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XIII. SUICIDE AND SELF-MUTILATION

Human Rights Watch exegesis: a seriously mentally ill inmate in a super-maximum security prison was caught eating his own flesh after having cut open his arm with a shard of glass. He was brought before a disciplinary committee, and was sentenced to a year in the prison’s segregation cells.

Self-mutilation, suicide attempts, and suicides are far too common in prison. The prevalence of such self-harm is linked both to the prevalence of mental illness among prisoners and inadequate mental health treatment.

Self-Mutilation

We were not able to find any national or state-wide statistics on the prevalence of self-mutilation in prison. Nevertheless, the extent of the mutilation and the determination exhibited by prisoners to engage in serious acts of self-harm is astonishing. Prisoners have swallowed pins, inserted pencils in their penises and paperclips in their abdomens, bitten chunks of flesh from their arms, slashed and gashed themselves. In many prisons around the country, Human Rights Watch has interviewed prisoners whose bodies are massively scarred from self-mutilation. Both correctional and mental health staff acknowledge that self-mutilation is a major problem.

Elaine Lord, superintendent at the Bedford Hills Correctional Facility in New York, catalogues the remarkable ways women have injured themselves: “cutting their own throat, legs, arms, or wrist; headbanging; inserting foreign objects under the skin or into wounds or surgical sites on the body; overdosing on medication; or swallowing an extraordinary variety of objects including, but not limited to, knitting needles, screws, straight pins, safety pins, pens, pencils, light bulbs, springs, nails, pieces of radiator, screens, uniform name tags, pieces of wall, and chips of paint.”⁵⁹⁸

The complaint in a lawsuit against the supermax prison in Tamms, Illinois, drawing on prisoner medical records and psychiatrist interviews, details the self-harm of several mentally ill prisoners.⁵⁹⁹ Among the examples cited:

• Twenty three year old D.T.Q. has an extensive psychiatric history that includes a year-long hospitalization at the Illinois State Psychiatric Institute as well as several suicide attempts. After D.T.Q. was incarcerated at Tamms, he

began hallucinating. He screamed and talked to imaginary people in his cell, once explaining to staff that he was busy having a party. Another time, he saw demons crawling out of his toilet and walls. He began to sit in a tent he had made himself from his blanket, explaining that he was hiding from five drunken correction officers who had threatened him. He began to think his food was being poisoned, that the walls were closing in on him, that the guards were conspiring with one of the inmates to kill him. Eventually, D.T.Q. became violent toward himself and he remains so today. He has repeatedly cut his arms and neck, bitten his shoulders, and bashed his head into a wall.

• T.C. routinely self-mutilates, slicing his arms, neck, and abdomen. He has had to be placed on suicide watch several times, once after he was found with a rope around his neck.

On August 20 [1998], with his arms already swollen from infected self-inflicted wounds, T.C. again cut his arm and began eating small pieces of his own flesh in front of a correctional officer. The officer ignored the medical emergency and also ignored T.C.’s pleas to speak with someone from the mental health unit. Eventually T.C. was removed from the cell and his arm was stitched. Despite the obvious danger T.C. posed to himself, he was returned to the same cell and left unattended (and evidently still in possession of a dangerous instrument); again he cut himself, again requiring stitches to close the wound…. T.C. pulled the stitches out of his arm and lost more than half a pint of blood before he was discovered bleeding in his cell.

In an interview, this prisoner explained to Human Rights Watch that after he had cut his arm with a piece of razor, he had inserted the piece into the gash on his arm. When his arm was stitched up in the infirmary, the razor piece was not removed. Once returned to his cell, he tore out the stitches, removed the razor, and began cutting himself again.⁶⁰⁰

• Another prisoner at Tamms sent Human Rights Watch a letter detailing his experience in Illinois prisons:

