Abstract
Suicide is a leading cause of death among prison inmates. A recent study found that nearly half of the inmates who committed suicide in a state prison system during the study period did not have a major mental disorder. This prompts the question of why a person in prison who has no mental illness decides to end his or her life by committing suicide. Stressors associated with maximum security settings that may contribute to the high incidence of suicide found in segregated housing units are explored through a description of the author's experience and inmate anecdotes.
Suicide is a leading cause of death in prisons.1,2 Most prisons are stark, impersonal, and devoid of the comforts and access to support that most of us in the community take for granted in our daily lives. Stress associated with the difficult conditions of confinement found in prison can overwhelm even the best set of coping skills and set off a downward spiral of emotional and psychological deterioration. Placement in segregated housing is especially challenging and has been found to be associated with extreme levels of stress and a large proportion of successful suicides within the prison setting.2,3 Stressors that contribute to an individual's decision to end his or her life in segregated settings are of interest to both clinical and security staff and administrators who work in correctional settings. An understanding of these factors can lead to the development of more effective suicide prevention plans and clinical programs tailored to the special needs of this population and assist forensic examiners who are constructing psychological autopsies and evaluating liability in cases of successful suicide in prison settings.
Psychiatric investigators have attempted to determine the factors associated with suicide in correctional institutions. Baillargeon et al.4 explored the association between major psychiatric disorders and suicide risk in prison inmates during a 1-year period in the Texas Department of Criminal Justice. They restricted their study design to four categories of psychiatric disorder: major depressive, bipolar, schizophrenic, and nonschizophrenic. Of the inmates who committed suicide during the study period, 51 percent had a diagnosis of a serious mental illness as defined by their four categories, whereas 49 percent did not. The authors acknowledge several possible explanations for the lower than expected proportion of inmates with no serious mental disorder who committed suicide, including not incorporating a broad enough definition of mental disorder (by excluding anxiety, personality, and substance abuse disorders) in their study design. However, the study's finding that nearly half of the inmates who committed suicide did not have a major mental disorder prompts the question of why a person in prison who has no mental illness decides to commit suicide.
Within the psychiatric profession, suicide is generally attributed to the presence of a psychiatric disorder. The possibility that a person without an active major mental illness would extinguish his or her life is a compelling problem that challenges us to explore the conditions and circumstances that may contribute to an inmate's making this decision in prison. How can we understand this phenomenon in the context of an inmate's experience during incarceration, particularly in segregated settings, where the frequency of suicide is so much of a concern?
A Vantage Point
I began working in maximum security settings in 1987 and over the past 22 years have had the opportunity to witness the conditions of confinement in facilities for men and women in a variety of state departments of corrections and to talk with thousands of inmates. I have listened to the perspective of hundreds of inmates who live or have lived in short- and long-term segregation. The objective of this article is to shed light on the experience of the inmate in segregation and the impact on the psyche that may contribute to a decision to attempt suicide, even in the absence of an active mental illness. I will offer a vantage point that is derived from my personal observations and conversations with inmates over the past two decades. I intend to present a perspective on the environmental and psychological factors that contribute to the extreme stress of segregation and are potential contributory factors to suicide in that setting. Most of my comments apply to male inmates, as my experience primarily has been working with incarcerated men. An essay or study illuminating the stressors for female inmates in segregation would be a welcome contribution to the literature.
Most of the quoted passages in the following text are derived from my notes of conversations that I have had with inmates over the past 20 years and were selected to illustrate the unique stressors of the segregated environment.
Life in Segregation
The penitentiary concept was first implemented in Philadelphia in the early 19th century. The Philadelphia model of incarceration established a policy of solitary confinement where, theoretically, an inmate would reform through making penance in isolation. Foucalt explained this proposed mechanism of reform in his examination of the development of the modern prison system: In absolute isolation, as at Philadelphia, the rehabilitation of the criminal is expected not of the application of a common law, but of the relation of the individual to his own conscience and to what may enlighten him from within. Alone in his cell, the convict is handed over to himself; in the silence of his passions and of the world that surrounds him, he descends into his conscience, he questions it and feels awakening within him the moral feeling that never entirely perishes in the heart of man [Ref. 5, p 238].
