1. Suicide Awareness In The
Corrections Environment
Guiding Principles for Suicide
Prevention
2. Definition of Suicide
“Suicide is a conscious act of self-induced
annihilation, best understood as a
multidimensional malaise in a needful
individual who defines an issue for which
the suicide is perceived as the best
solution.”
Malaise (mal-āz´) a vague feeling of
discomfort. A vague feeling of bodily
discomfort, as at the beginning of an illness.
general feeling of fatigue and bodily unease.
4. Chronic Risk Factors (If present,
these increase risk over one’s lifetime.)
Perpetuating Risk Factors
Demographics: White, American Indian, Male, Older Age (review current rates1),
Separation or Divorce, Early Widowhood
History of Suicide Attempts – especially if repeated
Prior Suicide Ideation
History of Self-Harm Behavior
History of Suicide or Suicidal Behavior in Family
Parental History of:
- Violence
- Substance Abuse (Drugs or Alcohol)
- Hospitalization for Major Psychiatric Disorder
- Divorce
History of Trauma or Abuse (Physical or Sexual)
History of Psychiatric Hospitalization
History of Frequent Mobility
History of Violent Behaviors
History of Impulsive/Reckless Behaviors
5. Predisposing and Potentially
Modifiable Risk Factors
Major Axis I Psychiatric Disorder, especially:
- Mood disorder,
- Anxiety Disorder
- Schizophrenia
- Substance Use Disorder (Alcohol Abuse or Drug
Abuse/Dependence)
- Eating Disorders
- Body Dysmorphic Disorder
- Conduct Disorder…
Axis II Personality Disorder, especially Cluster B
6. National Stats 2008
There is a suicide every 14.6 minutes
900,875 Attempts per year (every 35
seconds)
25 attempts for every 1 death
3 female attempts to 1 male
7. Jail Suicide Research 2005-06
696 Jail Suicides in the 2005-06 Study
In 1980’s, rate of suicide in county jails
was approx. 107 deaths per 100,000
inmates or an approx. rate of 9 times
greater than the community.
2005-06 Data indicate a decrease to 36
deaths per 100,000.
8. Jail Suicide Research, Nat’l
2005-06 (1986 stats)
67% of Victims were White (72%)
93% Male (94%)
Average age was 35 (30)
42% Single (52%)
43% Personal/Violent Charges (75% nonvio)
47% History of Substance Abuse Problems (27%)
28% Medical Problems
28% Mental Health Diagnosis
20% Psychotropic Medication
34% History of Prior Suicide Attempt
9. Suicide Characteristics
2005-06 Data
Seasons and Holidays did not account for
increase in suicidal behavior.
32% Between 3:01 PM and 9:00 PM
23% in the first 24 Hrs.
27% in 2-14 days.
20% 1-4 Months
38% in Segregation
10. Jail Environment
Suicide the #1 cause of death in jails
Why?
New or Authoritarian Environment
Lack of control
Shame and fear
Dehumanizing aspects of incarceration
Lack of family/social supports
11.
12. Common myths about
Suicide
Happens without warning
Low risk after mood
improvement
Once suicidal, always
Don’t mention suicide suicidal
Intent on dying
So rare, they won’t do it
Runs in the family
No note ==> no suicide
13.
14. Careful, Thorough Booking
The most important interaction is at booking
Observe signs/symptoms and interact with
arresting officer
Ask all questions, don’t assume.
Don’t get casual (lazy) on the screening
Ask more clarifying questions if needed
Be genuine real caring, look at the person
Refer to medical/mental health if concerns
15. Medical Screening
Observe the Mood and Affect of Pt.
Don’t go through the questions too fast
If there are any concerns, Refer to MH
16. Identification
Current Depression or
Severe Anxiety
Psychosis or Paranoia,
Delusional
Direct or Indirect Suicidal
Comments
Hopeless/Helpless,
Burdensome
Behavior Changes-
sleeping, eating etc
Mood variations, shame,
guilt, isolation
Agitation, Rage
17. High Risk Periods
First 24 Hours
Intoxication or substance withdrawal
Waiting for Trial or sentencing
Impending release
Holidays
Decreased staff supervision
Bad news after phone calls or visits, court
Serious Charge/High Profile
18. Mental Health
Rates of Mentally ill inmates increasing
Less funding for treatment
Not compliant to treatment
Lack of treatment resources
Incarceration usually the path of least
resistance
Increases risk of self-mutilation and SI
20. Symptoms of Mental Illness
Prolonged anxiety or panic
Abrupt mood changes
Hallucinations
Severe paranoia and delusions
Grandiosity (I’ll take on the whole dorm)
Confusion, disorientation
Prolonged severe depression
21. Critical Symptoms
Sadness Emotional flatness
Crying Self-doubt
Hopelessness Severe mood
Helplessness changes
Tension Shame
Agitation Fear
Emotional outbursts
22. Behavior Indicators
Loss of appetite or
overeating
Sleep problems, too
much or too little
Unusually slow reactions
Social withdrawal
Pacing
Reckless Behavior
Giving things away,
writing will, trying to repair
old relationships
Self-mutilation
23. Interventions
Try to calm inmate and relieve anxiety by
being calm, confident, firm, fair, and
reasonable.