I have been in Tamms [for two years]…. I have never had any major mental health issues until I arrived at the Tamms Supermax prison. Also before I came to the Tamms Supermax prison I have never self-mutilated myself. I was placed on (1) crisis in Western Illinois Correctional for saying that I felt suicidal, and I was place on (2) crisis watches while in the Pontiac Correctional Center for making a home made noose and the other for setting my cell on fire. Once I arrived at the Tamms Correctional Center I did not have any problems until about 5 months after my arrival when I was placed on a wing with all inmates who self-mutilated on themselves (at the time I was placed on this wing I had never mutilated myself). After this I soon started to mutilate on myself, this was around October of 2000. When I first started to mutilate on myself it was always labeled as superficial and swept under the rug. After a while it started to get worse and worse. But at no time from October of 2000 until January of 2002 was I given any treatment. Around August of 2001 it was getting so bad that I had to be placed in four point restraints when I mutilated myself. Around December of 2001 I had to start getting stitches for my self-mutilation. When I cut they just put me on a crisis watch, they never tried to find out the problem. They never appeared to be concerned about why I mutilated myself. The reason I mutilate myself is because of my anger. When I get angry I cut and it seems that the mutilation calms me down. Then in January of this year when my mother passed it started getting worser and worser. I was placed on enforced medication because of voices telling me to cut then when I cut I started to eat my own flesh. Whenever I cut on myself I have to placed into four point restraints because once I start it is hard to stop. I am housed in a cell that has hard gray plastic caulking all on the wall that makes it very easy for me to cut when I get angry. Prison officials and the mental health staff know that this is what I have used to cut myself but they refuse to remove it from my cell or move me to a more safer cell. I really need some outside help because the mental health staff is working with the prison officials to not properly treat me or diagnose my problem.⁶⁰¹

Other examples of self-mutilation from around the country include the following:

• Washington prisoner E.X. is imprisoned for manslaughter, robbery, assault, and burglary. E.X. was sexually abused as a child, and as a result has been diagnosed as suffering from Post Traumatic Stress Syndrome and panic attacks. In prison, he has been disciplined several times for fighting with other prisoners. At Walla Walla Prison, in the eastern part of the state, he spent a year in the Intensive Management Unit. There he began seriously hurting himself. He was transferred to Shelton prison, where his acts of self-harm continued. “I really deteriorated in IMU,” E.X. aged 30, recalled.

I was hurting myself, punching myself. One time I took a slipper and was beating myself. I stubbed my finger in my eye socket. I wasn’t getting the help I needed. They had a counselor down there, but he was so busy it was very hard to talk to him. One hundred and sixty people with one counselor. I was slipping into depression. I was hearing voices and stopped showering.⁶⁰²

All told, E.X. says he has been in IMUs about seven times during the ten years he has been incarcerated. During some of these occasions he began slamming his head against the wall.

The lights were on 24 hours a day, cuff ports being slammed all the time, the yelling and screaming, and the absence of human contact magnified my mental illness through the roof, till the only way I could get my mind off it was to hurt myself. The IMU is very detrimental to mental health. It magnifies my illnesses.

Not until E.X. was removed to the prison at McNeil Island, where the prison is working in conjunction with the University of Washington to up the level of its mental health provisions, did he begin receiving regular mental health treatment.

• In Graterford Prison, Pennsylvania, Human Rights Watch interviewed sixty-year-old mentally ill prisoner X.G., who reported extended episodes of self-mutilation. X.G. is originally from Pittsburgh and says that he has been in an out of mental institutions since he was hit by a bus at the age of fourteen and left with substantial brain injuries. A talkative, opinionated man, X.G. has spent much of his adult life in state mental hospitals, and much of the rest of his adult life in prison for extremely violent crimes. While in prison, he has combined acts of violence against others with ongoing attempts to mutilate and even kill himself, and as a result he has repeatedly cycled in and out of the Restrictive Housing Units (RHUs) in the prison system. When Human Rights Watch interviewed him, X.G. was serving time in disciplinary custody. “Once I set my cell afire and threatened to kill myself. I was setting myself on fire,” the prisoner asserted matter-of-factly. His legs are severely scarred from burning; and up and down both arms are literally dozens of scars from where he has cut himself with razors.⁶⁰³

• A lawsuit filed against the Georgia Department of Corrections in March 2002, alleges abuse and neglect of seriously mentally ill prisoners at the high security Phillips State Prison, Georgia.⁶⁰⁴ Among the allegations, attorneys claim that the prison has systematically ignored the mental health issues of prisoners who engage in acts of self-mutilation, tending to view self-mutilation as a gesture by manipulative prisoners seeking attention, or looking to be removed from the unpleasantly harsh environment of a maximum security prison, rather than as a symptom of bona fide mental health problems.

