7 Week 623 Clinical Psychopharmacology in Correctional Settings
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Week7ReadingDestructiveBehavior.pdf
Management of Suicidal and Self-Harming Behaviors in Prisons: Systematic Literature Review of Evidence-Based Activities
Emma Barker, Kairi Kõlves, and Diego De Leo
The purpose of this study was to systematically analyze existing literature testing the effectiveness of programs involving the management of suicidal and self-harming behaviors in prisons. For the study, 545 English-language articles published in peer reviewed journals were retrieved using the terms ‘‘suicid�,’’ ‘‘prevent�,’’ ‘‘prison,’’ or ‘‘correctional facility’’ in SCOPUS, MEDLINE, PROQUEST, and Web of Knowledge. In total, 12 articles were relevant, with 6 involving multi-factored suicide prevention programs, and 2 involving peer focused programs. Others included changes to the referral and care of suicidal inmates, staff training, legislation changes, and a suicide prevention program for inmates with Borderline Personality Disorder. Multi- factored suicide prevention programs appear most effective in the prison environment. Using trained inmates to provide social support to suicidal inmates is promising. Staff attitudes toward training programs were generally positive.
Keywords best practice, inmates, prison, suicidal behavior
INTRODUCTION
Research has consistently shown higher suicide rates in prisons and jails worldwide, when compared to the general population (Dooley, 1990; Hayes, 1994; Hayes & Blaauw, 1997). The prison environment presents many predictors of suicidal beha- viors which are unique from the general
population. Risk factors of suicidal behaviors in prisons could be divided into four distinct categories:
. Demographic risk factors including being a young male, having prior crimi- nal history, low education level, White race, and being of single marital status (Daniel & Fleming, 2006).
. Clinical factors including personal and family history of psychiatric problems, and dysfunctional family lives including parental substance abuse and violence (Laishes, 1997), and Axis I and Axis II
Color versions of one or more of the figures in the article can be found online at www.tandfonline. com/usui.
Archives of Suicide Research, 18:227–240, 2014 Copyright # International Academy for Suicide Research ISSN: 1381-1118 print=1543-6136 online DOI: 10.1080/13811118.2013.824830
227
psychiatric disorders (Daniel & Fleming, 2006).
. Psychosocial factors such as poor cop- ing methods, stressful life events, past suicide attempts, receiving a new charge or conviction, and experiencing shame or guilt (Daniel & Fleming, 2006), and family conflict (Laishes, 1997).
. Institutional factors such as overcrowded conditions, bullying and harassment, recent disciplinary action (Kovasznay, Miraglia, Beer et al., 2004), being in a new environment (Winkler, 1992), sentences of life imprisonment, being held on remand (Fazel, Cartwright, Norman-Nott et al., 2008), lack of staff supervision, isolation, and sensory depri- vation of suicidal inmates (Daniel, 2006).
Rising prison suicide rates since the 1980’s have seen an increase in the study of suicide in prisons (Daniel, 2006), and the introduction of new suicide prevention programs (SPP’s) and policies. For example, the World Health Organization (WHO) in collaboration with the International Associ- ation for Suicide Prevention (IASP) released the guideline ‘‘Preventing suicide. In Jails and Prisons’’ in 1999. However, despite the increased attention, there still seems to be lack of evidence-based activities and programs focusing on reducing suicidal behaviors in prisons.
The aim of current review is to system- atically analyze existing literature on suicide prevention activities in prisons, which have been tested for their effectiveness.
Methodology
A search was conducted of English- language, peer reviewed articles published between 1990 and 2012. The search terms applied in SCOPUS, MEDLINE, PROQUEST, and Web of Knowledge were ‘‘suicid�,’’ ‘‘prevent�,’’ ‘‘prison,’’ or ‘‘correctional facility.’’ The initial search
of the databases returned a total of 538 articles, with another 7 articles being added after checking the reference lists of the articles retrieved by the search. These 545 articles were then limited to 99 after con- sideration of the titles (Figure 1). The abstracts of these 99 articles were then read and reviewed according to the following criteria:
Studies that present an overview of suicide prevention activities in the correctional setting, and include an analysis of effectiveness measured in incidence of suicidal behaviors or a changing of staff=inmates attitudes.
Studies were excluded if they did not appropriately test the impact of suicide prevention activities (i.e., solely presenting numbers of suicides occurring while the suicide prevention program was in place without any comparison to numbers before program implementation), if they were too outdated, were not focused specifically on suicide prevention within prisons, or if they simply provided an overall summary of various suicide prevention recommen- dations without any support of the effec- tiveness of these recommendations.
RESULTS
A total of 12 articles fulfilled the selected criteria and are presented here in more detail (see Table 1 for a summary). Out of the 12 studies, 7 were conducted in the United States, 2 in the United Kingdom and 1 in Canada, Austria, and Australia. Six of these studies involved multi-factored suicide prevention programs. Two of the studies were peer focused suicide preven- tion activities. The other four studies included changes to the referral and care of suicidal inmates in prison mental health services, risk management skills based training for prison staff, changes in
Managing Suicide and Self-Harm in Prisons
228 VOLUME 18 � NUMBER 3 � 2014
legislation and a specific suicide prevention program targeted at inmates with Border- line Personality Disorder.
