Part 1
Prison suicide is recognized as a serious yet underrated problem. In the United States, suicide is two times more common among prison inmates than in the general population (Arnaut, 2010). It is estimated that 200 prison suicides happen every year in the US (Suto & Arnaut, 2010). It is the third leading cause of deaths in the U.S. prisons after natural causes and AIDS (Metzner, 2002). The suicide rate in U.S. federal prisons is lower than the nationwide average (Federal Bureau of Prisons, 2012).
According to White, Schimmel & Frickey (2002), the prison suicide rate is often compared with the commonly accepted national general population rate of 12 per 100,000. However, this comparison is incomplete due to the disparity in the distribution of male and female prisoners. When this overall population rate of 12 per 100,000 is categorized by gender, the rate for men is 18 and 6 for women (White, Schimmel & Frickey, 2002). The rate of 10 to 17 per 100,000 in federal prisons is slightly lower than the rates in state prisons (Federal Bureau of Prisons, 2012). The highest rate in a prison is noted among death row inmates with 146.5 per 100,000 (Lester & Danto, 1993). Meanwhile, the jail suicide rate is nine times compared to the overall population, with a range of 107 to 187.5 per 100,000 (Lester & Danto, 1993).
According to Suto & Arnaut (2010), initial studies have predicted that the prison suicide rate would grow because of new mandatory sentencing laws which would also increase the incarceration rate, life sentences and death penalties, overcrowding in the correctional facilities, increased prevalence of AIDS, and the aging of the inmate population. Several trends also increased the number of incarcerated individuals with mental health problems, including those at risk for suicide. These trends include the deinstitutionalization of mental health patients after 1963, global migration and the loss of traditional social networks (Suto & Arnaut, 2010).
According to Hayes (1995), prison suicides have not been given proper attention. There is a lag in the prison and jail suicide research and many researchers just assumed that the risk for suicide decreases in prison as inmates began to adjust to life behind bars. Hayes opined that this simplistic assumption lack empirical validation. Also, the researches involving suicide statistics have often produced unreliable results because of the validity of establishing appropriate groups of comparison (Way, et. al., 2005).
There is also limited recorded information like incomplete and biased data. There is also a discrepancy in the inmates’ understanding of their suicide attempts and the actual accounts of recorded suicide files in prison (Way, et. al., 2005). Historical and descriptive studies do not completely capture the process by which inmates decide to commit suicide (Hayes, 1995). As such, the quantitative data on prison suicide only capture a small part of the actual data on the said problem. More qualitative data and explanations which can describe the psychology of the inmates who attempt suicide must be taken (Hayes, 1995).
The research of Suto & Arnaut (2010) showed that there are three main categories for the reasons why prison inmates commit or attempt suicide. These are: mental health issues, relationship issues, and prison factors. The boundaries between these categories were overlapping since suicide is a complex attempt. Personal factors also intertwined with other factors. For example, a relationship problem would usually lead to feelings of hopelessness, a personal factor. However, personal factors also warrant an independent category because many inmates stated periodic feelings of hopelessness even without external causality. Also, majority of the inmates do not feel extremely hopeless and they generally adapt to prison life without resorting to suicide. On the other hand, relationship issues also interlink with prison factors and not just personal issues.
Mental health issues include depressive symptoms like depressive thoughts, low mood, feelings of hopelessness or loneliness, and feelings of shame or guilt pertaining to their crimes. It also includes symptoms of anxiety like those small anxieties which build up through time. Fears also instigate the need for ending one’s life. Other inmates may also feel anxious about his/her sexual orientation or gender identity or the other inmates’ behaviors like unwanted sexual behavior of his cellmate (Suto & Arnaut, 2010). Mental health issues also include hallucination and/or paranoid ideation, impulsivity, religious beliefs, and medication related problems (i.e. the lack of psychotropic medications).
Relationship issues include relationship problems with family of pro-creation or partner from outside prison, relationship problems with family of origin or adoptive family, and relationship problems with inmates and staff. The prison factors include problems like economic difficulties, transfers within prison cells, and disciplinary reports which lead inmates to attempt or commit suicide (Suto &Arnaut, 2010).