In the modern era, there continue to be proponents of using isolation during incarceration as an opportunity for inner development. For example, Bo Lozoff and his Human Kindness Foundation have worked with inmates in prison and encourage experiencing the isolation as an opportunity for introspection in the service of personal transformation.6 For most people in prison and in the community, extended isolation and solitude can be extremely challenging and difficult to tolerate.
In the modern prison setting, inmates with special security needs are placed in administrative segregation status for days to months or into secure housing units for months to years. Both of these housing situations are considered “segregation” because the inmate is removed from the general population of the prison and specialized security procedures are utilized for the residents in this setting. Administrative segregation units generally represent a small proportion of housing units in a given prison. Maximum security prisons contain a large proportion of secure housing units, while so-called supermax prisons are designed entirely for segregated populations. Inmates are placed in segregation for a variety of reasons. The largest proportion of segregated inmates have been found guilty of violent acts (assault, murder) on other inmates and correctional officers within the prison setting. Many states with high concentrations of gang activity have designed gang-intervention programs that separate rival members and place them in segregation as part of an institutional violence-reduction plan. Inmates placed in protective custody (PC) are frequently placed in a separate segregated housing unit. Inmates in PC are at risk of harm from other inmates because of their high-profile status (e.g., former law enforcement officers, judges, and those who have committed notorious crimes), history of sexual offenses, or status of renouncing gang membership.
Institutional procedures and conditions of confinement vary from state to state. Inmates in maximum security segregated settings are often placed in solitary confinement. They spend 23 hours a day in an 8- by 12-foot cell and are allowed to go into an exercise cell or enclosure for one hour a day at least five times a week for recreation. A typical segregation cell has a shelf to support a mattress, a shelf for use as a writing surface and to stack personal belongings, a stool, and a sink/toilet unit. When inmates leave their cells, security restraints are applied that shackle the wrists to the waist and the legs together. The only consistent human physical contact an inmate experiences during segregation is with the officer who applies the security restraints. The exercise cells or enclosures consist of either a large concrete-walled room or fenced-in cages with space between each enclosure to prevent contact between inmates. Visits with family and friends are noncontact and occur through a thick plate of glass in a special visiting area. Security personnel, in consultation with facility mental health staff, oversee a behavioral modification system that is designed to encourage a reduction in antisocial behavior and compliance with institutional rules. As an inmate advances through the levels or steps of the system, privileges are awarded: a radio, a television set, access to books and canteen items, more frequent phone calls, and more frequent visits. Any violation of the rules results in a regression: a loss of privileges and a return to a more restrictive step in the behavior plan. Time out of the cell is allowed for appointments with staff (medical, security, mental health, education, and chemical dependency), visits, recreation, or work.
The following themes have emerged from my professional experience and recollections of discussions with inmates about life in segregation.
The Strain of Daily Life
Lack of Work
Only a few residents in segregation are allowed out of their cells to work. Typically, they work as porters and provide cleaning and maintenance duties for the facility in which they are housed. Inmates on PC status are frequently the only ones allowed to work, because of the security concerns of mixing inmates from rival gangs or those with violent histories. The pay is minimal (as low as 20 cents an hour with a maximum of six hours of pay a day). In some systems, a percentage of wages is withheld to fund a gate fee, a sum of money given to the inmate at the gate upon release (typically 50 dollars). While most inmates working as porters value the time out of their cells, they may feel demoralized by the small amount of pay and the little it can buy. For those who cannot leave their cells, resentment builds toward those who can get out for most of the day to work, especially in systems that allow only PC inmates to have this privilege. Therefore, the benefits that come with work are often accompanied by the scorn of fellow inmates.