Multi-Factored SPPs
In 1986, the Galveston County Jail in the US implemented an SPP based on the
principles listed by Felthous (1994), includ- ing screening new inmates, giving specific attention to inmates during risky periods such as the 3 days before and after a court hearing, providing psychological support for inmates, and avoiding the isolation of suicidal inmates. The study also noted that the use of trained inmates to provide com- pany for inmates housed in isolation should
FIGURE 1. Flow chart of the identification, screening, eligibility assessment, and inclusion of articles.
E. Barker, K. Kõlves, and D. De Leo
ARCHIVES OF SUICIDE RESEARCH 229
T A B L E 1 . S u ic id e P re v e n ti o n P ro g ra m s in
P ri s o n s a n d C o rr e c ti o n a l F a c il it ie s
A u th o r
C o u n tr y /
P ri s o n a n d
p e ri o d
A c ti v it y / In te rv e n ti o n
E v a lu a ti o n m e a s u re
M a in
fi n d in g s
F el th o u s,
1 9 9 4
U n it ed
S ta te s,
G al v es to n
C o u n ty
Ja il
1 9 8 6 – 1 9 9 4
S u ic id e p re v en ti o n p ro g ra m
w as
im p le m en te d w h ic h in cl u d ed
sc re en in g o f
in m at es , p sy ch o lo g ic al su p p o rt ,
o b se rv at io n an d d is b ar m en t o f d an g er o u s
o b je ct s, cl ea r an d co n si st en t g u id el in es
an d h o sp it al iz at io n .
C h an g es
in su ic id e
n u m b er s.
O v er
th e p er io d o f 1 9 8 6 – 1 9 9 4 , n o
su ic id es
o cc u rr ed
at th e ja il . T h is is a
re d u ct io n fr o m
7 su ic id es
in th e te n
ye ar
p er io d b ef o re
th e p ro g ra m
w as
im p le m en te d .
H ay es . L .,
1 9 9 5
L o u is ia n a,
U n it ed
S ta te s,
E la yn
H u n t
C o rr ec ti o n al
C en te r
M u lt i- fa ct o re d S P P co n ta in in g si x m ai n
co m p o n en ts in cl u d in g : st af f tr ai n in g ,
in ta k e sc re en in g = as se ss m en t, ap p ro p ri at e
h o u si n g o f su ic id al in m at es , ap p ro p ri at e
su p er v is io n d ep en d in g o n su ic id e ri sk ,
in te rv en ti o n p ro ce d u re s, an d
ad m in is tr at iv e re v ie w
af te r a su ic id e.
C h an g es
in su ic id e
n u m b er s in
E la yn
H u n t
C o rr ec ti o n al C en te r an d
su ic id e ra te s ac ro ss
th e
st at e.
O n ly o n e su ic id e at
th e fa ci li ty
si n ce
p ro g ra m
im p le m en ta ti o n , si g n if ic an t
re d u ct io n in
st at e su ic id e ra te s fr o m
2 3 .1
p er
1 0 0 ,0 0 0 b et w ee n 1 9 8 4 an d
1 9 9 2 to
1 2 .4
p er
1 0 0 ,0 0 0 in
1 9 9 3 .
C o x &
M o rs ch au se r,
1 9 9 7
S ta te
o f N ew
Y o rk , U n it ed
S ta te s,
1 9 8 5 – 1 9 9 6
S P P u si n g co -o rd in at io n st ra te g ie s an d
ri sk -m
an ag em
en t co m p o n en ts . In cl u d ed
st af f co -o p er at io n , st ru ct u re d sc re en in g ,
su p er v is io n an d o b se rv at io n o f at -r is k
in m at es , sp ec ia l sa fe
ce ll s, im p ro v ed
st af f
tr ai n in g , cr is is in te rv en ti o n m en ta l h ea lt h
se rv ic es , in v es ti g at io n o f su ic id es
an d st af f
d eb ri ef in g .
C h an g es
in su ic id e
n u m b er s. F ee d b ac k fr o m
p ar ti ci p an ts as
to th e
ch an g e in
n at u re
o f
re la ti o n sh ip s b et w ee n
p ri so n s an d m en ta l
h ea lt h ag en ci es .
S in ce
im p le m en ta ti o n o f th e p ro g ra m
su ic id e n u m b er s d ro p p ed
fr o m
2 6 in
1 9 8 4 to
9 in
1 9 9 6 . F u rt h er m o re ,7 8 %
o f p eo p le w h o re sp o n d ed
to a su rv ey
co n d u ct ed
af te r im p le m en ta ti o n
re p o rt ed
im p ro v ed
co n n ec ti o n s w it h
m en ta l h ea lt h se rv ic es .
H ay es , L .,
1 9 9 7
U n it ed
S ta te s,
C o u n ty
D et en ti o n
C en te r
S P P im p le m en te d w h ic h in v o lv ed
st af f
tr ai n in g , id en ti fi ca ti o n = sc re en in g o f
su ic id al in m at es , b et te r st af f
co m m u n ic at io n , im p ro v ed
su p er v is io n ,
im p ro v ed
sa fe
h o u si n g an d ap p ro p ri at e
st af f in te rv en ti o n .
