(The following is a fictional vignette based on thousands of real patient encounters. Any resemblance to an actual person is purely coincidental.)

The heavy door slammed with an echo he’d never forget. He thought he could trust her, but he had been proven wrong. He should’ve known not to trust anybody in prison. In fact, throughout most of his life he’d known only a few people he ever could trust. Naked, cold, humiliated and feeling as though he had been violated again, “David” now wanted to die more than ever. He didn’t care how; it didn’t matter if it hurt. He just needed to end it all. But, he would soon realize that it would be nearly impossible to do. Nearly ever imaginable method of suicide had been removed from him. He was now “safe” in the eyes of the prison, but he sunk into a deeper depression.

It was David’s first time in prison. He had spent a few days in jail prior to his current age of 22, but it was remarkable that he hadn’t gotten himself into more trouble. His father was a career criminal who had repeatedly emotionally, physically, and sexually abused him as he was growing up. David had grown up far too fast. He had had few boundaries and rules and almost no adult supervision in his younger years. He started smoking cigarettes at age 10, started drinking at 12, and was using marijuana regularly by 13.

Despite having the deck stacked against him, David was a kind person who wanted a better life for himself and his new family. Tina was his girlfriend of three years, and they had a 2 year-old daughter together. They were planning to be married soon.

Unfortunately, though, David violated the rules of his probation. Revealing his recent use of marijuana, a urine test had been positive for THC. He knew he had broken the law and the rules of his probation, but he had never imagined that he would not only end up in prison for 2 years but in his current unimaginable state of hell.

He was being successfully treated for depression and post traumatic stress disorder with psychotherapy and an antidepressant medication in the community. Unfortunately, during his brief stay in the county jail prior to coming to prison, the medication was stopped. He could not afford it and was therefore not allowed to have it. When he arrived in prison 2 weeks later, he was placed on the list to see the psychiatrist, the doctor who would assess whether to restart David’s usual medication, but that appointment had not yet occurred.

Today he had seen the psychologist, Dr. Cook, for the second time. She had first seen him the day after he arrived in prison. She was aware of his mental health history and the fact that he was off his medication. David believed he could trust mental health professionals. He was therefore honest with Dr. Cook and revealed to her that he was not coping well. He was slipping quickly into a deeper depression and was thinking of hanging himself. He was frightened by these thoughts because he had previously believed that suicide was a selfish act. He had not wanted to hurt his family emotionally.

Dr. Cook cringed inside when she realized what she had to do. She had to follow protocol. Her patient was suicidal. As counter-therapeutic as she knew it would be, she placed David on suicide watch. She hated this part of her job.

All of his property was taken away from him. Initially he was naked but then offered a paper gown. He had a thin mattress with no sheets on a concrete floor. He was now in an observation cell that felt more like a fish bowl. Officers checked on him every 15 minutes. He knew they were just doing their jobs, but he hated them for their intrusiveness.

Other inmates on the segregation wing where his suicide observation cell was located jeered David from their cells and yelled derogatory comments about him to each other in an effort to further demean him. He had seen more difficult times in his young life than most other 22 year-olds, but now he was at rock-bottom.

Two days later, he did what he had to do. He repeatedly lied and successfully convinced Dr. Cook that he was no longer suicidal. In reality he still was, but fortunately he did not act on his thoughts. Finally he was allowed to return to a regular general population cell. Never again would he admit to a mental health professional that he was thinking of harming himself.

Unfortunately, the above scenario is played out hundreds of times every day inside U.S. jails and prisons. Prisoners who are believed to be at risk of harming themselves are thrown into segregation cells naked or nearly so, and are not allowed access to most of their own property. They are watched closely. Correctional institutions face litigation anytime inmates commit suicide.

While understandable that jails and prisons need to manage risk, I find the manner in which suicidal inmates are kept “safe” to be repulsive. The current system in most facilities around the country discourages inmates from speaking up and admitting to anyone that they need help. Just when they are at their lowest point, they are stripped of their dignity.

Outside of correctional facilities, we mental health professionals routinely make sure that patients who may harm themselves have responsible friends or family members with whom to stay. We never want patients who are severely depressed to be alone. Likewise, I believe that in prisons and jails, inmates who may be suicidal should be kept in cells with other inmates. I wish I could propose a comprehensive solution to this vexing problem, but I don’t have one. I’ve been stumped by this issue for years.

What do you think about this issue? Do you have any novel ideas? Please share your comments.

Suicide is an absolutely horrible phenomenon. It destroys families and forever leaves survivors on an elusive search for why it happened. Suicide is often viewed as a very selfish act, yet I believe that in many cases those who do it truly cannot endure the emotional pain any longer and believe that they are out of options. When I was a young adult, an extended family member committed suicide. During my career I have lost a small number of patients to suicide as well. These were all very tragic experiences.

In the United States, mental health professionals have a legal responsibility to take action when our patients appear to be at risk for harming themselves. It is not possible for us to accurately predict when a person is going to commit suicide, but we are expected to assess for and document suicide risk factors. If necessary, we may have to call police or take other action to have patients involuntarily admitted to an inpatient psychiatric unit.

Involuntary commitment is a very controversial topic. What usually does not get discussed, though, is the fact that many mental health professionals, including myself, are often very uncomfortable being placed in the role of essentially being responsible for someone else’s behavior.

Although the majority of people who attempt or commit suicide suffer from mental illness, some do not. For those who do, some may be psychotic and therefore completely out of touch with reality or so clinically depressed that they have lost all hope.

In the latter two examples, the patients likely have treatable conditions, and once treated, they may change their minds about wanting to die. Even when I believe a patient simply wants to die and has “legitimate” reasons for feeling this way, I always try to dissuade them from harming themselves. I have not, and will never, shirk my professional duties.

From a philosophic standpoint, it makes perfect sense to me that mental health professionals should do all that we can to help people however we can. What I find rather odd, though, is that people in our culture do not have a right under any circumstances to end their own lives. I am not in favor of physician-assisted suicide or suicide at all for that matter. But, on a human-to-human level, who the heck am I, anyway, to tell someone that they can’t end it all if they choose to? I’ve never been suicidal, but likewise, who is anyone else to tell me I cannot do it either?

I understand firsthand that if affects people other than the one doing it, but at some level, at least, isn’t that personal choice? And, if it isn’t, then who, if anyone, should be held responsible if someone chooses to end his or her own life – psychiatrists, psychologists, therapists, primary care physicians, family, friends? In various life situations, Western society is great at assigning blame when there is a bad outcome, but I rarely hear people talk about free will.

I’m really curious what people think about this issue. I don’t hear it discussed often, but I believe it should be.