Suicide Prevention

1. Suicide Prevention In the Corrections Environment

2. Objectives • Identify signs and symptoms of possible mental or emotional disorder • Identify behaviors which could indicate mental or emotional disturbance • Identify the well-established fables/myths concerning suicide • Identify a general suicide profile • Identify the high-risk times for the suicide-prone individual • Identify the signs and symptoms of depression • Identify how to handle an inmate who is exhibiting signs of suicide

3. Statistics • Suicide is the leading cause of death in American Jails • It is the third leading cause of death in American Prisons • The majority of suicides are accomplished through hanging, which causes brain death in 4 minutes, and result in death in 5 or 6 minutes

4. Statistics Per State • The leading 5 states in prison suicide are California, Texas, New York, Illinois, and Maryland. • Nevada is tied for 27th in prison suicides per state for 3 in 2010

5. Mental Health Prevalence • Major Depression • 29.7% of population in Jails • 23.5% of population in Prisons • 16% of population in Federal Prisons • Previous Mental Health Institutionalization • 10% in combined population of all three have had at least one psychiatric hospitalization prior to incarceration • APA review in 2000 found that 20% of prison and jail inmates are in need of psychiatric care and 5% are actively psychotic

6. Risk Factors • Depression • Any serious mental illness, such as schizophrenia and bipolar disorder • Substance Abuse • The combination of mental illness and substance abuse • Borderline and Antisocial Personality Disorders • Impulsivity and aggression • History of suicide attempt or family history of suicide • Serious physical illness or chronic pain • Long Sentence • Severe guilt or shame • Rape or threat of rape • Any recent drug/alcohol ingestion (Depression sets in when the euphoric effects wear off)

7. High Risk Time Frames • The first 24 hours of confinement! • Intoxication or withdrawal • Waiting for trial • During sentencing • After count time • Around holidays • After visitation • Impending release • After receiving bad news (i.e. death of a loved one, divorce, etc.)

8. Warning Signs • Talking about suicide or wanting to die • Discussing ways in which it can be completed • Talking about feeling hopeless • Talking about feeling trapped • Acting agitated or aggressive • Behaving recklessly • Sleeping too little or too much • Not talking to others; not coming out of cell for yard or tier time • Showing rage • Displaying extreme mood swings

9. Warning Signs Continued • Expressing excessive guilt or shame over offense • Having a history of suicide attempts • Expressing hopelessness/helplessness • Excessive anxiety • Extreme calm after a period of agitation • Preoccupation with the past • Packs up/gives away belongings • Participates in self harming (parasuicidal) behaviors for attention • Paranoia

10. Though any of the previous factors may contribute to suicidal intent, 70% to 80% of all suicides are committed by people who are severely depressed The most common symptoms of depression include: Feelings of inability to continue Extreme sadness and/or crying Social isolation Fluctuations in appetite, weight, and sleep Mood/behavior changes Tension and anxiety Loss of motivation Cont: Loss of self esteem Loss of interest Poor hygiene Difficulty concentrating Easily angered or increased agitation Depression

11. Suicide Prevention in Corrections • Upon intake, assess suicide risk and imminent suicide risk. Risk status can change over time; staff need to recognize and respond to changes in an inmate’s mental condition • Information to follow an inmate in case of movement: • Previous/current threats • Behaviors of depression • History of psychiatric care • PC or seg status • Appropriate observation in isolation cells—remember, any segregation increases the risk for suicide!

12. Identifying Suicidal Inmates PAY ATTENTION!!!!!

13. The MOST critical time to pay attention to warning signs is during the intake process!! • OBSERVATION Pay attention to the inmate’s speech, attitude, and state of mind. Look for scars from previous attempts. Look for signs of recent trauma. Look for signs of current intoxication or withdrawal.

14. Intake • QUESTIONNAIRE This screens inmates’ personal histories as well as past/current mental and physical health. Try to do it in private and use language the inmate can understand. If the inmate is intoxicated, put under direct observation until he can participate.

15. Intake • DISPOSITION Following the observation and interview steps, a housing determination is made. Automatic isolation is not the key for suicidal inmates! This reinforces the risk for suicide. If isolation is needed, they need to be under direct staff supervision.

16. Two Levels of Suicidality • Low Risk Suicidal Inmates • Not actively suicidal, but have a history of attempts or have current thoughts • Should be housed with other inmates and checked by staff at regular, frequent intervals • High Risk Suicidal Inmates • Actively suicidal by expressing threats or engaging in suicidal behaviors • Should be placed on suicide watch status and placed in suicide dress with no personal belongings

17. But what about fakers? TAKE ALL THREATS SERIOUSLY! Do not make a judgment call regarding the sincerity of the threat—contact medical or mental health staff to assess and make a decision about the necessary intervention.