C h an g es
in su ic id e
n u m b er s.
In th e 1 8 m o n th s af te r th e
im p le m en ta ti o n o f th e S P P , n o fu rt h er
su ic id es
w er e re co rd ed .
230 VOLUME 18 � NUMBER 3 � 2014
F ru eh w al d ,
F ro tt ie r, E h er ,
R it te r, &
A ig n er , 2 0 0 0
A u st ri a,
1 9 4 7 – 1 9 9 6
C h an g es
in le g is la ti o n ai m ed
at re d u ci n g
p ri so n su ic id es
sa w
fe w er
lo n g -t er m
se n te n ce s, m o re
fr eq u en t re le as es
o n
p ar o le an d sp ec ia l m an ag em
en t o f
m en ta ll y il l o ff en d er s, in cl u d in g in cr ea se
in m en ta l h ea lt h st af f. R ef o rm
s p ro d u ce d
a lo w er in g o f th e p ri so n p o p u la ti o n w h ic h
w as
ex p ec te d to
lo w er
su ic id e ra te s.
C h an g es
in su ic id e ra te s
B et w ee n 1 9 4 7 an d 1 9 9 6 th e p ri so n
su ic id e ra te s in cr ea se d fr o m
4 8 .6
p er
1 0 0 ,0 0 0 to
2 9 4 .4
p er
1 0 0 ,0 0 0 , d es p it e
th e re d u ct io n in
p ri so n p o p u la ti o n an d
in cr ea se d m en ta l h ea lt h st af f.
F re em
an &
A la im o , 2 0 0 1
U n it ed
S ta te s,
C o o k C o u n ty
D ep ar tm
en t
o f
C o rr ec ti o n s,
1 9 9 0 – 2 0 0 1 .
Im p le m en te d m u lt i- fa ct o re d S P P in cl u d in g
m en ta l h ea lt h sc re en in g , in p at ie n t ca re
fo r
su ic id al in m at es , fo ll o w u p tr ea tm
en t o n ce
st ab il iz ed , re lo ca ti o n in to
g en er al
p o p u la ti o n , co m m u n it y li n k ag e u p o n
re le as e, st af f tr ai n in g .
C h an g es
in su ic id e ra te s.
S in ce
im p le m en ta ti o n su ic id e ra te s
d ro p p ed
to fe w er
th an
2 su ic id es
fo r
ev er y 1 0 0 ,0 0 0 ad m is si o n s.
E cc le st o n &
S o rb el lo , 2 0 0 2
A u st ra li a
Im p le m en ta ti o n o f S P P ta rg et ed
at su ic id al
in d iv id u al s w it h B P D . P ro g ra m
in cl u d ed
fo u r m o d u le s w h ic h ai m ed
to te ac h
o ff en d er s m o re
ad ap ti v e co p in g sk il ls ,
re d u ce
su ic id e an d se lf -h ar m
b eh av io r an d
ad d re ss
u n d er ly in g cr im in o g en ic n ee d s.
A n al ys is o f B P D
sy m to m at o lo g y b ef o re
an d af te r p ar ti ci p at io n
th ro u g h a d ep re ss io n ,
an x ie ty
an d st re ss
sc al e
an d th ro u g h q u al it at iv e
an al ys is o f th er ap is t
n o te s.
M o st p ar ti ci p an ts ex p er ie n ce d a d ec li n e
in B P D
sy m p to m s d u ri n g th e
p ro g ra m , h o w ev er
2 o f th e g ro u p s (A
an d D ) h ad
le ss
g ro u p ex p er ie n ce
th an
th e o th er s an d re co rd ed
an in cr ea se
in
d ep re ss io n an d an x ie ty
d es p it e an
d ec ea se
in st re ss .
H al l &
G ab o r,
2 0 0 4
C an ad a,
S o u th er n
A lb er ta
P en al
In st it u ti o n ,
1 9 9 6 – 1 9 9 9 .
P ee r- fo cu se d su ic id e p re v en ti o n tr ai n in g
w h ic h fo cu se d o n tr ai n in g in m at es
in
li st en in g sk il ls , su ic id e p re v en ti o n , ri sk
as se ss m en t sk il ls , ef fe ct iv e an d ac ti v e
li st en in g , an d n o n -v er b al co m m u n ic at io n
sk il ls .
C h an g es
in su ic id e
n u m b er s o v er
th e p er io d
o f th e p ro g ra m
an d
as se ss m en ts fr o m
in m at es
an d st af f o n
p ro g ra m
ef fe ct iv en es s.
S u ic id e n u m b er s lo w er ed
fr o m
4 in
th e 5
ye ar
p er io d b ef o re
im p le m en ta ti o n to
2 d u ri n g th e 5 ye ar p er io d o f th e st u d y.
B o th
su ic id al in m at es
an d v o lu n te er s
fo u n d th e p ro g ra m
to b e v er y u se fu l.
C o rr ec ti o n al o ff ic er s w er e le ss
p o si ti v e, h o w ev er , p ro fe ss io n al st af f
co n si d er ed
th e p ro g ra m
to b e
(C on ti n u ed )
ARCHIVES OF SUICIDE RESEARCH 231
T A B L E 1 . C o n ti n u e d
A u th o r
C o u n tr y /
P ri s o n a n d
p e ri o d
A c ti v it y / In te rv e n ti o n
E v a lu a ti o n m e a s u re
M a in
fi n d in g s
ac ce ss ib le an d h el p fu l.
