives.

Other sources of information include the work of activists such as Sister Helen Prejean, a Roman Catholic religious sister and campaigner for the abolition of the death penalty. Sister Prejean provided particularly moving insights into the case of Karla Faye Tucker who was convicted of murder in Texas in 1984.37 Sister Prejean spent time with Ms. Tucker, talking and visiting a chapel. She noted that Ms. Tucker had transformed her life profoundly during her time on death row.

Notwithstanding the thousands of appeals for clemency sent to Governor George Bush, Ms. Tucker was executed on February 3, 1998. Her last words were in stark contrast with the nature of her offenses, some 15 years earlier.

*   Yes sir, I would like to say to all of you— the Thornton family and Jerry Dean's family—that I am so sorry. I hope God will give you peace with this. Baby, I love you. Ron, give Peggy a hug for me. Everybody has been so good to me. I love all of you very much. I am going to be face to face with Jesus now. Warden Baggett, thank all of you so much. You have been so good to me. I love all of you very much. I will see you all when you get there. I will wait for you.

This case generated considerable discussion. Pearlman38 examined the case with care, paying particular attention to Ms. Tucker's religious transformation on death row and questioning the effectiveness of capital punishment as a deterrent to others. He drew attention to the fact that the lengthy appeals process may stretch for over a decade, during which time there may be significant personality development or personal change resulting from rehabilitation in prison.

## Conclusions

The last statements of prisoners on death row most often demonstrate themes of love, spirituality, and regret. The most common psychological factors are indirect expressions, identification-egression, rejection-aggression, and unbearable psychological pain. These findings are consistent over time.

The similarity between themes and psychological constructs most common in last statements from death row and in suicide notes points to a possible convergence of concerns at the end of life, regardless of the circumstances of death. This area requires further study, but may have implications for mental health care at the end of life.

The involvement of psychiatrists on death row is complex: while ethical codes expressly forbid involvement in executions, there are high rates of mental illness, psychological problems and unbearable psychological suffering among death row prisoners. Notwithstanding the possibility that psychiatric treatment may restore competence and expedite execution, it still seems unethical to deny treatment.

There is strong evidence that being on death row is associated with difficulties with direct communication and unbearable psychological pain, as well as poor mental health and suicide. Whether this constitutes “torture” or “cruel, inhuman or degrading treatment or punishment”7 from a strictly legal perspective is not clear. From a medical ethics perspective, however, this creates an ethics-based duty for psychiatrists to object to the sending of individuals to death row, on the grounds that being on death row has an adverse effect on mental health, quite apart from the ultimate execution.

## Footnotes

*   Disclosures of financial or other potential conflicts of interest: None.

*   © 2013 American Academy of Psychiatry and the Law

## References

1.  1. Amnesty International: Death Sentences and Executions 2011. London: Amnesty International Publications, 2012
    
    

2.  2. Amnesty International: Amnesty International Report 2006: The State of the World's Human Rights. London: Amnesty International UK, 2006
    
    

3.  3. Snell TL: Capital Punishment, 2005. Washington DC: Department of Justice, Bureau of Justice Statistics Bulletin, NCJ 215083, 2006
    
    

4.  4. Executed offenders. Huntsville, TX: Texas Department of Justice. Available at [http://www.tdcj.state.tx.us/stat/dr\_executed\_offenders.html](http://www.tdcj.state.tx.us/stat/dr_executed_offenders.html). Accessed March 22, 2013
    
    

5.  5. Foley SR, Kelly BD: The psychological concomitants of capital punishment: thematic analysis of last statements from death row. Am J Forensic Psychiatry 28:7–13, 2007
    
    

6.  6. Kelly BD, Foley SR: The price of life. BMJ 335:938, 2007
    
    [FREE Full Text](http://jaapl.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiYm1qIjtzOjU6InJlc2lkIjtzOjEyOiIzMzUvNzYyNi85MzgiO3M6NDoiYXRvbSI7czoyMDoiL2phYXBsLzQxLzQvNTQwLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

7.  7. United Nations: Universal Declaration of Human Rights. Geneva: United Nations, 1948
    
    

8.  8. United Nations: International Covenant on Civil and Political Rights. Geneva: United Nations, 1966
    
    

9.  9. Council on Ethical and Judicial Affairs (American Medical Association): Physician participation in capital punishment. JAMA 270:365–8, 1993
    
    [CrossRef](http://jaapl.org/lookup/external-ref?access_num=10.1001/jama.1993.03510030089040&link_type=DOI) 
    
    [PubMed](http://jaapl.org/lookup/external-ref?access_num=8315782&link_type=MED&atom=%2Fjaapl%2F41%2F4%2F540.atom) 
    
