A Prison Psychologist Mourns the Patient He Couldn't Save

This article was published in collaboration with the Marshall Project.

I'd been working for several years as a psychologist for prisoners in Washington state when I was tasked with treating a deeply troubled man in his early 20s. I can't tell you his name, or his mental health diagnosis. I can tell you that treating him was the most significant professional challenge I have ever faced.

Prisons have developed various ways to respond to negative behaviors by prisoners—taking things away, more restrictive environments. These can work, but some of the men I've encountered, because of pain and trauma from earlier in their lives, have never learned positive behavior. The usual tools can make their problems worse; acting out is their way of handling desperation, of seeking help. It is not their fault, or the prison's; society has chosen prisons to be the places that manage these problems, and prisons aren't the right place for them.

But I've learned that the answer is for us to treat them as individuals.

This man had a reputation in the department for constantly harming himself. At first, he used shaving razors to cut himself. When the prison restricted his access to them, he broke his own fingers and swallowed inedible objects like plastic spoons, food wrappers, and batteries. He found ways to harm himself with playing cards, shower shoes, toothbrushes, and books. Even if he was restricted from all these objects, he could bang his head on a door.

At times, officers would place him in a restraint bed for his own safety, so he would not try to reopen his wounds. He often needed observation 24 hours a day. Sometimes he would assault other prisoners and staff.

I can help this person, I thought.

It was an attempted murder that brought him to prison in the first place, and it was clear to me that he had suffered from all kinds of trauma and was carrying around a lot of pain. He could be very social, talking about his fond memories of hunting and fishing and being outside, but then he would get a palpable anxiety over "what was going to happen next." Was he going to be placed in a new cell? Was he going to be allowed outside for recreation? In prison, you can't always answer those questions definitively; sometimes there is a lockdown or an emergency. This would only add to his anxiety.

The traditional way of dealing with his self-harming behavior was to further restrict his environment, but we realized that this might be hurting more than helping. I tried all sorts of special programs to help him manage, including private yoga lessons. Sometimes he would be successful for days, or even weeks. But inevitably he would harm himself again.

I think there were times he actually wanted to end his life, but other times I could tell that he simply hadn't learned how to communicate with words; he communicated with actions. He was so used to being neglected as a child that he saw self-harm as a way to get a big outpouring of emotion from a caregiver. This meant that by giving him lots of attention, we were unintentionally reinforcing the behavior. "The better I do, the less I see people," he told me.

I tried to explain this to the staff, since often his behavior could seem incomprehensible. They all wanted to help him, but there is a dynamic—not just in prisons—where caregivers take self-harm personally. They think I've worked so hard to help you, and then they feel burned by the setback. Part of my work was trying to explain to other staff members that he was doing his best, and to temper their expectations of how quickly he'd get better, if at all.

After harming himself, he would say, "I want to get back on track."

I'd say, "We begin again."

I developed a series of plans for him, collaborating with many other employees at the prison. He was placed in restrictive housing, but was also allowed go to the gym and the yard and spend more time out of restraints, in "medium custody" areas with other prisoners.

Making this work involved a lot of talking to staff in various departments and across the three work shifts, so that some officer wouldn't tell him, "I've never heard of this special plan" and deny him entrance to a class or the rec yard. I was working at two prison units, and developing and implementing these plans, along with providing him with care and programming, was like adding a whole other unit to my workload.

But his life got richer. He got to spend more time out of his cell and have access to objects that had previously been withheld. We'd go on walks. We played Uno. He laughed more. Every chance I could, I'd say: "Look how much better this is than when you were harming yourself." He would say, "People are telling me I'm doing well."

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Then one day last year as I arrived for work and walked from my car toward the facility gate, I saw an ambulance and a police car. That's around the time my cell phone rang.

I was told that he had taken his life.

I found myself sitting down on the sidewalk. Strangely, my mind immediately started trying to formulate a new plan to get him "back on track," as he used to put it. I was sure that I was going to see him again.

I was really touched by the outpouring of support from those I worked with. They all said, "I know how much effort you put into giving him a better life." And I thanked them, too. The medical staff, in particular, had tried so hard to prolong his life.

I later looked at a picture in his file. It must have been from long before, because his face looked very young, free of the scars it would later contain. I wondered what would have happened had I met him, and started working with him, at that moment.

Ryan Quirk is a staff psychologist with the Washington State Department of Corrections. He wrote about the case described here in the November/December 2015 issue of the Correctional Mental Health Report.