Interaction With Other Inmates and Its Toll
The opportunity to interact with fellow inmates in segregation is minimal, usually occurring from cell to cell or in the exercise enclosures. A typical cell design includes a grated air vent that connects adjoining cells. Neighboring inmates frequently converse with each other through the grate. At times, this is a welcome break from the monotony; at others, it is viewed as an intrusion. Some inmates describe developing a mutually supportive relationship with a neighbor, but such connections tend to be the exception rather than the norm. The typical verbal exchange is not positive. Frequently, the neighboring inmate attempts to encourage the recipient to engage in misconduct: exchanging possessions, passing prescription or illegal drugs down the line to another inmate, or participating in planned assaults. The pressure to comply can be immense.
Inmates describe a feeling of being under siege in the atmosphere of constant negativity and noise on the block (blaring radios and televisions, yelling). A common disruption in segregation is an event known as a cell war, which frequently occurs when an inmate is upset about a perceived injustice and begins a protracted tirade that typically involves yelling, kicking, and banging on the cell door; destroying personal belongings; or flooding the cell. If the inmate does not respond to verbal intervention from the security staff, officers may form a team to extract the offender from the cell, frequently using pepper spray to subdue him. The ensuing chaotic atmosphere can last for hours and impacts every resident in the unit.
Security is tight in segregation, but violence does occur. The possibility of a deadly assault by another inmate is very real; there is a need to be on guard at all times. Inmates described a feeling of “constant paranoia” that develops from “always watching your back” and a need to “strike first before someone gets you.” The energy expended to “keep strong to survive” and “keep up a front” in order not to be perceived as weak can be exhausting. The vigilance necessary for survival can cause “battle fatigue” from being in “constant fight-or-flight mode.” Older inmates who have a reputation and are serving long sentences are sometimes targeted by younger inmates who want to gain notoriety by assaulting or killing a well-known person. The perceived need for pre-emptive strikes can make it difficult for some to turn away from a violent past as inmates age during long periods of incarceration.
Limits on Property
In the stark surroundings of a concrete cell reverberating with the din of cell wars, slamming doors, and whispered demands to “donate” your hard-earned canteen items to another, solace often comes from an escape into one's personal belongings. Many inmates have described how listening to music delivers them momentarily from the overwhelming noise of the day or the monotonous dark silence of long nights. However, even for the best behaved, there are limits to what the inmate is allowed to have in a cell at one time. For example, in one system, they can keep only up to 10 cassette tapes and three books at a time and have a limited catalogue from which to order approved media. Redundancy and boredom are quick to take root.
Fear
Fear is not a subject that most inmates speak about openly. Survival requires an effort to maintain an impenetrable façade and not telegraph anything that could be perceived as a sign of weakness. Much like the advice found in How to Swim With Sharks, a primer on how to succeed in treacherous waters that has become an underground house officer's guide, a critical maxim is: “Do not bleed” in the water.7 However, when an inmate builds trust in staff and personal stories subsequently unfold, the underlying motif of fear as a driving force is readily apparent. It is not uncommon to hear how witnessing an inmate involved in a rape or a brutal stabbing during an initial incarceration as a teenager sets up a long pattern of preemptive violence. This response can result in decades spent in the pursuit of a sense of safety and maintaining personal and physical integrity.
Frustration
Many people who are sent to prison have a poor tolerance of frustration, which contributed to their criminal behavior. The prison environment, with its rules, regulations, and need for conformity and predictability, is generally rigid and inflexible. The collision of rigidity with short-fused tempers can lead to explosive confrontations over what seems to be the simplest request. Negotiating to obtain more than a weekly allotment of toilet paper can require a multitude of paperwork that can try even the most stalwart patience, which is not the average inmate's forte. Many inmates describe a sense of unbearable frustration arising from the constant friction with the bureaucratic nature of the security chain of command; the tension builds over time to the point where a release is inevitable.