K o v as z n ay ,
M ir ag li a, B ee r,
& W ay , 2 0 0 4
N ew
Y o rk
P ri so n s.
Im p ro v ed
su ic id e p re v en ti o n p ro ce ss es
in cl u d in g an
im p ro v ed
p ro ce ss
fo r th e
re v ie w
o f su ic id es , u p d at ed
cl in ic al
p o li ci es
an d p ro ce d u re s, im p ro v ed
o b se rv at io n ce ll s an d st af f tr ai n in g .
G ra d u al ch an g es
in su ic id e
ra te s.
A u th o r n o te s th at su ic id e ra te s h av e b ee n
g ra d u al ly d ec re as in g th ro u g h o u t th e
st at e si n ce
m ea su re s w er e
im p le m en te d . R at es
re ac h ed
a lo w
p o in t o f 1 0 .2
p er
1 0 0 ,0 0 0 in
2 0 0 1 .
Ju n k er , B ee le r, &
B at es , 2 0 0 5
U n it ed
st at es ,
F ed er al
B u re au
o f
P ri so n s
M ed ic al
R ef er ra l ce n te r
S P P u si n g in m at e o b se rv er s to
m o n it o r
in m at es
at -r is k o f su ic id e.
A n al ys is o f th e n u m b er
o f
su ic id e w at ch es
an d th e
m ea n h o u rs
sp en t o n
su ic id e w at ch
b ef o re
an d
af te r p ro g ra m
im p le m en ta ti o n .
N o n -s ig n if ic an t d ec re as e in
th e n u m b er
o f w at ch es
re q u es te d o v er th e p ro g ra m
co u rs e. M ea n ti m e sp en t o n su ic id e
w at ch
w as
si g n if ic an tl y d ec re as ed .
S h aw
&
H u m b er , 2 0 0 7
U n it ed
K in g d o m ,
p ri so n s m en ta l
h ea lt h
se rv ic es .
R ec en tl y im p le m en te d su ic id e p re v en ti o n
st ra te g ie s in cl u d in g th e A ss es sm
en t, C ar e
in C u st o d y an d T ea m w o rk
A p p ro ac h
(A C C T ). T h is m ea n s th at
an y st af f
m em
b er
ca n re fe r an
in m at e to
re ce iv e an
as se ss m en t an d p la n o f ca re .
C h an g es
in su ic id e ra te s.
S ig n if ic an t re d u ct io n in
su ic id e ra te s
fr o m
1 2 7 p er
1 0 0 ,0 0 0 in
2 0 0 4 to
9 0
p er
1 0 0 ,0 0 0 in
2 0 0 6 .
A . H ay es , S h aw
,
L ev er -G
re en ,
P ar k er , &
G as k , 2 0 0 8
E n g la n d an d
W al es , 5
p ri so n si te s.
R is k M an ag em
en t S k il ls B as ed
T ra in in g
p ro g ra m
w as
ad ap te d to
fi t th e p ri so n
en v ir o n m en t an d w as
p ro v id ed
to p ri so n
st af f. T h e p ro g ra m
in v o lv ed
4 m o d u le s
d el iv er ed
th ro u g h le ct u re s, v id eo s,
v id eo -t ap ed
ro le p la ys
an d fe ed b ac k o n
th e ro le p la ys .
S ta ff co m p le te d
q u es ti o n n ai re s b ef o re
an d af te r tr ai n in g , an d
ag ai n at
a 6 – 8 m o n th
fo ll o w
u p .
T h e p ro g ra m
re su lt ed
in im p ro v ed
st af f
at ti tu d es
to w ar d s su ic id e p re v en ti o n ,
an d in cr ea se d k n o w le d g e an d
co n fi d en ce
fo r ri sk
id en ti fi ca ti o n . T h e
v id eo ta p in g o f ro le p la ys
w as
n o te d as
th e le as t h el p fu l p ar t o f th e p ro g ra m .
232 VOLUME 18 � NUMBER 3 � 2014
not replace staff observation, and that closed-circuit television (CCTV) should not replace personal observation and interac- tion at least every 15 minutes (Felthous, 1994). According to Felthous (1994) inmates should be disarmed from poten- tially dangerous items depending on suicide risk, and suicide prevention procedures should be applied consistently, with clear outlines as to the responsibilities of invol- ved persons (Felthous, 1994). Finally, inmates who were psychotically disturbed were provided access to psychiatric hospi- talization when possible. Although the author notes the empirical testing of prison SPP’S is difficult to achieve, the impact of the application of these principles can be seen by the reduction in suicide deaths (Felthous, 1994). During the period from 1986 (when the program was implemented) to 1994 (when the article was published) no suicide deaths occurred in the jail, com- pared to seven suicides between 1976 and 1986 before the program began. This vast reduction is despite the jail population having more than doubled since 1986 (Felthous, 1994).