Through advanced statistical methods, Stuart (2003) has shown the link between suicide risk and the duration of incarceration. High suicide rates occur immediately after admission and two months thereafter for under-trial inmates (Stuart, 2003). The risk of suicide highly correlates with the length of the sentence. Higher rates of mental disorders among the prisoners also contribute to this high risk. Most of the inmates who commit suicide have a treatable psychiatric disease. Many of them communicate their intent before they become successful in their attempt/s. The rates of fulfilled suicides among inmates with past histories of attempts are 100 times the rate in the general population (Stuart, 2003).
According to Hayes (2011), the National Jail Exchange summarizes the characteristics of the suicide victims as follow:
67% were Whites.
93% were Male.
Average age was 35.
42% were single.
43% were sanctioned for a personal and/or violent charge.
Holidays or certain seasons do not account for more prevalence of suicides.
About 32% of suicide happened from 3:00 pm to 9:00 pm.
93% of the victims hang themselves.
66% of the victims used bedding to kill themselves.
30% of the victims used a bed or bunk as their anchoring instrument.
31% of the victims were found dead an hour after they were last seen.
In about 37% of the suicide incidents, CPR was not administered.
38% of the victims were isolated.
8% of the victims were listed on the suicide watch when they were found dead.
In 13% of cases, no-harm contracts were used.
35% of deaths happened near the victims’ date of a court hearing, with 69% happening in
less than 2 days before a court hearing.
22% happened near the date of a telephone call or visit, with 67% happening in less than
1 day.
The history of the victims includes the following:
47% had a history of substance abuse.
28% had a history of medical problems.
38% had a history of mental illness.
20% had a history of taking psychotropic medication.
34% had a history of suicidal behavior.
In the study of Anasseril (2006), the lack of outside contact was said to be a factor for prison suicide. The inmate is more likely to withdraw or isolate himself. Another instance which is particularly high risk for suicide is when an inmate has just started recovering from depression. He may have more energy to kill himself than when he was powerless during his depression mode. For example, an inmate may have experienced loneliness as one element of vulnerability (others include depression, poor family support and social deprivation). If these events concurrently occur with “prison-induced stress,” it is greatly that the inmate will be influenced by “situational triggers” (for instance, the break up with a spouse or boyfriend) (Anasseril, 2006). As the inmate lacks several protective factors (such as good family support or bright hope for the future), he/she may be more prone to commit suicide.
Before an inmate actually kills himself, it is likely that he will have climbed various steps on the “Suicide Ladder” (Anasseril, 2006). The inmate may have experienced thoughts of suicide (‘suicide ideation’), may have injured himself or attempted suicide and may have made concrete plans (such as saying goodbyes to friends or making letters). If he is into detoxification or has just completed detoxification, he has the greater tendency to develop suicidal feelings. (This goes to inmates who are withdrawing from cocaine or amphetamines) (Anasseril, 2006).
One of the root causes of incomplete prison suicide studies is the underreporting of suicide. Prison officials must oblige to address this problem. For instance, many suicides are reported as accidental deaths. The staff at some facilities may opt not to report a suicide incident to prevent litigation (Suto, 2007). Also, if an inmate dies in the hospital following a suicide attempt, the records may not show that he/she actually died in the prison (Suto, 2007). Prison staff also tends to report White inmate cases which may mean under representation of Black inmates who committed suicides. The prison personnel may also constantly interpret self-mutilations as mainly motivated for secondary gain and not to terminate one’s life (Suto, 2007). In addition, researchers also contended that inmates’ specific escape attempts, engagement in physical fights with an armed prison personnel or a tough inmate and failure to settle a drug deal or gambling obligations may not be considered as prison suicides. Hence, the prison officers must address prison suicide.
Part 2
Stuart (2003) lists the suicide prevention standards of the American Correctional Association (ACA). It includes:
A written policy and procedures to ensure that inmate so the suicide list is directly observed at least every 30 minutes.
Constant observation for inmates who are violent or have a mental illness.
Continuous observation for actively suicidal prisoners.
A stated suicide prevention program that has been permitted by mental health professionals.
Training for all prison facilities staff in suicide prevention and intervention programs.
Intake screening, identification and supervision of inmates who have the tendency to commit suicide.
