M.S. Daigle et al.: Preventing Suicide in Prisons, Part IICrisis 2007; Vol. 28(3):122–130© 2007 Hogrefe & Huber Publishers

Research Trends

Preventing Suicide in Prisons, Part II International Comparisons of Suicide Prevention

Services in Correctional Facilities

Marc S. Daigle1, Anasseril E. Daniel2, Greg E. Dear3, Patrick Frottier4, Lindsay M. Hayes5, Ad Kerkhof6, Norbert Konrad7, Alison Liebling8,

and Marco Sarchiapone9

1University of Québec at Trois-Rivières and Centre for Research and Intervention on Suicide and Euthanasia (CRISE), Canada, 2University of Missouri School of Medicine, Columbia, MO, USA, 3Edith

Cowan University, Joondalup, Australia, 4J.A. Mittersteig, Vienna, Austria, 5National Center on Institutions and Alternatives, Mansfield, MA, USA, 6Vrije Universiteit, Amsterdam,

The Netherlands, 7Institute of Forensic Psychiatry Charité, Berlin, Germany, 8Cambridge Institute of Criminology, Cambridge, UK, 9University of Molise, Campobasso, Italy

Abstract. The International Association for Suicide Prevention created a Task Force on Suicide in Prisons to better disseminate the information in this domain. One of its objectives was to summarize suicide-prevention activities in the prison systems. This study of the Task Force uncovered many differences between countries, although mental health professionals remain central in all suicide prevention activities. Inmate peer-support and correctional officers also play critical roles in suicide prevention but there is great variation in the involvement of outside community workers. These differences could be explained by the availability of resources, by the structure of the correctional and community services, but mainly by the different paradigms about suicide prevention. While there is a common and traditional paradigm that suicide prevention services are mainly offered to individuals by mental health services, correctional systems differ in the way they include (or not) other partners of suicide prevention: correctional officers, other employees, peer inmates, chap- lains/priests, and community workers. Circumstances, history, and national cultures may explain such diversity but they might also depend on the basic way we think about suicide prevention at both individual and environmental levels.

Keywords: prison, suicide, prevention, inmate, suicide attempt

This is the second paper published by the Task Force on Suicide in Prisons created in January 2006 by the Interna- tional Association for Suicide Prevention (IASP). The mandate of the group is to bring together the available knowledge and expertise on suicidal behavior in prisons in order to facilitate the wider dissemination of the fundamen- tals of effective suicide prevention. The nine members of the Task Force (all co-authors of these papers) represent eight different countries. With the help of the Internet, they held seven virtual meetings within one year. A typical web meeting starts with a first e-mail sent by the chair of the Task Force (Marc Daigle) to all the members. Each mem- ber sends his or her reply (with copies to all other members) within 2 or 3 weeks. Then the chair has 1 or 2 weeks to write a general consensus on the opinions of the members. That consensus is then sent to all members with new ques- tions or subjects to be discussed. Then a new virtual meet-

ing starts, again lasting 2 or 3 weeks. So far, this disci- plined process within the group has resulted in the organi- zation of a symposium and two publications. There are also plans for future tasks to be completed: collecting the grey literature on a website, comparing suicide screening instru- ments, and developing an international research project.

The first paper published by the Task Force (Konrad et al., this issue) represented the consensus of the nine experts about the basic essential practices for suicide prevention in correc- tional facilities that all countries should adopt. Resources per- mitting, countries would build on those basic essentials in order to achieve effective prevention of suicide and other self-harm. The first paper was published in collaboration with the World Health Organization. In this second paper we sum- marize the types of facilities for suicidal inmates and catego- ries of workers involved in suicide prevention within each country represented by the Task Force members.