In addition, the lawsuit alleges that prisoners are routinely disciplined for their acts of self-mutilation. The complaint includes the following examples of self-mutilation:

• A prisoner with a history of suicide attempts who took a razor back to his cell from the unit control room on September 21, 2001. He “cut his arms several times, and made a four-inch gash on his leg.” His action was treated as a disciplinary infraction.

• Another prisoner “cut himself on his arms, throat, and chest on numerous occasions… even while he was in an administrative segregation unit.” Although he was placed in a crisis stabilization unit each time he cut himself at Phillips State Prison, the lawsuit alleges that he was not provided with necessary long-term mental health services. Moreover, his actions were also treated as disciplinary issues and he was punished for hurting himself.

• In the summer of 2001, a third prisoner “died during a ‘cutting party’” — when several prisoners on a cell block begin cutting themselves in tandem — after being placed in a cell with a knife blade left in it. The prisoner “cut himself so severely that he bled to death.”

Suicide

Young men, persons with mental illness, alcohol and drug addicts, and people who are in custody, are amongst the most at-risk groups for suicide.⁶⁰⁵ Given the prevalence of all of these indicators concurrently among prisoners in the United States, it is not surprising that suicide attempts are a serious problem inside prison. A nationwide survey conducted by prison suicide expert Lindsey Hayes in 1995 found that suicide rates in state prison systems ranged from 18.6 per one hundred thousand all the way up to 53.7 per one hundred thousand.⁶⁰⁶ According to The 2001 Corrections Yearbook, the average suicide rate in prison was 0.26 per 1,000 prisoners, or twenty-six per 100,000, two-and-a-half times the rate of suicide in the U.S.population at large, which for 2000 was 10.6 per 100,000.⁶⁰⁷

Mental illness is a high risk factor for suicide; untreated or poorly treated mental illness even more so. NAMI reports research findings that about 90 percent of persons who completed suicides had a diagnosable mental or substance abuse disorder.⁶⁰⁸ The organization estimates that between 2 and 15 percent of persons diagnosed with major depression, 3 to 20 percent of persons diagnosed with bipolar disorder, and 6 to 15 percent of persons diagnosed with schizophrenia die by suicide. People with personality disorders are approximately three times as likely to die by suicide than those without.⁶⁰⁹

Human Rights Watch has not been able to find any national or system-wide statistics on the rate of mental illness among prisoners who committed suicide. Nevertheless, correctional and mental health staff and independent experts we interviewed agreed that attempted and completed suicides are more prevalent among prisoners with a diagnosed serious mental illness. A few studies of prison suicides support this view. For example, in Texas prisons, a study of twenty-five suicides committed between June 1996 and June 1997 found that 60 percent of the prisoners had been identified at intake screening with mental disorders, and 76 percent had psychiatric diagnoses at some point during their incarceration.⁶¹⁰ A study in 2002 of New York prison suicide risk factors by New York’s Office of Mental Health, which provides mental health services to New York prisoners found that 70 percent of prisoners who committed suicide had a history of mental illness. Forty percent of them had received a mental health service within three days of the suicide; and 40 percent had prior stays in psychiatric hospitals.⁶¹¹ A review by Prison Legal Services of individual reports of New York prison suicides between 1995 and 2001 prepared by New York State’s Commission of Correctionindicates that many of the prisoners had been on the mental health case load and had discontinued their medication (without receiving adequate medication compliance counseling) or had been seriously mentally ill but had been repeatedly underdiagnosed.⁶¹² In Pennsylvania, prisoners on the mental health/mental retardation roster committed approximately 56 percent of the suicides in 1997 and 64 percent of those in 1998.⁶¹³

Increased Risk of Self-harm and Suicide in Segregation Units

Efforts at self-harm are particularly prevalent in segregated, high security settings. According to Raymond Bonner, suicide prevention expert and chief psychologist at the Federal Correctional Institution at Allenwood, Pennsylvania, “By and large, most self-harm behavior in prison is exhibited by individuals who are confined in conditions of segregation, social isolation, and/or psychosocial deprivation.”⁶¹⁴