These features are the same with the standards of the National Commission on Correctional Health Care (NCCHC). This consists of inmate identification, prison staff training, professional assessment, constant supervision and communications, intervention, referrals, notifications, reporting, and reviews. The NCCHC advocates a more individualized approach to treatment and monitoring. Meanwhile, the Federal Bureau of Prisons’ program includes screening, treatment criteria, standardized record keeping, follow-ups and suicide data collection, and periodic reviews and audits.
According to Anasseril (2006), preventing prison suicide must be a collaborative effort of the administrative, custodial, and clinical staff in prison facility and it must be a main administrative and clinical priority in every US prison (Anasseril, 2006). A complete mental health and psychiatric service delivery system and a very supportive administration are the foundation of this important effort. The suicide-prevention program must integrate all aspects of identification, assessment, evaluation, treatment, preventive intervention, and training of all medical, mental health, and correctional staff (Anasseril, 2006).
At present, fully trained mental health and correctional staff in prisons are rare due to the lack of qualified professional pools, budgetary limitations, National Guard deployment, and the nature of correctional work (Anasseril, 2006). A particular division of administration dedicated to offender rehabilitation that oversees and coordinates medical, mental health, vocational, and educational services must be established in order to ensure a sustained staff-patient ratio, a multidisciplinary treatment team approach, timely treatment planning, staff training, and overall rehabilitative services (Anasseril, 2006).
This Prison Suicide Prevention Program is an example of a program which incorporates the principles and policies mentioned above.
Identification – consists of identifying possible suicidal inmates by asking questions about the suicide ideation; the inmates’ coping skills while in custody; hopeless feelings; requiring a personal confidante to discuss one’s personal feelings; the presence or absence of any suicide plans. These questions were based on the cognitive variables identified by mental health staff and the prison’s administrative team linked to suicide risk and they are included in a standard interview form used by nursing staff for screening upon admission. There is a Mental Health Behavior Checklist which lists several factors which are often identified with suicidal inmates i.e. agitation, bizarre behavior, depression and mood changes, hostility, insomnia/hypersomnia, self-destructive acts, suicidal or homicidal ideation, and significant changes in one's life. The checklist is used to determine suicidal behavior and relay the concerns of the direct-care staff to mental health and medical staff for initiation of suicide prevention process.
Staff Training – prison staff providing direct care (which includes administrative, managerial, correctional, mental health and medical professionals) must undergo a two hours training in prospective suicide recognition and intervention every year. The training sessions, held each Saturday of the month, include teaching them how to determine suicidal behavior and the features of the prison facility's suicide prevention program. All prison staff must also secure four hours of instructions in first aid and another four hours of CPR training every year. Prison officers are trained to promptly respond to emergencies, call for assistance, give first aid and CPR if needed, and transport the victim to a medical facility.
Assessment – upon admission to the prison facility, all inmates will receive an initial health screening by the medical staff. This includes queries concerning present and past history of suicidal tendencies. Inmates are also screened for assessment and intervention by mental health staff during interview. They are given additional information about the dangers of suicide. A direct-care staff (including supervisory and correctional line officers) can also determine if an inmate's suicidal behavior is risky and he/she can report the potential risk through the prison’s Mental Health Behavior Checklist.
When an inmate is determined as potentially suicidal, mental health staff evaluates the situation and, if warranted, formalize the placement of the inmate on regular or serious suicide watch. The Mental Health Management Order of the facility assigns the location of housing, the restrictions of personal property, and level of supervision. Mental health staff reevaluates all inmates placed on suicide watch every 24 hours. Only mental health staff (or an attending medical doctor) may change one’s status under the suicide watch.
Housing – this is a physical plant which houses suicidal inmates. This is a block where the regular suicide watch inmates are placed and another block is for those inmates who are listed under the more serious suicide watch. Each block contains closed-circuit television (CCTV), which properly supervise the suicidal inmates. Isolation is avoided, as much as possible. If a suicidal inmate must be placed in isolation, the prison’s security officers must initiate a conversation with the inmate. The facility’s medical clinic has 20 beds, three of which are dedicated to suicidal inmates under the serious watch list. This is because they might have other medical and mental health problems. Mental health staff chooses the beddings and the clothing of the suicidal inmates.