    [Web of Science](http://jaapl.org/lookup/external-ref?access_num=A1993LM43500033&link_type=ISI) 

10. 10. Society of Correctional Physicians Board of Directors: Code of Ethics of the Society of Correctional Physicians. Chicago, IL: Society of Correctional Physicians, 1997
    
    

11. 11. Gawande A: When law and ethics collide: why physicians participate in executions. N Engl J Med 354:1221–9, 2006
    
    [CrossRef](http://jaapl.org/lookup/external-ref?access_num=10.1056/NEJMp068042&link_type=DOI) 
    
    [PubMed](http://jaapl.org/lookup/external-ref?access_num=16554524&link_type=MED&atom=%2Fjaapl%2F41%2F4%2F540.atom) 
    
    [Web of Science](http://jaapl.org/lookup/external-ref?access_num=000236164200001&link_type=ISI) 

12. 12. Matthews D, Wendler S: Ethical issues in the evaluation and treatment of death row inmates. Curr Opin Psychiatry 19:518–21, 2006
    
    [PubMed](http://jaapl.org/lookup/external-ref?access_num=16874127&link_type=MED&atom=%2Fjaapl%2F41%2F4%2F540.atom) 

13. 13. Leong GB, Silva JA, Weinstock R, et al: Survey of forensic psychiatrists on evaluation and treatment of prisoners on death row. J Am Acad Psychiatry Law 28:427–32, 2000
    
    [Abstract](http://jaapl.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFhcGwiO3M6NToicmVzaWQiO3M6ODoiMjgvNC80MjciO3M6NDoiYXRvbSI7czoyMDoiL2phYXBsLzQxLzQvNTQwLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

14. 14. Cunningham MD, Vigen MP: Without appointed counsel in capital postconviction proceedings: the self-representation competency of Mississippi death row inmates. Crim Just Behav 26:293–321, 1999
    
    [Abstract/FREE Full Text](http://jaapl.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToic3BjamIiO3M6NToicmVzaWQiO3M6ODoiMjYvMy8yOTMiO3M6NDoiYXRvbSI7czoyMDoiL2phYXBsLzQxLzQvNTQwLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

15. 15. Cunningham MD, Vigen MP: Death row inmate characteristics, adjustment, and confinement: a critical review of the literature. Behav Sci Law 20:191–210, 2002
    
    [CrossRef](http://jaapl.org/lookup/external-ref?access_num=10.1002/bsl.473&link_type=DOI) 
    
    [PubMed](http://jaapl.org/lookup/external-ref?access_num=11979498&link_type=MED&atom=%2Fjaapl%2F41%2F4%2F540.atom) 
    
    [Web of Science](http://jaapl.org/lookup/external-ref?access_num=000175388000013&link_type=ISI) 

16. 16. Stoupel E, Kalëdienë R, Petrauskiene J, et al: Suicide-homicide temporal interrelationship, links with other fatalities, and environmental physical activity. Crisis 26:85–9, 2005
    
    [PubMed](http://jaapl.org/lookup/external-ref?access_num=16138745&link_type=MED&atom=%2Fjaapl%2F41%2F4%2F540.atom) 

17. 17. Large M, Smith G, Nielssen O: The epidemiology of homicide followed by suicide: a systematic and quantitative review. Suicide Life Threat Behav 39:294–306, 2009
    
    [PubMed](http://jaapl.org/lookup/external-ref?access_num=19606921&link_type=MED&atom=%2Fjaapl%2F41%2F4%2F540.atom) 

18. 18. Asnis GM, Kaplan ML, van Praag HM, et al: Homicidal behaviors among psychiatric outpatients. Hosp Community Psychiatry 45:127–32, 1994
    
    [PubMed](http://jaapl.org/lookup/external-ref?access_num=8168790&link_type=MED&atom=%2Fjaapl%2F41%2F4%2F540.atom) 

19. 19. Asnis GM, Kaplan ML, Hundorfean G, et al: Violence and homicidal behaviors in psychiatric disorders. Psychiatr Clin North Am 20:405–25, 1997
    
    [CrossRef](http://jaapl.org/lookup/external-ref?access_num=10.1016/S0193-953X(05)70320-8&link_type=DOI) 
    
    [PubMed](http://jaapl.org/lookup/external-ref?access_num=9196922&link_type=MED&atom=%2Fjaapl%2F41%2F4%2F540.atom) 

20. 20. Lester D, Tartaro C: Suicide on death row. J Forensic Sci 47:1108–11, 2002
    
    [PubMed](http://jaapl.org/lookup/external-ref?access_num=12353556&link_type=MED&atom=%2Fjaapl%2F41%2F4%2F540.atom) 

21. 21. Lewis DO, Pincus JH, Feldman M, et al: Psychiatric, neurological, and psychoeducational characteristics of 15 death row inmates in the United States. Am J Psychiatry 143:838–45, 1986
    