The confinement of mentally ill prisoners in segregation also heightens the risk of their suicide, indeed, it heightens the risk of suicide for all prisoners. The World Health Organization has reported that “the majority of suicides in correctional settings occur when a prisoner is isolated from staff and fellow prisoners. Therefore, placement in segregation or isolation cells…can increase the risk of suicide.”⁶¹⁵ U.S. statistics reflect the higher prevalence of suicide in segregated settings. One study found that “approximately 68 percent of the inmates who committed suicide were on special housing status (e.g., segregation, administrative detention, or in a psychiatric seclusion unit) and, with only one exception, all victims were in single cells at the time of their deaths.”⁶¹⁶

It is a tragic irony that many of the mentally ill who attempt or commit suicide were originally placed in segregation because of acts of self-harm. Segregation is, however, perhaps the worst possible setting for suicidal prisoners. As Raymond Bonner notes, “Social and environmental isolation is never an appropriate consequence [of acts of self-harm or attempted suicide] as it undoubtedly worsens emotional state, hinders problem-solving and can increase the risk for life-threatening behavior.”⁶¹⁷

The experiences of individual state prison systems bears this out.

• Arkansas has had fifteen suicides in the past five years, ten of which were in the state’s supermax prison and two of which occurred while the inmates were supposedly under close supervision in mental health units.⁶¹⁸

According to a study of suicides in New York prisons between 1998 and 2000, 54 percent of the suicides took place in the Special Housing Units.⁶¹⁹ Citing the result of suicide reviews by the New York Commission of Corrections, the complaint filed in 2002 by Disability Advocates Inc. against the New York Office of Mental Health and the New York Department of Correctional Services stated that: “for each year from 1998 through 2001, from 30% to 50% of the suicides for the entire prison population occurred within the 8% of the prison population confined in twenty-three hour isolated confinement housing…[D]eficient mental health treatment and the stresses of isolated twenty three hour confinement have been significant facts leading to suicide.”⁶²⁰

• In the Mecklenburg Correctional Center, Virginia, twenty-one-year-old Teko Williams committed suicide in a segregation cell in 1997. Williams had a history of serious mental illnesses ranging from major depression to psychosis. He also had a long history of self-harm gestures and suicide attempts. In August 1997, Williams began smearing feces on himself and his cell walls, and also began eating his feces. Because of these acts and the fact that other prisoners on his cell-block were complaining about the smell, Williams was transferred to a segregation unit where he was reportedly kept chained to his cot for much of the last two weeks of his life.⁶²¹ The prison psychologist was not consulted about this move. A few days later, Williams used a sheet to hang himself from the bars of the inner-cell door. It took the correctional staff over five hours to realize Williams had killed himself. As a result of this negligence and failure to make the mandatory hourly checks, a correctional officer was fired.⁶²²

• In June 2000, twenty-year-old Carol Ann Bell, a bipolar female prisoner at the Ohio Reformatory for Women in Ohio, hanged herself in her cell.⁶²³ After an escape attempt, Bell had been placed in administrative segregation. She was kept in solitary confinement for a period of thirteen months, interrupted only by brief periods in the prison’s residential treatment unit when she was on suicide watch(which happened at least five times) and after she slit her wrists once.⁶²⁴ After she was released from solitary confinement, she was moved to maximum security. She allegedly saw her psychiatrist only once every two months, despite guards and prisoners noticing, and reporting, that her mental health was deteriorating. The complaint indicates that the mental health staff simply did not believe her suicidal actions were genuine. Despite a history of suicidal actions and verbal communications with mental health personnel indicating she wanted to take her own life, the complaint asserts that:

approximately 2 months passed between Carol Ann’s last appointment with [the prison psychiatrist] on January 20, 2000and their next contact on March 15, 2000. At this March meeting, Carol Ann was upset, restless and tearful. Her prescriptions had expired. [The psychiatrist] updated her prescriptions, yet failed to ask Carol Ann about the circumstances leading up to the Crisis Evaluation in February.

