A major problem encountered by Terry Kupers, M.D., when he works in prisons and jails is the widespread and often erroneous designation of inmates as malingerers by correctional mental health staff.

When conducting psychiatric evaluations of inmates, he said, "I find that many inmates who have bona fide mental illness are diagnosed with malingering on their charts and removed from mental health treatment," he said.

Kupers cited a common scenario: an inmate superficially cuts his wrists and, upon questioning, reports that he did not mean to kill himself but was desperate to talk to a mental health professional after receiving an upsetting phone call from a family member.

"No one was paying attention to me," the inmate tells Kupers," so I needed to get someone's attention."

Said Kuper, "What we have is someone who because of his emotional problems needs treatment and is manipulative. In the average case, we have both."

The inmate may then be punished with a "ticket" for possessing glass or some other contraband material used to cut himself.

What often happens is that "in a system that doesn't provide sufficient [mental health] services, you have to be manipulative" to get the necessary treatment, he noted.

Another problem is that jails and prisons tend to focus exclusively on preventing people from committing an act that will lead to their suicide—those who are at risk for suicide are placed in an observation room without clothing, for example. Sheets must be constructed of a material that can't be used for self-harm. Instead of focusing on preventing suicide, however, "we need to get at the despair that drives inmates to attempt suicide," he said.