DOI 10.1027/0227-5910.28.3.122 Crisis 2007; Vol. 28(3):122–130 © 2007 Hogrefe & Huber Publishers

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© 2007 Hogrefe & Huber Publishers Crisis 2007; Vol. 28(3):122–130

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Method and Results

Inspired by clinical experience and international literature on suicide prevention, a questionnaire was built by the chair of the Task Force. The information was then com- mented on by each member of the Task Force. Table 1 shows the types of correctional facilities (excluding police facilities/lockups or juvenile institutions) in the different countries. The table makes the usual separation between remanded inmates (those who are not yet sentenced) and those with different lengths of sentence. While some of the same terms are used in different countries they do not al- ways cover the same realities. For example, the term “pris- on” is usually generic but in some countries it has a more specific meaning. For that reason, the Task Force of the IASP refers to “prisons,” as does most of the literature. But, to be more specific to the countries covered in this study, there are more names for such facilities: prisons as such but also gaols, jails, penitentiaries, casa circondariale, and casa di reclusione. Beyond these technicalities, usually un- known in the general population, this table also shows where inmates with mental health problems are directed within or parallel to the correctional system. So-called fo- rensic hospitals or units often house those very high-risk prisoners but those hospitals differ in terms of the degree of the independence that patients can be legally and/or pro- cedurally permitted. Nevertheless, this diversion of some inmates is of special interest in the field of suicide preven- tion if we agree that mental health problems are often re- lated to suicidal ideations and behavior. As for the prison population rate, often called the incarceration rate, the table also shows that the United States has by far the highest. The other seven countries have rates below 150 per 100,000, as do 58% of countries of the world (Walmsley, 2005). Table 2 shows that, at many steps of the process and in most countries, mental health professionals are present in all correctional systems: psychologists, psychiatrists, and general medical practitioners. Nurses and social work- ers are present in smaller numbers, but they might not have specific training in mental health or suicide prevention. In- mate peer-support and correctional officers (guards), who have day-to-day contact with vulnerable prisoners, also play critical roles in suicide prevention (Liebling & Tait, 2006). Across countries there is great variation in the in- volvement of outside community workers.

Discussion

The data reported in this paper are specific to Western countries and, indeed, only to eight of them. In less devel- oped countries, the situation might be much different, es- pecially in countries at war or with many political prison- ers. Consequently, the present picture might only represent the best practices in the Western world. Incidentally, it may

not be by chance that the experts of the actual Task Force are from these eight countries. Nevertheless, “best practic- es” are not the same across these eight countries. Mental health professionals are present in all systems but each country has its own way of looking at suicide prevention. Most people would agree that suicide prevention is not only a matter of medical services but not all countries have de- veloped parallel services. For example, peer inmates are not used the same way in all countries and we know of substantial resistance to this form of help, considering es- pecially that the ultimate legal responsibility for suicide prevention has to be assumed by the authorities of the pris- ons. As for these peer groups, they may also be trained by outside workers like The Samaritans but, again, contacts with such community organizations seem rare in many countries. This seems to confirm that some prisons often behave as closed systems. As we have previously argued (Konrad et al., this issue), suicide prevention not only in- volves evaluating and treating individuals, as Table 2 sug- gests. Individuals come to correctional settings with certain vulnerabilities but it is when these vulnerabilities are cou- pled with the crisis of incarceration and the ongoing stress- ors of prison life that they tend to culminate in emotional and social breakdown and possibly also suicide or other self-harming behavior. Therefore, we must also act on im- proving meaningful social interaction and the quality of the general prison environment (Liebling, 2006).

Moreover, Table 2 by itself does not illuminate the ex- tent or quality of the services available in prison. As a first step in international collaboration, it is mainly a listing of what may be available. Consequently, the general impres- sion offered by the table may be biased high up. Neverthe- less, the table shows, especially to those who do not know the field, the diversity of approaches used in prison. Some settings may even be innovative and original.The subse- quent sections provide brief commentaries on the data per- taining to each of the eight countries, emphasizing the na- tional specificities.