In June, shortly before Bell’s death, the same psychiatrist failed to read her chart and thus was unaware of the fact that she had been burning herself with cigarettes in recent days. A few days later, Bell ended her own life.⁶²⁵

• At the Waupun Correctional Center in Wisconsin, a seriously mentally ill prisoner named Matthew Sanville was placed into a segregation cell after assaulting another prisoner in July 1998. Sanville repeatedly asked guards to arrange for him to see mental health staff and repeatedly threatened to kill himself. Nevertheless, he was never removed from the unit and placed on a suicide watch. On the morning of July 29, Sanville covered all the openings in his cell with paper. He ripped his pillowcase into strips, wet the strips in his sink, tied them together into a noose and hanged himself. Several guards passed his cell during this period, peered in through the paper coverings and then continued on their rounds. Not until 3 o’clock that afternoon did correctional staff enter his cell. By that time Sanville had been dead for several hours. A court subsequently found that the guards had exhibited “deliberate indifference” to Sanville’s serious medical needs.⁶²⁶

Suicide Protocols

Litigation has established suicide prevention as a required component of mental health services.⁶²⁷ Nevertheless, in 1995 when custodial suicide prevention expert Lindsey Hayes surveyed prison responses to suicidal prisoners, he found a pattern of neglect and an inadequate invention system. In his Department of Justice-funded report, he urged correctional systems to improve staff training, better identify prisoners at risk of suicide, improve communication between different offices within prisons, provide special housing for suicidal prisoners to be placed within, increase the supervision of these prisoners, and encourage interventions by staff to minimize the chances of a prisoner actually attempting to kill him or herself. Hayes found that only four of the fifty states had all of these elements within their suicide prevention policies. He found that while 79 percent of state departments of correction had suicide prevention policies, only 15 percent of the policies covered the majority of the elements in the American Correctional Association or National Commission on Correctional Health Care standards.⁶²⁸

Eight years later, Hayes believes that, nationally, many of the problems remain: “Inmates reporting that they are taken out of cells and thrown into another cell and stripped naked. That obviously shouldn’t happen. Nobody should be stripped naked and left without protective clothing — a paper gown, there are various smocks and safety garments.”⁶²⁹ In fact, prisoners across the country also told Human Rights Watch that all too often suicide attempts resulted in being placed naked for days in cold, barren observation cells. Interaction with mental health staff while in the observation cell is minimal. Some prisoners told Human Rights Watch they do not tell mental health staff of suicidal thoughts because they want to avoid at all costs being put in the observation cells.

• Y.P., a one-time prisoner at the women’s prison in Washington, diagnosed with post-traumatic stress disorder, obsessive compulsive disorders, and major depression, told Human Rights Watch:

In prison, every time you talked to them about what was bothering you, they’d say “No, you’re not feeling that way.” They’d shut down my feelings. When I cut myself they put me in one-on-one observation. I was locked in a room, with a mattress on the floor and you’re lucky if you get a blanket. You’d have male officers watching you the whole time. I didn’t want male officers watching when I went to the bathroom. That’s humiliating.

Y.P. stated that she asked to talk to her counselor once and the nurse refused to send for her. Y.P. responded by swallowing a bunch of pills she had managed to hoard. ⁶³⁰

• Outside experts found that in Alabama’s St. Clair correctional facility, a suicidal prisoner:

may be placed in a mental health cell by security staff but is discharged by a psychiatrist. Since a psychiatrist is on-site only one day a week, the inmate may remain nude in the Spartan cell for six days without a psychiatric evaluation. There is no documentation of active treatment of the inmate during the interim…. The delay in the treatment of inmates experiencing a crisis is totally unacceptable by any professional standard of which we are aware for an inmate whose behavior or verbalizations resulted in placement in this restrictive setting. Indeed, if it is a mental health crisis that precipitates…the move…then the inmate suffers needlessly in this cell and there is a strong likelihood of preventable deterioration in the inmate’s mental health.⁶³¹

• According to a class action complaint filed on behalf of mentally ill prisoners at Tamms Correctional Center, a supermaximum security prison in Illinois, Robert Boyd, a prisoner with an extensive psychiatric history and a prodigious self-mutilator, has also attempted suicide several times. After these attempts, he has been placed on suicide watch,

a procedure in which the sole treatment consists of being placed in isolation in a cold stripped cell, without clothes and without conversation, for several days in a row…. At times, while in the isolation of suicide watch, he is placed in four-point restraints for hours at a time and forcibly injected with high doses of a tranquilizer…. Other times he is simply observed, naked, by the guards and nurses. Rarely, is there an attempt at therapeutic conversation; the mental health workers tell him that talking to them is a privilege that he must earn by agreeing not to kill himself.⁶³²

