Reasons Inmates Attempt Suicide or Die by Suicide

1. Reasons Inmates Attempt Suicide or Die by Suicide Implications for Assessment, Treatment, and Institutional Prevention Programs Robert Horon, Ph.D. California Department of Corrections and Rehabilitation/Division of Health Care Services March 14, 2019

2. Disclosures I am an employee of the California Department of Corrections and Rehabilitation (CDCR)’s California Correctional Health Care Service (CCHCS). Other than employment, I have no financial or commercial interest in presenting this material.

3. Outline • Review of the complexity of suicide phenomena in correctional and forensic settings • Obtaining accuracy in suicide risk assessment and risk formulation in these settings • Studies of suicide survivors in prison—relevant findings • Motivations found in suicide death reviews • Summary of findings and implications • Applying findings to suicide risk assessment interviews and practices via group discussion • Reports from groups, discussion, Q&A

4. I. The complexity of suicide phenomena in correctional and forensic settings

5. Complex phenomena “Clinicians in correctional settings are particularly vulnerable to underestimation or overestimation errors, as (1) there has been little empirical study of correctional suicide risk assessment procedures; (2) prisons predominantly house individuals with externalizing psychopathology that differs significantly from the internalizing psychopathology commonly related to suicidality (Verona, Patrick, & Joiner, 2001; Young, Justice, & Erdberg, 2006); and (3) attributions of manipulative motivation associated with suicidal behavior may underestimate actual risk (Dear, Thomson, & Hills, 2000).” Horon, McManus, Schmollinger, Jimenez, & Barr, SLTB, 2013

6. Was this a suicide attempt? Likelihood of rescue? Intention? Ambivalence?

7. Complex phenomena To evaluate a behavior such as this, consider: 1.) The inmate’s impression management: Does he want us to see him as ill and in crisis? Did he panic within an attempt and now tells us he made an error and is fine (now)? 2.) How does the inmate want to be seen by other inmates? 3.) External factors: Was he told to end his life? Pressured to leave the building or yard? About to be transferred to/from a medical/psychiatric setting? 4.) Internal factors: Did he believe he would instantly die? What are his beliefs about and relationship with dying? Is this part of an ambivalence about living or dying? 5.) Was this an impulsive act or an act long considered?

8. Complex phenomena Clinician 1: “This was not an attempt, it was manipulation.” Clinician 2: “This was an attempt, not manipulation.” The reality:

9. Complex phenomena Or, the reality looks something along this line…

10. Complex Phenomena “The paradigm of suicide is not the simplistic one of wanting to or not wanting to. The prototypical psychological picture of a person on the brink of suicide is one who wants to and does not want to. He makes plans for self-destruction and at the same time entertains fantasies of rescue and intervention. It is possible – indeed probably prototypical – for a suicidal individual to cut his throat and to cry for help at the same time.”

11. Complex phenomena Let’s look briefly at a few specific issues to illustrate the complexity of the suicidal phenomena in the context of correctional and forensic settings.

12. Would you have known the risk? One day away from a parole hearing…

13. Would you have known the risk? One day after a court hearing…

14. Complex phenomena 35-50% of jail suicides occur with 7 days of adjudication, either before or after a hearing.* *Hayes, L. (2010) National Study of Jail Suicide: 20 years later. US DOJ/National Institute of Corrections

15. Complex phenomena Several studies have noted high-risk periods: • The first hours and days of a stay and court outcomes (James & Glaze, 2006) • Release from prison: 156 suicides per 100,000 in 1st year; 21% occur in the 1st month after release (Pratt et al., 2006) • Many prison suicides occur shortly after incarceration or in transition periods (e.g. placement in Administrative Segregation; Patterson & Hughes, 2008) • 19% of males who were sexually assaulted in prison attempted suicide following the incident (Struckman-Johnson, 2006).

16. Complex phenomena Several studies have noted high-risk periods: -Transitions out of psychiatric inpatient settings confers risk for correctional patients (Hayes et al., 2008; Sirdifield et al., 2009). -The community rate for suicide post-inpatient psychiatric hospitalization are markedly high in the first week and first 90 days after discharge, estimated at 178 per 100,000 in the 90 days after discharge. Heightened risk exists post-release for longer time-frames (Chung et al., 2017).

