Adverse Outcome

Wednesday, we had an "adverse outcome" at work. Such words are a euphemism for someone died. Of course in our environment, there will be an autopsy because---in our setting, things are never what they seem.

So, on the surface, it appears the death was self inflicted.

In the prison setting, the threat of suicide is another bargaining chip the offender has to manipulate for practically anything. If one does not like his cell mate, he can threaten self harm. If he does not like his cell location, he can threaten suicide. If he does not like the security officers on his shift, he can threaten suicide. If he does not get his demands met soon enough, he can threaten suicide.

The issue of suicide in the correctional setting has come to have the flash point it has because it gives an emotional message that offenders feel hopeless, neglected, and abused therefore killing themselves is the only way out. Sometimes that is true.

Prison, at least the prison in which I work, is not a hopeful place. Nothing about it is hopeful. The building are poorly built, not air conditioned, stale aired, grey walled, loud, and full of people judged by society as unwilling to live by the rules of conduct the rest of the world lives by. One 18 year old offender told me "these are not nice people." No, they are not and one of these not so nice persons will be one's cellie.

Additionally, the food is barely palatable, security officers often unqualified and emotionally unsuitable for their jobs. Freedom is non existent, and everything is regimented. The snotty nosed teenager whose surly "Nobody going to tell me what to do" has no idea the Hell he will be in when he ends up in prison. The offender is told what he can wear, when he can sleep, where he can work, what he can eat, when he can shower, when he can shave, how can share a cell with him and what he can keep and what he can possess.

What medical and mental health care is available is parceled out often at maddening levels.

It should not be surprising that suicide is an issue in prison. And it should not be surprising that institutional prison administration should be hyper sensitive about the issue. Nothing so unmasks the facade of adequacy of prison care as a suicide.

However, given the hypersensitivity of the issue, offenders have found another way to attempt to manipulate a tired and often unresponsive system.

Additionally, the incarcerated setting has a higher than normal percentage of felons with personality disorders. The most troublesome lot are those who have "cluster B" personality disorders: which are identified as Borderlines, Antisocials, Histrionics, and Narcissitics. Simply explained these are folks who have a pervasive disregard of the presence, the rights, the needs, and the existence of others. Their worlds are very small with themselves at the center of the universe and pretty much the only one who matters at any given moment.

If this pervasive view of the world were not enough, Cluster B folks have great difficulty regulating their emotions and mood. So, when they are frustrated, it is not unusual for these folks run to the outcry of self harm or the attempt at self harm.

The most mind bending moment for me has been when an offender says, "If I don't get _________(you fill in the blank) I am going to cut my throat/hang myself/take this handful of pills/jump off my top bunk."

I know the anticipated response and the professional response is supposed to be "Oh, please don't do that." However, I find myself thinking,"Oh, OK, mind if I watch? I fail to grasp why that threat should motivate me to do anything to mediate your threat."

Institutionally, that is not the right answer. We don't want offenders to self harm because--well, there are too many papers to fill out, and well, it just don't look good.

My therapeutic approach is the old familiar "call their bluff." Institutionally, we are not equipped to do that.

So, as long as the institution responds with a frantic knee jerk reaction, offenders will continue to threaten self harm. And with the frequency of the threats, there will inevitably be "adverse outcomes." Not because they intended such an end, but because like everything else in most of their lives, they were as good at bluffing as they were successful as criminals.