Independent correctional experts condemn the practice of leaving suicidal prisoners naked, exposed, and without intensive mental health services. According to Lindsey Hayes, such treatment “further enhances the potential of them becoming suicidal or engaging in self-injurious behavior. It’s degrading, humiliating.”⁶³³ Dr. Terry Kupers told Human Rights Watch that placing suicidal prisoners in barren observation cells:

is counter-therapeutic in that no therapeutic relationship is formed and the prisoner learns it’s better to keep suicidal thoughts and plans to him — or herself. In jails and prisons isolation “safety cells” are used instead of doing what is essential in the treatment of anyone seriously contemplating suicide: talk to them. Thorough evaluation, continuity of contact with mental health clinicians, establishment of a trusting therapeutic relationship — these are the things that prevent suicides and assure the effectiveness of treatment — not fifteen minute checks on a prisoner in an observation/safety cell.⁶³⁴

Dr. Janet Schaeffer told Human Rights Watch of a suicidal prisoner she had encountered in a Pennsylvania facility who was repeatedly stripped naked and put into an observation cell despite a history of having been sexually abused as a child that had left him terrified when he did not have his underwear on. “It contributed to his anxiety,” Schaeffer reported.

To have your body that exposed, it’s an invasion of your privacy and it causes a great deal of psychological distress. In addition, you’re in an environment where you can’t get out. You’re trapped. You’re already feeling pretty horrible. You feel like you want to die and you’re at the mercy of people with a lot of power and control. It’s a terrible situation, being alone, for someone who’s already really suicidal. They already feel very isolated, alienated.⁶³⁵

Instead of such isolation, Schaeffer maintains that suicidal prisoners should be talked to by staff, encouraged to interact with their surroundings and with other people; they should, she told Human Rights Watch, be helped to “[re-]establish social relations, not placed in a situation where such interactions are further broken off.”

Recognition of their legal obligations, a genuine commitment to avoid suicide (which is one of the most traumatic experiences for correctional staff and surviving prisoners), and the development of national standards for suicide prevention⁶³⁶ have prompted corrections authorities to begin establishing more effective suicide prevention protocols. Some states have implemented significant measures to limit suicides within their prisons. For example, the Secretary of Corrections of Pennsylvania appointed a Suicide Prevention Task Force to analyze suicide risk factors, department and prison responses to suicide attempts and completed suicides, and to propose recommendations for changes in department policies, procedures and training. Based on the report and findings of the task force in 1999, the department implemented a series of new procedures and policies and expanded the use of others.

Among other things, Pennsylvania prison authorities revised the suicide prevention policy to improve suicide watch procedures, mandate that watches be conducted outside of administrative segregation areas, require that prisoners be provided anti-suicide smocks, and mandate use of a suicide risk indicators checklist. The prison superintendent’s prerogative in determining which incidents were suicide attempts and which were merely “gestures” was reduced. The department also undertook to expand the range of mental health treatment services by, for example, increasing the number of psychiatric observation cells, streamlining procedures for committing prisoners in psychiatric crises into inpatient treatment, and increasing the number of Special Needs Units — specialized housing areas where prisoners with handicaps can receive additional services and protection. Recognizing that mentally ill prisoners placed in segregation are at particularly high risk of suicide, the department modified administrative segregation policies to increase the diversion of prisoners with mental illness from these housing areas. Disciplinary proceedings include an assessment of the role of mental illness in the commission of an infraction and the possible impact of segregation on the prisoner’s illness. Prison officials are encouraged to reduce disciplinary time for mentally ill prisoners who commit infractions, and to provide enhanced mental health services and tracking for prisoners with mental illness who must be placed in segregation. The department also now uses a suicide risk indicators checklist for prisoners being placed in segregation to ensure that clinical staff visit any at risk prisoners.⁶³⁷ The aggressive and comprehensive effort is paying off: the number of suicides within the Pennsylvania system declined from fourteen in 1995 to five in 2000, despite an increase of over eight thousand in the size of the state’s prison population.⁶³⁸