The regular suicide watch is applied to those inmates who are not actively suicidal but have mentioned suicidal thoughts or have prior history of suicide attempts. Extreme suicide watch is applied to inmates who present a strong evidence of clear and continuous risk of suicide. Acts include banging their heads against a wall or cell bars, threatening to hurt himself, among others. The frequency of observation for both watch list categories varies from 15-minute intervals to continuous observation, with each observation averaging by 5 minutes. This is specifically monitored under the extreme suicide watch list category.
Again, a complete documentation of the inmate observations is prepared by a correctional staff on a Suicide Watch Log Sheet. Further, within the prescribed interval, additional observations are occasionally and randomly made to prevent the planning of suicide attempts. A correctional officer is assigned to the two blocks. Another correctional staff supervises these blocks and a medical officer also observes the inmates under the two watch lists. Another medical staff monitors all inmates placed in restraints every two hours. Also, a mental health staff discusses with both the psychiatrist and physician about the continued suitability of the watch level and the treatment plan for the suicidal inmates within 12 hours from the start of the watch.
Intervention – in the advent of an actual suicide attempt, intervention procedures are put in place. Aside from the prison staff trained in first aid and CPR, each of the two blocks at the prison facility is designated with at least two correctional officers who are called "first responders." They have advanced trainings in suicide incidents. The prison also has a fully operational ambulance for taking the victims to the local hospital. The control desk in the physical plant has oxygen tanks and a fully armed "suicide prevention kit." This kit contains first aid items (such as ace bandages, a bite block, an elastic roll, cloth tape, a disposable pocket mask, paramedic shears, latex gloves, small and large gauze bandages, and a tool made to cut various materials that could be used in attempted hangings).
Administrative Review – after a suicide, the prison’s policy requires that a formal post-suicide investigation be made by a six-member team composed of a mental health staff, two correctional investigators, a security supervisor from the physical plant, and two medical staff members such as a physician, registered nurse or paramedic. This investigative team interviews staff and inmates, reassess pertinent documents, and prepares and forwards a report to the warden.
This component also takes care of administrative records of prisoners and their data records as well as a separate medical and mental health records, including personal interviews with suicidal inmates. These records may be used to correlate suicide to socio-demographic variables and mental health categories (e.g., depression).
References
Anasseril, E. D., MD. (June, 2006). Preventing Suicide in Prison: A Collaborative Responsibility of Administrative, Custodial, and Clinical Staff. Journal of American Academy of Psychiatry Law, 34:2:165-175.
Hayes, L. M. (1995). Prison suicide: An overview and guide to prevention. Washington, DC: U.S. Department of Justice, National Institute of Corrections.
Hayes, L. (2011.). National Study of Jail Suicide: 20 Years Later. The National Jail Exchange. Retrieved on November 1, 2012 from, https://docs.google.com/viewer?a=v&q=cache:i_W_lHTayWMJ:community.nicic.gov/cfs-filesystemfile.ashx/__key/CommunityServer.Components.PostAttachments/00.00.03.16.10/Jail-Suicide-Study.pdf+&hl=en&gl=ph&pid=bl&srcid=ADGEEShao8q8gT1_v6UZHsSF7uP424BdbjHsWWtdXYQsZ11QpiRvD7x2ATcYa02Di0rpHrrzSHKNPhTAec2RYOGW53ahvenMWr7voDQTro_EZ-Rw_dILqtiIxJZlo2j-u3224IkeVVtZ&sig=AHIEtbRlbC6UiE8ZIrzsxoBPtH06zH3mAg.
Lester D, Danto B. L. (1993). Suicide Behind Bars: Prediction and Prevention. Philadelphia: The Charles Press.
Metzner J. L. (2002). Class action litigation in correctional psychiatry. Journal of American Academy Psychiatry Law, 30:19–29.
Stuart H. (2003). Suicide behind Bars. Current Opinion in Psychiatry, 16: 559-564
Suto, I. (2007). Inmates Who Attempted Suicide in Prison: A Qualitative Study. Thesis. School of Professional Psychology. Pacific University.
Way, B. B., Miraglia, R., Sawyer, D. A., Beer, R., & Eddy, J. (2005). Factors related to suicide in New York state prisons [Electronic version]. International Journal of Law and Psychiatry, 28, 207-221.
White TW, Schimmel D. J., Frickey R. (2002). A comprehensive analysis of suicide in federal prisons: a fifteen-year review. Journal of Correct Health Care, 9:321–45.