Similar to the previous study, Hayes (1995) reported on the effectiveness of the SPP at the Elayn Hunt Correctional Centre (EHCC) in Louisiana, US. The prison acts as both an intake and assess- ment point for male offenders committed to the Louisiana Department of Public Safety and Corrections, and as a permanent housing facility for sentenced prisoners. The SPP tested at EHCC addressed the six main components of a successful pro- gram as listed by Hayes (1995), including staff training, intake screening=assessment, appropriate housing of suicidal inmates, appropriate levels of supervision according to active suicide risk, intervention proce- dures in the event of an attempt (staff first aid and availability of an ambulance for transportation to hospital), and adminis- trative review following a suicide. Between the period of 1983 and 1994, 57,091
inmates were processed through the EHCC adult reception and diagnostic center (ARDC), only one of whom completed sui- cide (Hayes, 1995). This was coupled with a significant reduction in suicide in prisons all across the state after the introduction of a departmental suicide review committee in 1992, to aid in coordinating suicide pre- vention practices across the state’s 11 prison facilities and to supplement internal investigations. Since the introduction of this committee, Louisiana’s suicide rates dropped from a rate of 23.1 per 100,000 between 1984 and 1992 to 12.4 per 100,000 inmates during 1993 (Hayes, 1995).
A large metropolitan County Deten- tion Centre (CDC) in the US experienced nine suicides within 24 months, a much higher rate than the national average (Hayes, 1997). Reasons for this high rate were attributed to lack of staff supervision, inadequate response time by medical staff, hazardous cell conditions, and inadequate staff training (Hayes, 1997). Following these nine suicides, a comprehensive sui- cide prevention program was implemented to resolve these shortcomings, including improved staff training through the intro- duction of 8 hour suicide prevention train- ing sessions as well as 2 hours of refresher training each year, identification=screening of all inmates on intake and for all inmates identified as being suicidal during their incarceration, improved communication between staff, the availability of suicide resistant housing, and appropriate staff intervention and use of first aid and cardio- pulmonary resuscitation (CPR) when sui- cide attempts occur (Hayes, 1997). In the 18 months following the nine inmate sui- cides and the implementation of the new suicide prevention program, no further suicides were recorded (Hayes, 1997).
Also in the US, Freeman and Alaimo (2001) provided an outline of an effective SPP applied in the Cook County Depart- ment of Corrections (CCDOC), the third largest pre-trial detention system in the
E. Barker, K. Kõlves, and D. De Leo
ARCHIVES OF SUICIDE RESEARCH 233
country. This program included the mental health screening of all new detainees (utilizing structured questionnaires, clinical observation, and previous staff member experience to detect high risk individuals), staff member training, inpatient care and monitoring of suicidal inmates, emergency procedures such as close observation and the use of medical restraints for highly sui- cidal inmates, and follow up treatment once inmates were stabilized (Freeman & Alaimo, 2001). The care of inmates per- sisted after they were released back into the general prison population; with a crisis team available at all times (Freeman & Alaimo, 2001). Finally, the SPP introduced new training procedures for correctional officers with regards to better identification of the mental health needs of the prison population. One unique factor of this pro- gram was the community linkage of detai- nees who were suicidal. This involved the petition to the court to have inmates who remained suicidal on release, committed to a state hospital for further treatment. Since 1990, after the implementation of the SPP at CCDOC, suicide rates were reduced to less than 2 per 100,000 admis- sions at the prison (Freeman & Alaimo, 2001). This low rate is impressive consider- ing departments which hold pre-trial inmates have been shown to generally have higher incidences of suicide than those which detain inmates on longer sentences (Blaauw, Kerkhof, & Hayes, 2005). How- ever, authors did not provide a baseline rate for CCDOC, though it was noted that suicide rates across New York State showed an average of 42.2 suicides per 100,000 admissions between 1988 and 1997 (Freeman & Alaimo, 2001).
Two of the studies involved multi- factored SPP’s implemented in prisons across New York. The first, by Cox & Morschauser (1997), focused on a multi- factored SPP addressing increasing prison suicide rates in New York Prisons between 1983 and 1984. The program was named
the ‘‘Local Forensic Suicide Prevention Crisis Service Program’’ and was imple- mented in 57 counties, with revisions made in 1993 to keep the program up to date (Cox & Morschauser, 1997). This program included many components seen in previ- ously mentioned programs such as inmate screening, supervision of high risk inmates, and staff training. In addition, it included details of the review process after a suicide occurs to prevent future incidents, and staff debriefing to provide support for staff involved in the incident (Cox & Morshauser, 1997). Cox and Morschauser (1997) report that the program had great success across the state, with a decrease in suicide numbers from 26 in 1984 to 9 in 1996, despite a doubling in the jail popu- lation. Strengthened relationships between prisons and mental health agencies were also reported by 78% of respondents (Cox & Morshauser, 1997).