17. Complex phenomena Who Commits Suicide in Jails? -By offense type: • Rate for Violent Offenders= 92 per 100,000 • Rate for Nonviolent Offenders=31 per 100,000 • By offense category: • Kidnapping = 275 per 100,000 • Rape offenses = 252 per 100,000 • Murder offenses = 182 per 100,000 • Drug offenses =18 per 100,000 Source: Mumola, C. U.S. Dept. of Justice, Bureau of Justice Statistics Special Report, “Suicide and homicide in state prisons and local jails,” August 2005).

18. Complex phenomena It’s not just prisons and jails…

19. Complex Phenomena -A study of prisons and forensic hospital patients in Germany (Voulgaris, et al., 2018) found no statistically significant difference in the rate of suicide per setting (both were very high; 123 per 100,000 vs. 130 per 100,000) [yes, this is a real prison cell in Germany]

20. II. Obtaining accuracy in suicide risk assessment and risk formulation in these settings

21. Obtaining accuracy in risk assessment and formulation Accuracy requires, or may require: • An understanding of the patient’s historic risk of self-harm, including the triggers, purposes, response to survival, degree of lethality and preparation, etc. during prior events. • A thorough interview with consideration of risk factors, a formulation of risk status, an understanding of protective factors, etc. • Use of structured interview guides that help clinicians consider all key factors. • Use of instruments developed or normed to the inmates/patients seen (to aide precision).

22. Obtaining accuracy in risk assessment and formulation Accuracy requires, or may require (cont.): 5. Careful methods for assessing acute and imminent risk. 6. An understanding of the patient’s baseline vulnerability to suicide (chronic risk). 7. A good understanding of the phenomenology of suicide. 8. An effective approach to framing suicidal inquiries and potential suicide interventions. 9. An understanding of suicide inquiry that can be used in the service of safety planning, crisis intervention, and treatment planning.

23. Obtaining accuracy in risk assessment and formulation Obtaining competency and proficiency in suicide risk assessment and risk formulation takes time, mentorship, an understanding of the suicidology literature, and more. • Rudd, Cukrowicz, & Bryant (2008). Core Competencies in Suicide Risk Assessment and Management: Implications for Supervision. .Training and Education in Professional Psychology, 4 219-228

24. Obtaining accuracy in risk assessment and formulation One competency discussed by Rudd, Bryant and Cukrowicz is an understanding of the phenomenology of suicide as a method to inform our risk assessment and frame our risk formulation. Let’s listen in on some aspects of suicide phenomena with suicidologistDavid Jobes, Ph.D.

25. Video 1 David Jobes, Ph.D.

26. Low to High Press (Stress) Completed Suicide 1 5 4 3 2 1 5 High to Low Perturbation/ Agitation 1 2 3 4 5 Low to High Psychache (Pain) Shneidman’s Cubic Model of Suicide (1987)

27. Obtaining accuracy in risk assessment and formulation How do these concepts inform risk assessment, risk formulation, and help frame treatment? In essence, we can’t discuss the reasons inmates or forensic patients attempt or die by suicide without understanding what drives such behavior in general, just as we can’t understand suicidal behavior for inmates and patients outside the context of their environment.

28. Obtaining accuracy in risk assessment and formulation What we discuss below is meant to be understood in the context of competency in suicide risk assessment, formulation, and risk management/treatment. That is, the information is meant to be additive or complementary to adequate practice in assessing and treating suicidal patients.

29. Video 2 Jail hanging

30. Studies of suicide survivors in prison—relevant findings • As you’ve just heard, the individual discussed in this story did not survive. • Video surveillance shows the inmate: • Tying a noose on the upper bunk (at noon) • Practicing trying on the noose and tightening it • Receiving a meal from an officer while the noose is clearly visible tied to the upper bunk (at 1715 hours) • Hanging himself (at 2030 hours), discovered roughly 15 minutes later • Jail policy was officer checks every 20 minutes • We’ll return to reviews of deaths by suicide later, but for now, think of ways the death could have been prevented.

