Corrections officers have all the tools to make it difficult for a prisoner to commit suicide --- the blankets that don't knot, the cut-down tools, 15 minute-checks. But what some corrections agencies may be lacking is a way to pinpoint the likelihood of a suicide attempt in the first place.

It is no crystal ball, but knowing the right questions to ask at intake and having staff with a mental health background "red-flag" offenders who show certain risk factors can improve the odds of saving an offender's life.

Some agencies have embraced that idea with open arms.

"For years we said if someone is going to kill themselves they will, [but] we don't have that attitude anymore. We do play a part in prevention and we can prevent them [although] we may not prevent them all," said Teri Goodall, Undersheriff for the El Paso County, Col., Sheriff's Department.

El Paso County officials solicited assistance from the National Institute of Corrections to evaluate suicide prevention efforts within the county jail and recommend changes. But while El Paso County has made adjustments, some observers say that too few corrections agencies have improved their prevention methods.

"There is an epidemic in the number of suicide attempts in the U.S. and in jails," said Margaret Severson, Associate Professor at the University of Kansas School of Social Work and a NIC consultant.

Severson, who spoke at the recent American Jail Association conference in Kansas City, told attendees that there has been no formal study on the number of suicide attempts in corrections, but the sense of those who do research in this arena believe that the number is high.

She said jails and corrections facilities have a tendency to house people who are already at high-risk for suicide. But unless these institutions understand what those risks are, they won't be able to adequately prevent offenders in this group from hurting themselves.

Risks and Assessment

According to Severson, offenders fall into categories that already are high risk for suicide such as the poor, undereducated, unemployed and male persons. Beyond these factors, of those who have competed suicide, 60 percent have major depression and 75 percent have alcoholism - both common attributes of offenders.

General risk factors for those who are likely to attempt suicide also include a history of mental disorder, a family history, a history of childhood maltreatment, aggressive behaviors, barriers to mental health treatment, financial challenges or physical illness.

In addition, when people with these risk factors end up in jail, Severson said, the facilities can serve as emotional and environmental catalysts.

The authoritarian environment, uncertain future, distance from staff, isolation and shame felt by those incarcerated can all enhance already suicidal feelings, she added.

With these elements in play, Severson advocates for jails and correctional facilities to pay special attention to certain offenders at intake and also at critical moments in incarceration - such as court hearings or sentencing.

As part of that screening, Severson said offenders should be asked certain questions, although there is some debate over who should ask them and how they should be asked.

"There are critical questions that are evidence-based that we know highlight risk and I think there is general agreement that those risk questions should be asked of everyone. How, who and when they are asked should be answered based on cultural [norms]," she said.

Questions that Severson deems a "must" for any screening tool include whether an offender has a history of suicide attempts, if they are currently thinking about suicide and whether there is a history of psychiatric intervention.

Severson also suggests that officials investigate whether the policy, procedures and post orders for the facility actually mirror the practices and use isolation for suicidal offenders sparingly.

Agencies also should institute specialized training for staff on assessment techniques, how to identify suicidal behavior, signs and symptoms and behaviors as well as training on communication skills and how to develop "comfort with asking someone about suicide."

Finally, Severson recommends that corrections officials and staff recognize that manipulation is a survival skill and can show signs of suicidal tendencies.

"When they are self-harming, they are saying to the system 'I am contemplating suicide.' Manipulators kill themselves accidentally," she said.

The information on suicide prevention is extensive and not always known by those who operate correctional facilities. Some corrections agencies are paying more attention to what they ask offenders to help them identify any risk factors.

Suicide Screening in Canada

To identify suicidal inmates, some correctional institutions in Canada are using a screening tool designed to alert staff if an offender is feeling hopeless or depressed and has a history of suicide.

"It was developed because we were looking for a self-report instrument that could screen offenders for suicide-related risk factors," said Jeremy Mills, one of the psychologists who created the 39-question Depression, Hopelessness and Suicide Screening Form (DHS).

Mills, who works for Correctional Services Canada in the psychiatric department at the Bath Institution, a medium security prison in Ontario, said staff members at his facility administer the DHS after an offender is sent to them by security personnel, who interview inmates during intake. 

"If the offender has a history of suicide or has recently expressed suicidal ideation or is being treated for mental health-related issues, then they are referred to our department," said Mills, adding that inmates from the general population also arrive in his department if correctional staff have seen them exhibit signs of personal distress.

Once offenders land in the psychiatric department at the prison, they are given the DHS, which is a paper-based survey that asks inmates to respond true or false to statements about a variety of issues, including their feelings about the future, their energy level and their appetite.  The form also gives staff insight into offenders' thoughts about suicide, like whether or not they think about harming themselves, whether or not they have any close friends or family members who have committed suicide and whether or not they have attempted suicide in the past.