The second, more recent, study from New York focused on a program imple- mented by NYS Department of Correc- tional Services (DOCS), Bureau of Forensic Services (BFS), and the Central New York Psychiatric Centre (CNYPC). Similar to other studies, measures included an improved process for the review of suicides, with each completed suicide undergoing a psychological autopsy and a special investigation, and quality assurance reviews for both completed suicides and serious non-fatal attempts (Kovasznay, Miraglia, Beer et al., 2004). Clinical Policies and procedures were improved through changes to the inmate service level classi- fication process, the admittance of inmates into the observation unit, methods to engage reluctant inmates with appropriate treatment, and modification of observation cells for enhanced safety (Kovasznay, Miraglia, Beer et al., 2004). Despite fluctua- tions, suicide showed an overall declining trend (dropping from 15.8 per 100,000 in 1993 and 24.4 per 100,000 in 1994 to 10.2 per 100,000 in 2001, 19.4 per
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100,000 in 2002). Kovasznay, Miraglia, Beer et al. (2004) suggest that it is related to these measures implemented as well as quality assurance reviews, an increase in mental health staff in prisons, and the col- laboration between DOCS and mental health agencies.
Peer Focused Prevention Activities
The potential for using other inmates as suicide prevention has come to attention due to suggestions that inmates are more able to relate to the experiences of their peers, therefore being more likely than staff to gain the trust of other inmates (Laishes, 1997). The SAMS in the Pen, peer SPP was implemented in a medium security facility in Southern Alberta, Canada. The program was created by collaboration between the prison and the Samaritans of Southern Alberta (SAMS; an inmate suicide preven- tion group). Training was provided to selected inmates covering topics such as the concept of befriending, effective and active listening, nonverbal communica- tions, the nature of mental illness, suicide prevention and intervention, and policies and procedures of SAMS (Hall & Gabor, 2004). After participation in the program, the general inmate population, as well as SAMS volunteers, perceived the program to be quite helpful, however correctional staff were not as certain about the effec- tiveness (Hall & Gabor, 2004). Professional staff (parole officers, mental health work- ers, chaplains) were more impressed than correctional officers about the accessibility of the program and its helpfulness (Hall & Gabor, 2004). The program appeared to have potential for suicide prevention, with suicide deaths lowering from four suicides in the 5-year period before implementation, to two completed suicides during the 5-year period of the program (1995–2000). Unfortunately, due to low absolute numbers it was not possible to
demonstrate effectiveness statistically. However, Hall and Gabor (2004) concluded that the comments from parti- cipants and the low suicide rate over the duration of the program indicated the pro- grams potential for suicide prevention.
The Inmate Observer Program (IOP) implemented at a Federal Bureau of Prisons Medical Referral center, specifically aimed to prevent the negative effects of isolation through the use of inmate obser- vers in the correctional setting (Junker, Beeler, & Bates, 2005). During the 24-week study period, 82 suicide watches were initiated for 37 individuals who were placed on suicide watch in an inpatient restricted housing unit. These inmates were obser- ved through direct observation by trained inmate observers as well as staff obser- vation through CCTV and rounds by staff (Junker, Beeler, & Bates, 2005). The num- bers of suicide watches in the 12-week per- iod prior to the program were compared to the 12 weeks following, with watches being reduced from 48 to 33 (31.25% reduction), however this reduction was not significant (p ¼ 0.096) (Junker, Beeler, & Bates, 2005). Nevertheless, one group of inmates, those with personality disorders had signifi- cantly fewer watches than before program implementation (p ¼ 0.033). The mean hours on suicide watch was then analyzed before and after initiation of the program. Before implementation, inmates spent an average of 108.88 hours on suicide watch, which was reduced significantly to 64.5 hours after implementation (p ¼ 0.036) (Junker, Beeler, & Bates, 2005).
Other Studies
In 1975, law reforms in Austria imposing fewer long term sentences, more suspended sentences, more frequent release on parole, and special requirements for the management of mentally ill offenders (those not guilty by reason of insanity,
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ARCHIVES OF SUICIDE RESEARCH 235
highly dangerous and mentally ill offenders, and alcohol and drug addicted offenders) were expected to lower prison suicide rates (Fruehwald, Frottier, Eher et al., 2000). The reform also saw an increase in staff, impro- ved staff training, and better facilities to treat mentally ill inmates. Fruehwald, Frot- tier, Eher et al. (2000) analyzed the statisti- cal reports from the Ministry of Justice between 1947 and 1996 to get an overview of annual suicide rates over this time per- iod. It was found that despite the measures implemented to reduce suicide and a lower- ing of the prison population, the rates of suicide increased significantly since 1947 (6 suicides or 48.6 per 100,000 in 1947, to 20 suicides or 294.4 per 100,000 in 1996). Authors stated that this increase may be partly attributed to the fact that the reform saw only highly dangerous or violent offen- ders incarcerated; a population which has been shown to have increased suicide risk. Furthermore, despite the reduced prison numbers, the housing arrangement of pris- oners remained much the same, which may have still given inmates the impression of unpleasant overcrowded conditions (Fruehwald, Frottier, Eher et al., 2000).