31. Studies of suicide survivors in prison—relevant findings

32. Studies of suicide survivors in prison—relevant findings • Greg Dear and colleagues worked with the Australian prison system, evaluating all inmates who had survived suicide attempts. They conducted a series of studies on these inmates, with interviews within 3 days of attempt survival. • 71% of attempters reported the reason for attempting to be within prison stresses, categorized as “stressful events that occurred within the prison.” • *Dear, Thomson, Hall, and Howells(2001). Non-fatal self-harm in Western Australian prisons: Who, where, when and why. Australian and New Zealand Journal of Criminology, 34, 47–66.

33. Studies of suicide survivors in prison—relevant findings Key finding: The potential lethality of suicide attempts did not differ between inmates who reported their attempt was motivated by new charges, safety concerns, or conflict with other inmates versus those who reported mental health reasons—e.g., depression, anxiety, bereavement, etc.

34. Studies of suicide survivors in prison—relevant findings In a summary article,* Dr. Dear wrote, “Importantly, prisoners who reported manipulative or attention-seeking motives for self-harming were just as likely as other prisoners to show a high degree of suicidal intent (Dear, Thomson, and Hills, 2000). The desire of some…to separate the manipulative gestures from the genuine suicide attempts seems to be a risky strategy as one cannot assume that manipulators and suicide attempters are mutually exclusive groups. Failing to treat seriously an apparently or reportedly manipulative act can result in a subsequent suicide, particularly if the response is to punish or ignore the prisoner in order to avoid reinforcing or rewarding the manipulation.” *Dear, G.E., (2008). Ten Years of Research into Self-Harm in the Western Australian Prisons. Psychiatry, Psychology and Law, 15, (3), 469–481.

35. Studies of suicide survivors in prison—relevant findings In the same article,* Dr. Dear wrote, “We proposed that the critical determinant of self-harm is the severity of distress that results from the interaction of psychological vulnerability and the intensity or nature of the stressful events the prisoner faces.” *Dear, G.E., (2008). Ten Years of Research into Self-Harm in the Western Australian Prisons. Psychiatry, Psychology and Law, 15, (3), 469–481.

36. Studies of suicide survivors in prison—relevant findings Dear, 2008

37. Studies of suicide survivors in prison—relevant findings

38. Studies of suicide survivors in prison—relevant findings • Our suicide risk assessment study took place at an inpatient psychiatric facility located within a prison (CMF). The goals of the study were: • Explore reliability, validity,and clinical utility of commonly used suicide risk measures in a correctional setting • Generate a normative comparison group to help clinicians interpret assessment results • Evaluate current forms and procedures processing suicide risk • Assess other variables related to risk within the population, such as violence history, etc. • Determine which variables and test findings most relate to high risk within the study population.

39. Studies of suicide survivors in prison—relevant findings

40. Studies of suicide survivors in prison—relevant findings The study sample consisted of 617 male inmates admitted to the Department of State Hospitals-Vacaville between May, 2007 and February, 2015 • All inmates were referred for inpatient psychiatric care, with nearly equal numbers admitted for acute psychiatric services (average stay of 75 days) as those admitted for intermediate care services (average stay of 180 days) • The Department of State Hospitals-Vacaville (now a CDCR Psychiatric Inpatient Program) is a large inpatient psychiatric facility that admits 1,200-1,400 patients per year • Approximately 84% of admissions for the Acute Psychiatric Program (APP) are for suicidality (ideation/attempt/reported intent), distilled mostly from MHCB settings (where >90% of admissions relate to suicidality).

41. Studies of suicide survivors in prison—relevant findings We looked at differences between three groups of CDCR patients referred to an inpatient psychiatric hospital : • Patients with no history of suicide attempts • Patients with a history of one suicide attempt • Patients with a history of multiple suicide attempts We found stark differences between groups based on attempt status. *Horon, McManus, Schmollinger, Barr, & Jimenez (2013). A Study of the Use and Interpretation of Standardized Suicide Risk Assessment Measures within a Psychiatrically Hospitalized Correctional Population, Suicide and Life‐Threatening Behavior, 43, (1): 17-38.