In California, the largest prison system in the country, thirty-two prison suicides occurred from October 1998 to December 1999.⁶³⁹ Underneath these numbers, however, were large discrepancies between prisons. While many California prisons had no suicides, the supermax prisons at Sacramento and Pelican Bay each had three suicides, and Corcoran had five.⁶⁴⁰ That is, the three supermax prisons accounted for one-third of the state prison suicides. The authors of a report on California prison suicides wrote that “review of data submitted on individual suicides indicated a delivery of care that was inconsistent with established program guides and/or suicide policies” in twelve California prisons, including the above-mentioned three.⁶⁴¹ While California’s prison system, as a whole, had a suicide rate only marginally higher than that found in the American population at large, the suicide ratein prisons such as Corcoran were far higher than the national average. “The five suicides that occurred at Corcoran during the period reviewed reflect the difficulties that facility had in providing adequate mental health treatment to seriously mentally disordered inmates generally, and to inmates at risk for suicide in particular,” the report noted.⁶⁴² The report authors recommended better training for clinicians and correctional officers alike in recognizing and responding to indicators that a prisoner might be a suicide risk.

California appears to have taken these criticisms to heart and to have expanded its suicide prevention activities. In the year 2000, there were only fifteen suicides throughout the California system. The following year, that number rose again to twenty-seven, suggesting the decline in 2000 might have been a statistical blip.⁶⁴³ Generally, though, California appears to have dedicated considerable resources to monitoring suicide risks, one of the reform measures it has adopted following a federal court decision that mental health care in California prisons was unconstitutionally deficient.⁶⁴⁴

Punitive Responses to Suicide Attempts

Self-harm is not always a symptom of a serious mental illness. Nevertheless, the desire to harm oneself warrants careful attention by mental health staff. Similarly, all attempts at suicide must be dealt with as a mental health emergency. Yet in prison self-harm or attempted self-harm is frequently dismissed as malingering — without consideration of whether the effort to attract attention is being made by someone with serious psychiatric needs. Dr. Terry Kupers has testified:

I have in all my tours of prisons checked on the psychological autopsies of suicides…. In reviewing those reports, in 100 percent of cases in about 16 different institutions I have found that successful suicides are preceded by a note in the [medical] chart saying this individual is just malingering or is manipulating or is an antisocial personality; don’t pay any attention…. [O]ne can manipulate and be mentally ill or at serious risk or suicide; one can be malingering, and the malingering can be a symptom of the mental illness. Overall my impression is that the mental health staff [at Wisconsin’s supermaximum security prison] doesn’t take that into consideration.⁶⁴⁵

“Inmates display a variety of self-harm behaviors for different reasons in response to varying problems in living behind bars,” Raymond Bonner has written.⁶⁴⁶ “Motives may range from actually wanting to die to wanting specific solutions to problems or emotional relief. The term manipulation serves little useful purpose in understanding self-harm behavior and often hinders objective problems-solving and risk assessment….”

Prisoners who injure themselves or attempt suicide are often disciplined, and usually placed in segregation, if they were not there already. The treatment of self-harm as a disciplinary matter is rooted in the corrections paradigm. Self-harm violates the rules, and rule-breaking must be punished. As Fred Cohen explains, corrections officials are also concerned about deterring malingering: “The mind-set in corrections is that there has to be a ‘price’ for self-mutilation or suicide attempts; otherwise, inmates would begin to believe that they can ensure a transfer to better housing conditions simply by a simple cut or threat of suicide.”⁶⁴⁷

The response to self-harm and attempted suicide as a disciplinary rather than mental health matter is also rooted in the way prisons distinguish between what they consider serious mental illness, which they consider to be solely Axis 1, and personality disorders. Self-harm is often a consequence of certain personality disorders. As discussed above in chapter VIII, prisonmental health staff tend to discount the importance of personality disorders because they lack the resources to address the high number of prisoners with such disorders, because they get frustrated trying to deal with the notoriously difficult to treat personality disorders, and because they often themselves become “institutionalized,” adopting the correctional staff attitude that these prisoners are simply “bad,” not “mad.” They discount the mental health significance of acting out behavior, including self-harm, by prisoners diagnosed with personality disorders, and see malingering which warrants punishment, rather than illness that needs treatment.