Eccleston and Sorbello (2002) pre- sented an Australian program adapted from Dialectical Behavior Therapy (DBT), which was piloted in Victoria, called RUSH (Real Understanding of Self-Help). The program aimed to teach offenders with Borderline Personality Disorder (BPD) more adaptive coping skills, to reduce suicide and self- harming behavior, and reduce recidivism by addressing underlying criminogenic needs (Eccleston & Sorbello, 2002). Five groups participated in the program, with group A comprising inmates who were highly vulnerable to suicide, group B com- prising violent offenders, group C, vulner- able and first time offenders under the age of 25, and groups D and E, protection offenders. Quantitative evaluations were conducted before and after participation in the program using the depression,
anxiety, and stress scale (DASS) (Lovibond & Lovibond, 1995). It was found that the majority of participants experienced a decline in Borderline Personality Disorder symptoms during the program, particularly groups B, C, and E (Eccleston & Sorbello, 2002). Interestingly, groups A and D showed a reduction in stress, but an increase in depression and anxiety. The author noted that this may be attributed to the fact that these participants had less group experience than the other groups, and therefore had more difficulty identify- ing feelings of depression and anxiety on entering the program. This prediction was supported by participant feedback, with those inmates who had little group experi- ence admitting that they had denied symp- tomology when completing the initial questionnaire (Eccleston & Sorbello, 2002). Qualitative analysis of facilitator therapy notes showed that most participants had high levels of motivation and commitment, actively demonstrated the RUSH skills, established group cohesion quickly and regularly confirmed the programs useful- ness during the program and in formal feedback administered during the last session (Eccleston & Sorbello, 2002). Cor- rectional officers perceived the program to be useful; indicating anecdotally that the self-harming and dysfunctional behavior had declined in participants.
To address criticism of staff suicide prevention training in England and Wales, a well-known suicide prevention training package called Skills-Based Training on Risk Management (STORM) was adapted to fit the prison setting (Hayes, Shaw, Lever-Green et al., 2008). The program was evaluated at two adult male establish- ments and one juvenile offender establish- ment, through measurement of staff attitudes to the training (using the adapted Attitude to Suicide Prevention Scale). Fur- thermore, a measure of knowledge about suicide was developed for the study, and a measure of self-efficacy was used to
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evaluate staff confidence in their abilities and satisfaction with the training. Results of surveys completed before and after the training showed a significant improvement in scores for attitudes, knowledge, and con- fidence (Hayes, Shaw, Lever-Green et al., 2008). The majority of staff were satisfied with the program with 78% enjoying the course, 95% saying they would recommend it to colleagues and 94% finding the skills and techniques learned to be relevant to the prison setting. The videotaping of role plays was perceived to be the least helpful part of the training, with only 42% of participants reporting satisfaction with this activity. Follow up surveys issued 6–8 months after program completion had poor response rates (38%) making inter- group comparisons difficult (Hayes, Lever- Green et al., 2008).
Another paper from the United Kingdom by Shaw and Humber (2007), specifically focused on improvements to prison mental health services in the UK. The article presented the introduction of suicide prevention procedures, namely the Assessment, Care in Custody and Team- work (ACCT) process, in which any staff member can seek mental health services for an inmate who appears to be at risk of suicide. After being identified, these individuals will be monitored, assessed, and provided with a plan of care, all of which will be supervised by a case manager (Shaw & Humber, 2007). After the implementation of these procedures there was a decline in the prison suicide rate from 127 per 100,000 in 2004 to 90 per 100,000 in 2006. Shaw and Humber (2007) noted that this cannot yet be con- sidered a definite trend as prison suicide rates may fluctuate.
DISCUSSION
Prison SPP’s are difficult to empirically asses, and as the study by Fruehwald,
Frottier, Eher et al. (2000) indicated, the success of SPPs may rest partly on the characteristics of the individual prisons being analyzed. Despite this, the current literature shows that multi-factored suicide prevention programs focusing specifically on reducing unique risk factors for suicide in prison have the potential to lower the incidence of suicide. Programs are most likely to succeed when implemented as prisoners arrive and are maintained until inmates leave the facility. Effective multi- factored programs may include screening and assessment of inmates on intake, improved staff training, post intake obser- vation for suicide risk, monitoring and psychological treatment of suicidal inmates, limited use of isolation and increased social support, and adequate and safe housing facilities for at-risk individuals (Cox & Morschauser, 1997; Felthous, 1994; Freeman & Alaimo, 2001; Hayes, 1995; 1997; Kovasznay, Miraglia, Beer et al., 2004). Procedures implemented after a suicide or serious suicide attempt, such as internal and external review processes and staff debriefing and support can also aid in preventing further incidents and lower the burden of these events on staff (Cox & Morshauser, 1997). Successful SPPs in the prison environment do not appear to be limited to multi-factored programs. While still in the early stages of development, programs aimed at pro- viding support and observation of suicidal prisoners through the use of trained inmates may help to prevent suicides and limit the negative effects of isolation (Hall & Gabor, 2004; Junker, Beeler, & Bates, 2005). However, despite positive results, these inmate observers must be carefully selected and trained, and inmate observation must be coupled with frequent observation by trained staff members (Junker, Beeler, & Bates, 2005). If inmates are not carefully selected there exists the risk of volunteers misusing the program to facilitate social visits, illegal activities or
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ARCHIVES OF SUICIDE RESEARCH 237
transferring information (Hall & Gabor, 2004).