Explain how you see the problem, what is
being done and what the outcome will be.
Do they need a time-out?
Is housing appropriate?
Instill hope
Dispel thoughts of being a burden
24. Major Predictors of
Suicidal Behavior
• Current plan:
• Specificity of their plan
• Availability of means
• Lethality of method
• Previous History:
• A prior suicide attempt
• A family history of suicide behaviors
• Resources available
25. ASIST Training
Applied Suicide Intervention Skills Training
Connect- Inmate invites
Understand- Staff Clarifies-Suicide CPR
Assist- Create a Plan and Follow-up
26. Important Questions/Assessment
Have you been thinking of hurting or killing yourself?
How would you kill yourself?
Do you have the means available?
Have you ever attempted suicide?
Has anyone in your family attempted or completed
suicide?
What are the odds that you will kill yourself?
What has been keeping you alive so far?
What do you think the future holds in store for you?
Follow Your Gut!
27. If Yes
Discuss with Detention Staff
Have Pt. placed in Suicide Smock
Put in appropriate housing on a 15 min
documented watch
Best to keep in for 24 hours
Have the Pt. on MH caseload until cleared
Sometimes we need to make time to talk
28. Serious Attempt or Completion
CISM Defusing within 24 Hours for staff
and inmates.
CISM Debriefing as soon as it can be
scheduled for staff and inmates.
Follow-Up as-needed.
Effects can last months to years if not
addressed effectively and appropriately.
29. Toward a Better Understanding of
Suicide Prevention
We do an admirable job of managing
inmates identified as suicidal and placed
on precautions.
Very few inmates successfully commit
suicide while on suicide watch.
How do we prevent suicide of an inmate
who is not easily identifiable as being at
risk for self harm?
30. Guiding Principles for Suicide
Prevention
The assessment of suicide risk should not
be viewed as a single event, but as an on-
going process.
Intake screening should be viewed as
something similar to taking one’s
temperature – it can identify a current
fever, but not a future cold.
31. Guiding Principles for Suicide
Prevention
Prior risk of suicide is strongly related to
future risk.
Do not rely exclusively on the direct
statements of an inmate who denied that
they are suicidal and/or have a prior
history of suicidal behavior, particularly
when their behavior, actions and/or history
speak louder than their words.
32. Guiding Principles for Suicide
Prevention
Many preventable suicides result from
poor communication amongst corrections,
medical and mental health staff and
inmates.
Avoid creating barriers that discourage
inmates from accessing mental health
services.
33. Guiding Principles for Suicide
Prevention
Create more interaction between inmates and
correctional, medical, and mental health staff in
“special housing units.”
Create and maintain a comprehensive suicide
prevention program that includes the following
essential components: Staff Training, Intake,
Screening/Assessment, Communication,
Housing Levels of Observation, Intervention,
Reporting, Follow-up, Review
34. Legal Liability
Grossly Negligent
“Deliberate indifference”
Definition: “knows of and disregards an
excessive risk to inmate health and safety;
the official must both be aware of the
facts from which the inference could be
drawn that a substantial risk of serious
harm exists, and he must also draw the
inference”
Individual Introductions Introduce myself and my qualifications Do Pre-Test
Show video clip from In Our Own Voice
Important information to know for assessment. May or may not be appropriate for your audience. Prior attempt - best predictor of future behavior is past behavior. Repeat attempters say subsequent attempts are “easier” than initial attempt in that they struggled less with their ambivalence. Family history - suicide modeling as a coping mechanism by family members can be a powerful motivator. Plan: more specific ==> higher risk. Assess means and lethality of means. E.g., a handgun is usually more lethal than a handful of aspirin or jumping off a 3 story building. Resources available may be a positive influence against suicide
Top line is the my recommendation for asking about suicide. Direct questions often elicit direct answers. If you get a ‘yes’ to the top Q, follow-up with the next 4 about current plan and history. This will help you assess your referral options. Generally, the more detailed their plan, the higher the risk. If they have a plan and the means and the means are lethal, a hospital/ER is probably your only referral option. The last 3 questions are useful for additional information: Odds - a followup to the top Q or for additional confirmation. What’s keeping you alive so far - 2 most common answers are family and religion. Can use these as ‘hooks’ Future - gives clue to hopelessness level. If no future, probably high hopelessness which correlates strongly with increased risk.