    [PubMed](http://jaapl.org/lookup/external-ref?access_num=3717422&link_type=MED&atom=%2Fjaapl%2F41%2F4%2F540.atom) 
    
    [Web of Science](http://jaapl.org/lookup/external-ref?access_num=A1986C994200004&link_type=ISI) 

22. 22. Freedman D, Hemenway D: Precursors of lethal violence: a death row sample. Soc Sci Med 50:1757–70, 2000
    
    [CrossRef](http://jaapl.org/lookup/external-ref?access_num=10.1016/S0277-9536(99)00417-7&link_type=DOI) 
    
    [PubMed](http://jaapl.org/lookup/external-ref?access_num=10798330&link_type=MED&atom=%2Fjaapl%2F41%2F4%2F540.atom) 
    
    [Web of Science](http://jaapl.org/lookup/external-ref?access_num=000086375400005&link_type=ISI) 

23. 23. Gallemore J, Panton J: Inmate responses to lengthy death row confinement. Am J Psychiatry 129:81–5, 1972
    
    

24. 24. Johnson R: Under sentence of death: the psychology of death row confinement. Law Psychol Rev 5:141–92, 1979
    
    

25. 25. Elder RK: Last Words of the Executed. Chicago: University of Chicago Press, 2010
    
    

26. 26. Leenaars A: Suicide Notes. New York: Human Sciences Press, 1988
    
    

27. 27. Leenaars AA: Psychotherapy with Suicidal People: A Person-Centred Approach. Chichester, United Kingdom: John Wiley and Sons, 2004
    
    

28. 28. Leenaars AA, Haines J, Wenkenstern S, et al: Suicide notes from Australia and the United States. Percept Mot Skills 96:1281–2, 2003
    
    [PubMed](http://jaapl.org/lookup/external-ref?access_num=12929782&link_type=MED&atom=%2Fjaapl%2F41%2F4%2F540.atom) 

29. 29. O'Connor R, Sheehy N, O'Connor D: A thematic analysis of suicide notes. Crisis 20:106–14, 1999
    
    [PubMed](http://jaapl.org/lookup/external-ref?access_num=10553305&link_type=MED&atom=%2Fjaapl%2F41%2F4%2F540.atom) 

30. 30. SPSS Inc: SPSS 12.0 Base Users Guide. Upper Saddle River, NJ: Prentice-Hall Regents, 2003
    
    

31. 31. Henriksson MM, Aro HM, Marttunen MJ, et al: Mental disorders and comorbidity in suicide. Am J Psychiatry 150:935–40, 1993
    
    [PubMed](http://jaapl.org/lookup/external-ref?access_num=8494072&link_type=MED&atom=%2Fjaapl%2F41%2F4%2F540.atom) 
    
    [Web of Science](http://jaapl.org/lookup/external-ref?access_num=A1993LD84300015&link_type=ISI) 

32. 32. Masters JJ: Finding Freedom: Writings from Death Row. Junction City, CA: Padma Publishing, 1997
    
    

33. 33. Jacobs S: Stolen Time: The Inspiring Story of an Innocent Woman Condemned to Death. London: Doubleday, 2007
    
    

34. 34. Kaplan MS, Huguet N, McFarland BH, et al: Suicide among male veterans: a prospective population based study. J Epidemiol Community Health 61:619–24, 2007
    
    [Abstract/FREE Full Text](http://jaapl.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiamVjaCI7czo1OiJyZXNpZCI7czo4OiI2MS83LzYxOSI7czo0OiJhdG9tIjtzOjIwOiIvamFhcGwvNDEvNC81NDAuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

35. 35. Miller M, Azrael D, Barber C, Mukamal K, Lawler E: A call to link data to answer pressing questions about suicide risk among veterans. Am J Public Health 102(suppl. 1):S20–2, 2012
    
    [PubMed](http://jaapl.org/lookup/external-ref?access_num=22390593&link_type=MED&atom=%2Fjaapl%2F41%2F4%2F540.atom) 

36. 36. United Nations: Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care, New York: United Nations, Secretariat Centre For Human Rights, 1991
    
    

37. 37. Prejean H: Death in Texas. The New York Review of Books. January 13, 2005
    
    

38. 38. Pearlman T: The ethics of the Texas death penalty and its impact on a prolonged appeals process. J Am Acad Psychiatry Law 26:655–60, 1998
    
    [Abstract/FREE Full Text](http://jaapl.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFhcGwiO3M6NToicmVzaWQiO3M6ODoiMjYvNC82NTUiO3M6NDoiYXRvbSI7czoyMDoiL2phYXBsLzQxLzQvNTQwLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==)