Australia

In Australia the system varies markedly across the eight states and territories, although the information in Tables 1 and 2 is true in most jurisdictions. Several states have in- troduced “crisis care” units in prisons, enabling placement of high-risk prisoners into high-monitoring, high-support units that avoid the usual isolating and dehumanizing sui- cide-watch procedures that are applied in many prisons around the world. For example, in the Western Australian crisis care units, prisoners wear normal prison clothes in- stead of the usual ill-fitting and uncomfortable rip-proof safety clothing that prisoners are normally made to wear while on suicide watch. Another feature of prisons in most Australian states is the important role that prison officers play in determining the level of supervision needed (con- jointly with psychologists and other mental health clini-

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cians), and in providing practical and emotional-welfare support to prisoners. In fact, the dominant paradigm in Aus- tralian prison systems is that preventing suicide and other self-harm is the duty of all who live and work in prisons. For example, psychological, medical (including nursing), and correctional staff contribute to both the formal (e.g., screening instruments) and informal (e.g., monitoring pris- oners for signs of distress) identification of self-harm risk. Furthermore, multidisciplinary teams are responsible for designing and monitoring the management of high-risk prisoners and for documenting team decisions.

Peer-support programs (Snow & Biggar, 2006) operate in most states and outside community groups (The Samar- itans or others) provide different levels of services to pris- oners’ families. Such family support is known to be critical to prisoners’ adjustment (Adams, 1992; Bennett, 1988; Dear, Thomson, Hall, & Howells, 2001). Finally, all deaths in custody in Australia are investigated by the State Coro- ner, providing the impetus for many of the procedural im- provements and increases in resources. On the other hand, coronial recommendations are piecemeal and sometimes frustrate administrators’ genuine efforts to maintain consis- tent effective policies and procedural guidelines for staff.

Austria

Epidemiological surveys conducted in custodial settings concluded that a negative consequence of the shift of psy- chiatric care from mental hospitals to community-based services was that some of the most disadvantaged dis- charged mental patients could not cope with their new sit- uation and finally entered the correctional system (Frottier, Matschnig, Benda, König, & Fruehwald, 2002). Recently, further evidence for a “new era of institutionalization” was presented, showing the increase of forensic beds not only in Austria but in various European union member states during recent years (Priebe et al., 2005). Because of the increase of inmates with psychiatric needs in correctional settings, and the increase of suicide rates in custody, which seems to be a direct consequence (Fruehwald & Frottier, 2005), suicide prevention is a major task for staff of custo- dial institutions in Austria (Frottier, Fruehwald, Schwärz- ler, & Bauer, 2002).

The investigations show that suicide rates have been continuously rising in the past 2 decades. In Austria, as in other countries, the evaluation of incoming inmates is not done by a trained psychiatrist and the examination takes place only within the first week of incarceration. Therefore, a suicide screening instrument for prison officers (Frueh- wald, Frottier, Matschnig, König, & Bauer, 2004) will be used in all 28 Austrian prisons by the end of 2007. The screening, which is completed immediately after entering prison, provides a first estimation of suicide risk and dif- ferentiates between low, medium, and high suicide risk. Further preventive decisions (e.g., increased frequency of control, no use of single-cells, offering a “listener,” struc-

turing the day by means of prison work, referral to medi- cal/psychiatric care, etc.) can be more easily recommended according to this baseline estimation. If the suicide risk is estimated to be high the patient is put under observation until he/she has been assessed by a psychiatrist. If neces- sary, a transfer to psychiatric inpatient units is recommend- ed. Mentally disordered offenders not guilty by reason of insanity (NGRI) are treated in a special forensic institution or in regional psychiatric hospitals. Only a few of the latter have special forensic-psychiatric departments. Compared with psychiatric hospitals, the situation in the special fo- rensic institution is rather poor in regard to staffing. Despite this fact, NGRI exhibiting a higher degree of dangerous- ness are placed in these institution because of their higher security standards. Mentally disordered guilty offenders are mainly treated in a special institution in the capital and in special departments of the Austrian prisons for offenders with longer sentences. Until recently, the majority of re- sponsible mentally disordered offenders were kept in pris- ons together with all other not mentally disordered inmates. The expansion was carried out to cope with the increasing numbers of responsible mentally disordered offenders. However this was not accompanied by an increase of psy- chiatrists, psychologists, or social workers. Moreover, modern instruments and standardized programs are only used in the two special institutions for the treatment of men- tally disordered offenders.

