Suicide rates in prisons in developed countries are 3–8 times higher than the community (Fazel et al., 2011). Australian prison suicide rates have declined following implementation of suicide prevention initiatives and now are the lowest internationally (approx. 58 per 100,000). Yet suicide accounts for 30%-50% of Australian prisoner deaths (Lyneham & Chan, 2013).
Psychologists play a critical role in identifying and managing prisoners at risk of suicide. Incarceration can be distressing and rates of mental illnesses are dramatically higher in prisons than the community (Schilders & Ogloff, 2014). The State bears a duty of care for the physical and mental health of prisoners (UNESC, 2015). The UNESC mandates that prisoners receive the same standard of health care as in the community and that health care professionals examine all prisoners to identify suicide risk and manage such risk appropriately.
Suicide and suicide risk in prisons
Attempts to understand and ultimately prevent suicides in prisons began in the 1960s, with theories proposing the inherently deprived prison environment (Goffman, 1961) and importation of community stressors to custody (Irwin & Cresssy, 1962) as core to suicide in prison (Danto, 1973). Contemporary research suggests that suicides result from an interaction between prison factors (e.g., prison environment and risk management systems) and prisoner characteristics (e.g., vulnerability and coping capacity) that lead to prisoner distress (Dear, 2008; Liebling, 2006).
Unique risk factors when working with prisoners
When examining prisoner risk, it is important to consider general and prison-based suicide risk and protective factors in a structured and comprehensive manner (see Hawgood and De Leo article pgs 10-11 for discussion on suicide risk assessment). Unfortunately, no well-validated measure for assessing suicide risk in prison exists. Psychologists working in prisons should therefore familiarise themselves with known prison-specific risk factors (see text box below) (Fazel et al., 2008; WHO, 2007).
Prison-specific risk factors
|
Individual
|
Forensic
|
- Male (especially young males)
- Elderly (especially males)
- Indigenous
- Mental illness
- Pharmacological treatment
- Substance related/addictive disorder
- Previous suicide attempts
- Relationship/social support changes.
|
- Single cell incarceration
- > 18 month sentence
- Incarceration prior to conviction
- Violent offence.
|
Effective suicide prevention in prisons
Best-practice in suicide prevention requires collaboration and open communication among administrators, medical and mental health clinicians (including psychologists), and custodial staff to identify at-risk inmates, intervene, and manage risk appropriately (Dear, 2008; WHO, 2007). Suicide risk is dynamic and the prison environment can fluctuate considerably; prison services must therefore be mindful of identified risks, prisoner distress, and coping capacity at all times. Clinical services are required, beginning with screening prisoners upon reception, following transfer, and when court/significant events occur.
With respect to the prison environment, it is important to eliminate factors found to increase prisoner suicide (e.g., by ensuring appropriate prisoner placement, enhancing meaningful social interaction, and reducing physical risks; Liebling, 2006). Positive staff-prisoner relationships are core to reducing prisoners’ stress levels and maximising the likelihood of prisoners’ notifying staff about periods of increased risk. Distressed prisoners require careful management through provision of humane support rather than physical restrictions and restraints. Appropriate staff training is requisite to ensure proficiency and capacity to provide frontline suicide intervention via identifying, intervening, and managing the distress of prisoners.
It is critical that reliable systems are implemented for detecting prisoner distress. When levels of distress appear elevated or prisoners are otherwise identified as at risk, effective management is required, including increased monitoring and appropriate mental health treatment and crisis intervention.
In addition to assessment, psychologists play an important role in addressing prisoners’ skills deficits, increasing coping capacity, and thereby reducing risk. Clinical psychological services in a prison setting largely aim to build an individual’s resilience via the use of CBT and related interventions.
Despite all efforts, suicides in prison – as in the community – will continue to occur. Careful review is required to ensure that policies, procedures, and practices are as effective as possible. For all involved suicides are among the most traumatic events that occur in prisons. Bereaved and vulnerable individuals (staff and prisoners alike) must be supported and steps should be taken to limit the risk of additional suicides.
Conclusion
While suicide prevention strategies and programs have successfully led to the reduction of prison suicides, there remains room for improvement. Additional research is required to evaluate and refine both suicide risk assessment and intervention strategies implemented in prisons. Psychologists working in custodial settings need to practice in a research-informed manner, drawing upon the best available evidence to ensure the provision of the highest quality services and the prevention of as many suicides as possible.
The first author can be contacted at [email protected]