42. Studies of suicide survivors in prison—relevant findings Differences between groups: • Demographic: Multiple attempters were more likely to have endured a host of childhood traumas, particularly witnessing domestic violence. They were more likely to have been in special education during school years and to have experienced significant head trauma with loss of consciousness and/or the development of seizures. • Endorsement Patterns: Multiple attempters endorse more concerning answers for both direct (face valid) and indirect measures of suicide risk

43. Studies of suicide survivors in prison—relevant findings Compared to non-attempters and single attempters, multiple attempters endorsed: • More desire to die and more frequent preparation or planning for suicide (BSS) • More frequent contemplation of suicide across a broader range of thoughts related to suicidality (ASIQ) • Fewer or less protective degrees of emotional, spiritual, behavioral, or interpersonal barriers to suicide (CRQ, CAPSSIP, CAI-Id.) • More painful emotional experiences, such as worthlessness, agitation, and psychache (CAI-Acute, RASQ-Internal) • More problematic clinician ratings, suggesting a likelihood of the patient resisting suicide prevention/risk management efforts (CAI Idiosyncratic)

44. Studies of suicide survivors in prison—relevant findings Compared to non-attempters and single attempters, multiple attempters endorsed: • A greater sense of being a burden to others, such as family and loved ones (INQ-Perceived Burdensomeness) • A more frequent belief that suicide would not negatively affect the afterlife or that no afterlife exists (CAPSSIP interview) • More likely to report “loopholes” to familial, cultural, or religious prohibitions to suicide (CAPSSIP interview)

45. Studies of suicide survivors in prison—relevant findings Factors that were found not to distinguish groups: • Endorsement of extrapunitive or manipulative reasons for suicide attempts (RASQ-Ext) • Fearlessness about death (ACSS) • Only slightly increased feelings of lack of belonging in multiple attempters (INQ Belonging)

46. Studies of suicide survivors in prison—relevant findings Let’s take a closer look at one study measure, the Culture and Protective Suicide Scale for Incarcerated Persons (CAPSSIP). The tool was designed to assess protective factors and cultural barriers to suicide for inmates. • Analyses of protective factors on a suicide risk assessment checklist (SRAC) found no difference in attempt groups—protective factors are not ‘yes/no’ variables. • CAPSSIP sought to quantify degree of protection present and to evaluate if the patient had maintained or moved away from familial, cultural, and/or religious/spiritual prohibitions to suicide. Horon, R., Williams, S. N., McManus, T., & Roberts, J. (2018). The Culture and Protective Suicide Scale for Incarcerated Persons (CAPSSIP): A measure for evaluating suicide risk and protection within correctional populations. Psychological Services, 15, 45-55. doi:10.1037/ser0000197

47. CAPSSIP “Recognizing the need to assess suicide protective factors with items that are relevant to incarcerated individuals, and recognizing a need to incorporate cultural assessment within suicide risk evaluations of inmates, the authors of the present study developed a measure called the CAPSSIP. The CAPSSIP was designed to reflect the unique environment within prisons. The individual’s cultural, religious, and familial beliefs that prohibited suicide may be challenged in the setting. The context of incarceration is also very relevant to how protective factors function within this population... The socioeconomic, racial, and cultural make-up of individuals inhabiting prison systems clearly impacts suicide risk formulation.”

48. Studies of suicide survivors in prison—relevant findings

50. Studies of suicide survivors in prison—relevant findings So what? The impact of distress in correctional and forensic institutions is moderated by vulnerability to suicidal contemplation and attempts. That is, of 2 patients or inmates facing the same stress: • Suicide or suicide attempts are more likely in individuals who have already previously crossed the line and engaged in suicidal behavior. The prior behavior(s) point out a lack of protections or barriers to suicide, a willingness to engage in self-harm, and a recklessness about living. • Chronic or frequent contemplation of suicide leaves patients and inmates less likely to benefit from activities ‘connected to living.’