For example, Dr. Thomas Conklin evaluated aspects of mental health care in certain Texas prisons in 1998. Following a review of the charts of thirteen suicide attempts and gestures among prisoners in the Estelle Unit, he found that “all suicide gestures by inmates are seen as manipulating the correctional system with the conscious intent of secondary gain. In not one case was the inmate’s behavior seen as reflecting mental pathology that could be treated.”⁶⁴⁸ Similarly, Dr. Jeffrey Metzner, after reviewing the medical charts and post-mortem psychological evaluation report, made the following assessment about the treatment of a Texas prisoner who committed suicide in 1997:

This inmate was clearly difficult to treat and had multiple serious self-inflicted wounds. Unfortunately, his problems were ultimately determined to be manipulative in nature and not due to a mental illness but due to malingering and/or an antisocial personality disorder. This ultimately resulted in discontinuation of his medications and the later reemergence of a major depressive disorder which was diagnosed one day prior to his suicide. There appeared to be little attempt to understand the dynamics of his behaviors and provide appropriate interventions and/or consultations to the security staff. It is likely his depression was exacerbated by his placement in segregation. This documentation concerning the changes in the diagnosis leading to malingering was poor. This case is another example of systemic problems related to documentation, diagnosis, and treatment which contributed to this inmate’s dismal outcome.⁶⁴⁹

The reports of punitive responses to self-harm are legion:

• In his book Prison Madness, Terry Kupers reported viewing security files for prisoners in many state prison systems who had killed themselves and been issued “a posthumous citation for violating the prison rule against attempting suicide.”⁶⁵⁰

• Todd Winstrom, an attorney with Disability Advocates, told Human Rights Watch of one client at Taycheedah prison in Wisconsin who slit her throat, was patched up by prison doctors and then sentenced to 180 days in segregation for her actions. When she cut her throat a second time, she received another 180 days in solitary.⁶⁵¹

• According to a New Jersey prisoners’ class action complaint:

A.O. is a prisoner currently confined to Northern State Prison’s administrative segregation unit for women in Newark, New Jersey. A.O. has been diagnosed by DOC psychiatrists as suffering from schizophrenia, adjustment disorder, and multiple personality disorder, and she also suffers from seizures as a result of a stroke which she experienced at age fifteen. Her mental illness makes it difficult for her to control her behavior. She has received numerous disciplinary charges, including several for self-mutilation, drug overdoses and assaults on correctional staff…. [She] has attempted suicide or engage in self-mutilation approximately 15 times. Although she attempted to explain the role her mental disorder played in her suicidal behavior at her disciplinary hearings, she received additional time in both disciplinary detention and administrative segregation as a result of her suicidal behavior.⁶⁵²

• Dr. Janet Schaeffer, who held senior mental health positions in the Washington Department of Corrections, told Human Rights Watch that:

Women who attempted to commit suicide were put in [Administrative Segregation] just the same as somebody might be put there because they’d committed some horrible rule infraction. Which is probably one of the worst things you could do to a suicidal person. There’s a culture that is very powerful and very strong and permeates the entire place. It’s very militaristic. They have a chain of command. I’d voice my opinion and argue and it wouldn’t go anywhere. After a while it became part of what we knew would happen. That was just the deal. That was what happened. The rules of the prison are driven by issues of power and control.⁶⁵³

• As a plaintiffs’ expert in the lawsuit against Wisconsin’s supermaximum security prison, Dr. Terry Kupers wrote of one prisoner who came to the prison with a clinical chart from the Mendota Mental Health Institute indicating that he had “a pattern of escalation in terms of inappropriate behaviors and deterioration in terms of mental status which are associated with the use of isolation as a management strategy,” and noted that the prisoner had a history of suicide attempts.

[H]e had attempted suicide on more than one occasion in segregation at another institution, and then at SMCI he cut himself badly with broken glass…. He attempted suicide again on 12/10/00, a hanging that resulted in his face turning purple before he could be cut down by staff, and again he was retained at SMCI in isolation. Finally, this prisoner made a serious enough suicide attempt for the mental health staff to transfer him to Wisconsin Resource Center for intensive psychiatric treatment in late August 2001.⁶⁵⁴

• The above-mentioned Disability Advocates, Inc. complaint against the Office of Mental Health (OMH) and the Department of Correctional Services in New York stated that:

for each year from 1998 through 2001, from 30% to 50% of the suicides for the entire prison population occurred within the 8% of the prison population confined in twenty-three hour isolated confinement housing…. According to State Commission of Correction (SCOC) investigations of suicides, deficient mental health treatment and the stresses of isolated twenty three hour confinement have been significant facts leading to suicide.⁶⁵⁵