Release of pent-up anger can take the positive form of calisthenics in the cell but can also be violent, directed toward inmates and staff or self-injury. An inmate serving an accumulated sentence of over 100 years for a series of assaults in the community and homicides while incarcerated reflected on the effect of segregation on his ability to relieve stress. He described a long pattern of releasing tension through assaultive behavior that helped him achieve momentary periods of calm. The segregated nature of maximum security, with its imposed separation from others, prevented him from having access to potential victims. Isolation left him with no other acceptable outlet, he explained, and he began to cut himself and to rub his skin until he bled. When this method of tension release waned in its ability to soothe, after a series of conflicts with security staff, he attempted suicide and almost succeeded.
Despair
Many inmates in segregation find a way to channel their frustration into pro-social avenues: developing artistic skills (drawing, soap carving), academic pursuits (obtaining a GED, taking college correspondence courses), and completing clinical material (chemical-dependency workbooks). However, for some, a constant sense of frustration with no perceived resolution leads to resignation and eventually desperation. Externalized anger toward others shifts and is channeled inward. The constant drain of experiencing negative interactions with both staff and fellow inmates can engender a pervasive sense of pessimism that colors self–perception. One inmate explained that he became “sick of the evil in human nature and lost all hope.” He pointed out that watching a 24-hour news channel (CNN) all day further reinforced a sense that there was no hope for the human race and what was waiting for him in the community may be worse than what he was experiencing in prison. He believed that his plight was not likely to improve, which sent him into a downward spiral of despair and self-loathing. Many of his waking hours were spent ruminating on the thought “I let myself down…; I won't change…; this (prison) won't change.”
Shame
Criminal behavior has its personal toll. In the isolation imposed by an extended prison sentence, inmates often reach out to their families, which can be a mixed experience. On the one hand, the contact can provide solace and a sense of belonging. On the other, it can stir up feelings of guilt and shame for “letting them down over and over again.” One inmate explained, “I feel like a burden to my family…; maybe they will be better off without me and the tension I cause them…. I should let them get on with their lives.” An inmate contemplating returning to the community where he had been well known for his extravagant lifestyle stated, “I will be out there with people who used to know me as The Man, but I'll just be a convict wearing an apron flipping burgers.” For some, the friction between wanting to be accepted by others and the fear of rejection by their families or ridicule by their peers in the community leads to a sense of shame and desperation and then to contemplating whether life is worth living.
A Demoralizing Loss of Manhood
Maintaining an identity separate from being an inmate is extremely important in weathering the storms of a long incarceration. Many inmates have spouses and children. Continuing a role in the day-to-day decision–making for the family crystallizes a sense of purpose that extends beyond the walls of the institution. Disconnection from the family both physically and functionally can be devastating to an inmate's identity as the man of the family. Contact with the outside world is a privilege that has to be earned. For those who have violated the rules, telephone contact and visits can be infrequent. Visits in maximum security are noncontact and require leg and wrist shackles. Interaction occurs through a thick plate of glass with conversations over a speaker line. Inmates have described how visits in this type of setting feel demoralizing. One inmate described the devastation that came from not being able to “hold and comfort my children or be a man for my wife…. They see me standing there as if I was an animal in chains…; after a while, I just asked them to stop coming…. I get down on myself and give up.”
Monotony
Inmates in a maximum security setting describe a dulling monotony in the daily routine. Meals are a welcome momentary diversion; however, the menu tends to be on a predictable and repetitive rotation. There are no group events to mark or celebrate holidays and other special occasions. Time can move very slowly. Some inmates try to pass the time by talking to a neighbor through the vents but describe how quickly they tire of the stories they hear over and over. The arrival of a new neighbor can be a mixed bag as the new resident may bring a fresh batch of stories but may be the cause of turbulence on the housing unit. From this perspective, setting a mattress on fire may seem to be worth the loss of privileges, if only to create a chaotic diversion in an otherwise boring day.