According to Mills, he and his colleague, Daryl Kroner, developed the DHS in 2002 for use with inmates specifically.  He said that the most widely-used screening tool in corrections, Beck's Depression Inventory, covers issues, like whether or not an individual feels like he or she is being punished.  With people who are incarcerated, even those who are not suicidal may feel that way, he explained.

"We looked at a number of those items and thought they were potentially a problem with our client group, so we developed the DHS in order to be able to screen for depression and hopelessness and other suicide predictors," said Mills.

Mills added that the DHS is a solid predictor of whether or not an inmate is suicidal because it takes into consideration and offender's hopelessness, depression and history surrounding suicide.  And based on research he and his colleagues have conducted, there is an interaction between depression and/or hopelessness and a history prior suicide attempts.

"What we have demonstrated is that depression, by itself, or hopelessness, by itself, is related to suicidal ideation, but if you have both depression or hopelessness and a history of suicide, the likelihood that the person have experience suicidal thoughts or suicide-related thoughts is proportionally much higher," Mills said.

Despite the DHS's ability to flag inmates as a potential suicide risk, Mills said that the screening tool only identifies offenders who require further assessment.

"Its primary use is really as a screening instrument," said Mills.  "It's really not meant as a diagnostic instrument."

After inmates at the Bath Institution take the DHS, staff in the psychiatric department score the form and pass that information along to the psychiatrist so he or she can decide what the next step will be.

"In our screening of offenders, more importantly than simply the offender exhibiting some signs of depression, we look for both the negative affect component, either hopelessness or depression, in conjunction with suicide and we target those offenders for interview and follow-up," said Mills.

While the DHS is currently a paper-and-pencil form, appropriate for people with a fifth-grade reading level or higher, a new format for the tool is in the works.

Mills said that one of his colleagues is currently developing a computer-based version of the DHS, which he hopes will be available by summer.

"The computer will not only score [the form], but give an interpretive description along with the results," said Mills.

He added that he hopes to see the DHS expand into United States correctional facilities, as well. 

Other Agencies Make Changes

After a spate of suicides and suicide attempts, El Paso County officials several years ago took a hard look at what they knew about suicide. They determined, with assistance from Severson, that they could improve prevention efforts.

"I have been here 23 years and our [statement] has always been, We will do what we can, but we can't prevent it. But you know what? Yes we can," said Goodall. "Before when we had a successful suicide, we'd talk about it for a week, now we talk about it on a constant basis."

In terms of screening, Goodall said, the jail's computerized assessment screen alerts jail staff to any offenders who have previously been incarcerated and have a history of suicidal behavior or mental health problems that have been previously identified.

According to Goodall, after the computer alerts staff, medical personnel are called in to continue the assessment.

"We do that with every prisoner before they go to their cells. We interview them about mental illness, and suicide," she said.

The jail has also instituted a 15-minute staff visual check on all new inmates at the jail within the first 24 hours of their stay - based on research that shows a likelihood of suicide within the first 24 hours of incarceration for some offenders.

Other improvements include a special mental health ward where suicidal inmates are housed and wear special gowns. In this unit, where there is constant observation of the inmates, the mental health team conducts group sessions and encourages offenders to discuss with staff if they or others are thinking about suicide.

But suicide prevention doesn't stop there.

Even the transportation officers are trained to alert officers at the jail when an offender has received a long-term sentence from the court. Those officers and others in the jail all write their observations in a log that is passed on to the next shift.

"We have a pass-on log for each deputy. They watch an inmate with an "x" [beside their name]," Goodall, who added that the notes may indicate if an inmate received a life sentence or if an inmate recently received divorce papers.

Another change made by jail administrators was with the food servings and types of meals served to offenders. Goodall said that the number of carbohydrates was lowered and protein was added to the inmate meals. In addition, the amount of candy and chocolate sold in commissary was reduced.

"Our complaints about food are less. When I walked around [before] they complained about not getting enough food, but that has evened out," Goodall said.

But probably the greatest change that Goodall says has happened at the jail is the shift in thinking among the officers and staff that they can make a difference to someone who is suicidal.

"It used to be when we found someone who tried to hang themselves, we thought, 'Oh we did a good job.' Now we do debriefings and any suicide attempt we have, we have a debriefing and talk about how they did it, what could we have seen, how was medical's response. When we call in a Code Blue we try to evaluate every aspect. We pick it apart and usually something comes out of it that we could do better," she said.

Resources:

Suicide Prevention Resource Center

The Suicide Prevention Resource Center (SPRC) supports suicide prevention with the best of science, skills and practice. The Center provides prevention support, training, and informational materials to strengthen suicide prevention networks* and advance the National Strategy for Suicide Prevention.

http://www.sprc.org/aboutsprc/index.asp

Margaret Severson -  email mseverson@ku.edu

El Paso County Jail - 719-520-7204

Jeremy Mills (613) 351-8399