All except one of the programs evalu- ated (Fruehwald, Frottier, Eher et al., 2000), achieved positive outcomes. Three of the studies reported decreases in suicide rates (Freeman & Alaimo, 2001; Kovasznay, Miraglia, Beer et al., 2004; Shaw & Humber, 2007), while four studies obser- ved changes in suicide numbers (Cox & Morschauser, 1997; Felthous, 1994; Hayes, 1997; Hall & Gabor, 2005). One study found both changes in numbers at the particular prison where the program was implemented as well as changes in rates state-wide after the introduction of a committee to co-ordinate the states suicide prevention practices (Hayes, 1995). The study which evaluated staff attitudes to an improved training program retrieved posi- tive results (Hayes, Shaw, Lever-Green et al., 2008), as did the study analyzing the mean number of hours prisoners spent on suicide watch before and after imple- mentation of a peer observer SPP (Junker, Beeler, & Bates, 2005). Eccleston and Sorbello (2002) found that the SPP targeted specifically at individuals with BPD gener- ally achieved a decline in BPD symptoms during participation in the program. The study by Fruehwald, Frottier, Eher et al. (2000) found that suicide rates continued to rise after the implementation of new policies and procedures regarding suicide prevention. However, this was the only study that analyzed a longer period (50 years) across a whole country (Fruehwald, Frottier, Eher et al., 2000). Furthermore, the author partly attributed the rise to the fact that the change in legislation resulted in mainly highly violent offenders, who are known to have a higher risk of suicide, being housed in the prison (Fruehwald, Frottier, Eher et al., 2000). The main find- ing of the current literature review was that there may be potential to reduce the occur- rence of prison suicides, however this appears to depend on programs addressing
all four major categories of risk specific to prison suicides including demographic, clinical, psychosocial and institutional factors, through the use of comprehensive multi-factored prevention programs. Fur- thermore, the review indicates that the progression of suicide prevention practices around the world varies greatly from one country to the next, with innovative SPP’s such as the use of trained inmate observers achieving positive results when carefully implemented.
Limitations
The studies presented in this literature review have several limitations which should be noted. Due to the nature of prison suicides, and the inability to use controls to empirically test programs by withholding treatment from some indivi- duals (Felthous, 1994), most studies in this review had to rely solely on changes in sui- cide numbers or rates (Cox & Morschauser, 1997; Felthous, 1994; Freeman & Alaimo, 2001; Hayes, 1997, 1995) or perceived changes in attitudes from staff and inmates (Hayes, Shaw, Lever-Green et al., 2008). It is noted that prison suicide numbers are always fluctuating, meaning that small changes may be difficult to attribute to the implementation of a SPP (Shaw & Humber, 2007). Other limitations include small sample or group sizes due to partici- pant attrition in follow-ups (Hayes, Shaw, Lever-Green et al., 2008) or during the course of the program (Eccleston & Sorbello, 2002), problems with program implementation due to the prison environ- ment, prisoner behavior and attitudes, and the complexity of some parts of the pro- gram (Eccleston & Sorbello, 2002) and poor generalizability of results from the prison mental health setting to other prison environments (Junker, Beeler, & Bates, 2005).
The current systematic literature review was not without limitations itself.
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Firstly, the review was limited to articles published in English, which may have resulted in the exclusion of some studies. In fact, the majority of the studies included, and all multi-factored SPPs were from the US, and all of the studies came from Westernized nations. Furthermore, there may be unpublished reports that were not found through our searches. Some studies which were included in the systematic review were not able to evaluate their programs through changes in suicide rates or numbers, meaning they depended on personal perceptions which might be less reliable. Finally, there is a possibility of publication bias and studies which retrieved undesirable results have not been published.
CONCLUSIONS
Prison suicide is a major problem world- wide, with prisons constantly showing higher suicide rates than the general population (McArthur, Camilleri, & Webb, 1999). This indicates the need for effective suicide prevention programs in the prison environment. Findings of the review dem- onstrate that well known therapies or programs such as DBT and the STORM training package may be successfully adapted for use in the prison setting, indicating the potential to similarly adapt other existing therapies or programs. Those suicide prevention programs utilizing vari- ous methods such as initial screening, staff training, increased observation and moni- toring, safer physical environments, mental health services including external hospitali- zation, reduced use of isolation, and post suicide debriefing and staff support have been found to be the most effective at reducing suicidal behaviors in prisons. Despite the effectiveness of multi-factored programs it is important in the future to continue considering the unique charac- teristics of the prison environment by
including innovative methods such as the use of trained inmates as observers to reduce the problem of understaffing in prisons.
The review highlights the lack of current research and the need for future studies analyzing the effectiveness of sui- cide prevention practices in prisons. The known general fluctuation of prison suicide rates and the fact that the article analyzing suicide prevention measures over the long term was the only one to return negative results, indicates the importance of studies covering longer periods of time to lend strength to current positive findings.
AUTHOR NOTE
Emma Barker, Kairi Kõlves, and Diego De Leo, Australian Institute for Suicide Research and Prevention; National Centre of Excellence in Suicide Prevention; and World Health Organization Collaborating Centre for Research and Training in Suicide Prevention, Griffith University, Queensland, Australia.
Correspondence concerning this article should be addressed to Diego De Leo, AISRAP, Griffith University, Mt. Gravatt Campus, Mt. Gravatt, QLD 4122, Australia. E-mail: [email protected]
FUNDING
This review was supported by the Queens- land Corrective Services.
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