Isolation and Loneliness
Separation from loved ones and a lack of opportunity for human communication and connection can take its toll. Inmates frequently describe the crushing weight of solitude and the loneliness that stems from infrequent human interaction. One inmate explained, “You're stuck in your room 23 hours a day, living with your thoughts nonstop… . You just keep thinking ‘I let myself down and that won't change.’ After a while you can't stand it.” Some find it painful to break the loneliness by reaching out to loved ones. Talking with people in the community is a reminder of what life is like in the outside world. That reminder can amplify the feeling of separation and generate a deeper sense of loneliness as the stark deprivation of solitary confinement comes more sharply into focus. Efforts to reconcile can deliver a serious blow if friends and family have “moved on” and do not return the overtures.
The Stress of Reentry
The friction of reentry into the community can begin to burn in the minds of those facing release as parole or the end of a sentence nears. Ironically, one of the most stressful times of incarceration occurs as the sentence is nearing its completion. Inmates' concerns involve where to live, how to earn money, and a fear of relapsing on drugs, returning to criminal behavior, or both. Those who are paroled from maximum security are often placed on intensive parole with a short leash and very strict conditions of release; most fear returning to prison for a minor infraction. Upon arrival in the community, the inmate faces a vastly different landscape from the one he knew 10 to 30 years earlier. A new state of the economy, advancements in technology, and a new set of social expectations present situations that the inmate may not feel adequately prepared to navigate. Family members may have died, loved ones may have moved on, and friends may be few and far between. A person incarcerated at 20 years of age may emerge into the community at midlife or beyond and face the sometimes bewildering task of how to build a new life and identity as a citizen. For those with spouses and children, pressure flows from anticipating the stress of returning to the family. Although maintaining connections over the phone and through the plate glass of the visit-room booth may have seemed adequate to maintain some semblance of intimacy, what will it be like to return to home life where the family will depend on the success of the inmate's reintegration? Is another failure waiting to unfold?
Suicide on the Eve of Release: The Pains of Reintegration?
In my experience working in prisons, I have encountered inmates who commit suicide just before release from prison. This seems counterintuitive to most people who have never been to prison. Why would someone despair at the prospect of being released from a segregated maximum security environment that most people in the community would find unbearable? This fascinating and disturbing paradox is worthy of further exploration in the psychiatric and psychological literature.
Inmates may figuratively throw stones at the prison gate. However, incarceration, with all of its deprivation, stress, and bursts of chaos, is a source of stability and security for many. Stressors are known and predictable. When the explosive turbulence of a cell war crescendos, the response from security follows an expected protocol. Meals come three times a day. Medications are provided on a regular schedule. Medical care is readily accessible. Many inmates have never had the stability of a predictable place to sleep and eat.
Prison can provide an opportunity to build a sense of self-respect and identity that fit the nuances of that matrix. An inmate builds a reputation during an incarceration that is a central driver for how staff and other inmates will interact with him. His reputation is especially powerful with the overlay of gang membership and related self- and group identity that fit within the hierarchical nature of the organization. One inmate who had served over 30 years and was facing release within 12 months explained, “Stephen King got it right with that old man in Shawshank [Redemption]. In prison, people look up to you and ask you for advice. You've got a position and a role to play. When you leave here, you're just one of the rat race…. In here, you are something. Out there, you return to nothing.”
Conclusions
The stressors associated with placement in segregated housing units are probable contributing factors to the high incidence of suicide in that setting. While initially designed to provide the atmosphere for penitent reflection and transformation in the Philadelphia model, solitary confinement in the modern prison is challenging for those with even the strongest coping skills. Inmates struggling with their conditions of confinement may develop a major affective illness or psychosis and subsequently contemplate and commit suicide. However, the findings of Baillargeon et al.4 and the compelling anecdotes of inmates living in segregation suggest the likelihood that some inmates without a major mental disorder in prison will respond to their external environment and internal experience by committing suicide. Further exploration of this phenomenon is needed as the psychiatric field strives to improve the quality of care in prisons.
Acknowledgments
I thank those inmates who over the years have provided me with compelling glimpses into their efforts to live amidst the myriad challenges of the maximum security, segregated environment.
- American Academy of Psychiatry and the Law