18. When communicating with suicidal inmates, do not… …offer solutions or give advice …become angry, judgmental, or threatening …act sarcastically or make jokes …placate and make promises …challenge the inmate to follow through on the suicidal threat And above all, DO NOT IGNORE THE THREAT!

19. Manipulation Inmate may threaten suicidal behavior to get something they want, or avoid something they don’t want. Remember, it’s not your responsibility to make this call! Refer the inmate to mental health and DOCUMENT, DOCUMENT, DOCUMENT!

20. Suicide Attempt/Completion • 94% of inmate suicides are by hanging. • NEVER assume the inmate is dead! • 1. Call for back up • 2. Survey the area for safety and security • 3. Get help and cut inmate down • Protect the head and neck as much as possible • 4. Initiate CPR while back up calls for medical • Even if there are no vital signs, do not stop CPR until medical staff tells you to do so

21. Suicide Myths (Don’t believe them!!!) • Myth #1: People who threaten suicide don’t commit suicide. • FACT: Most people who commit suicide have made direct or indirect statements of their intentions. • Myth #2: People who have attempted suicide in the past will not do it again. • FACT: A history of attempts increases the likelihood of repeated attempts.

22. Suicide Myths Continued… • Myth #3: Suicidal people are intent on dying. • FACT: Most suicidal people don’t WANT to die, but they believe that is the only way out of their current situation—they think they are out of options. • Myth #4: Talking to people about their suicidal thoughts will cause them to follow through. • FACT: You CANNOT make someone suicidal by discussing suicide.

23. Suicide Myths Continued • Myth #5: All suicidal people are mentally ill. • FACT: Suicidal people are extremely depressed and unhappy, they are not necessarily mentally ill. • Myth #6: If someone really wants to kill themselves, there’s nothing you can do about it. • FACT: Almost ALL prison and jail suicides CAN BE PREVENTED!

24. You have the ability to prevent suicides. It takes attention to, observation of, and knowledge of the information we’ve discussed, and the courage to take action.

25. Discussion: Case Example

26. Mr. Thomas • Mr. Thomas is in his sixties. He has been incarcerated for 10 years for the murder of his wife. He is being treated for a serious medical condition which may be cancer. • He has never had communication with family or friends. He works as a porter and is trusted by the officers. He was told yesterday that the parole board continued him for 10 more years. • His parole appearance occurred during a week when the normal unit SC/O was on leave. Mr. Thomas often spoke with him about life in general. • Today, two days after the parole hearing, Mr. Thomas was found hanging in the supply closet.

27. What were Mr. Thomas's Risk Factors? • Serious physical illness • Possible undiagnosed depression • Parole news creating hopelessness • Lack of usual social stimulation while SC/O was away; isolation • Access to supply closet and lethal means

28. How could Mr. Thomas's suicide have been prevented?

29. Hey you…yeah, YOU! • Correctional staff, NOT just inmates, can also be at risk for suicide. This includes officers, nurses, case workers, psychologists, etc. • Not only do you have "normal" problems—not enough money, not enough time, stress, bills, etc.—you work everyday with some of the darkest of human kind that view you as "the enemy."

30. Sound familiar? After balancing the checkbook until 1am and finding that the mounting bills provided you nothing more than a fitful sleep, you wake up and realize that it's 4:45am, and your shift starts at 5am. No time to prepare yourself for the day, you battle terrible drivers, arrive at work, and are greeted by your supervisor that is none too happy about your tardiness. During your shift, you feel underappreciated by "the brass" and are subjected to constant verbal harassment by inmates. After enduring this for 8 hours, you encounter the same bad drivers on the way home, where financial, relational, and other stressors await. On top of other potential risk factors, is it really that surprising that officers, specifically, commit suicide at a rate that is double that of the regular population?

31. You are NOT alone! • Don't hold everything in. Talk to family and friends. See a therapist. Set aside time for things you enjoy. But don't ignore your stress and hope it goes away. • Stress, depression, anger, etc. will ONLY go away if you face it with healthy coping skills.

32. Put beautifully by a former C.O.: • We have all been in some very dark places in our lives.  I know that I have, and sometimes suicide seems like a solution. What has helped me to hold on in seemingly hopeless times is something my father shared with me in my darker days. “No matter what position you are in, there is always hope and potential while you still have life. Once your life is gone there is no hope, there is no recovery. It is over, and there is no getting it back.” If this reaches anyone out there who is contemplating this as an option, please talk to someone.Call the Ventline. I hate hearing the news of corrections workers killing themselves. Everyone makes mistakes, poor choices, and is afraid of consequences. But no consequence is so severe that one should do this to themselves. God bless you all. Take care of yourselves and one another.