Canada

As shown in Table 1, the Canadian correctional system op- erates at two levels, the provincial one with its correctional centers (called prisons or jails) and the federal one with its penitentiaries. Although the federal system may have more resources and more time to treat inmates (especially those sentenced to longer terms), both systems offer the same array of services that are pictured in Table 2. Mental health professionals are more often present at the federal level but a comprehensive suicide prevention program exists at both levels. In the Canadian correctional systems, peer programs and structures for communication with the community may be considered two original national experiences.

At the federal level, peer programs were implemented in two regions. They are small group of inmates who oper- ate as first-line people and whose role is mainly to identify those at risk, to give them some first-hand advice, and to refer them to professional services. The evaluation of these programs could not really demonstrate their efficacy, show- ing also that the recruitment of peer inmates to be included in these programs may be problematic. For example, cor- rectional officers may not agree with the selection of some older inmates who may be perceived as gaining some con- trol when participating in the group. There are also some concerns about security and responsibility when including peers in the process of helping suicidal inmates. Neverthe- less, interviews with inmates involved with the programs

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have indicated that they have been helpful (Daigle & Bis- todeau, 1998; Schlosar, 1997). Both levels of Canadian fa- cilities have long term experience with using community resources in suicide prevention, especially offering easy ac- cess to community crisis lines. Some training on correction matters may be offered to the community telephone work- ers but some of them may also be involved in the training of correctional employees. At the provincial level, the Que- bec prisons, where they have local suicide prevention com- mittees in each large facility, a community representative is often part of the meetings. That helps to disseminate in- formation to the community about positive work done in- side the walls and it also brings new and original ideas inside the prison. For example, following a coroner’s in- quest on the suicide of an inmate, the local committee of the Sept-Îles prison was able to identify one weakness in its suicide prevention program: the lack of communication with the families of inmates. Consequently, the committee added a message on plastic-coated cards on each table in the prison visitors’ lobby: “If the inmate you visit talks about suicide, call us at 99999.” Innovative, simple, and at almost no cost.

Germany

The obligatory physical examination upon entering a Ger- man prison includes an evaluation of a history of addiction in order to combat a possible dependency disorder or with- drawal symptoms. At the same time, the prison physician must diagnose the suicidal risk, even if standardized instru- ments are not used to do so. Inmates judged to be actively suicidal get constant supervision. Inmates who have raised staff suspicions regarding suicide but who do not admit to being actively suicidal will be observed frequently. Nor- mally the suicidal inmate is housed in a dormitory or shared-cell setting.In cases of imminent suicide risk or sui- cidal behavior, transfer to a general psychiatric hospital or other nonprison facilities as well as obligatory transfer to medical prison are possible options. Inpatient psychiatric care of prisoners is subject to wide regional variations in Germany. Only four federal states (Baden-Württemberg, Bavaria, Berlin, Saxony) have psychiatric departments in penal institutions under the legal authority. In the other fed- eral states, inpatient and outpatient psychiatric care of pris- oners is provided by external institutions and consulting specialists. External institutions for inpatient psychiatric care include forensic-psychiatric security hospitals and general psychiatric facilities.

Italy

The Italian Justice System prescribes subjects not liable for reason of mental insanity to be interned in forensic psychi- atric hospitals, and a differential treatment system and sen- tence calculation, which also takes into account social dan-

gerousness, is provided compared to other penitentiary in- stitutions. Inmates who develop a psychiatric disorder dur- ing imprisonment commonly receive treatment inside the penitentiary institution; only severe cases are transferred to Penitentiary Psychiatric Observation Wards. Such struc- tures, however, are only charged with evaluating and ob- serving inmates, as treatment is not provided. As soon as a diagnosis of psychiatric disorder is made, the judge decides if clinical conditions are consistent with continuation of sentence in jail. In every Italian jail, medical services are provided night and day in institutions with more than 225 inmates; in minor institutions only a daily service is pro- vided. A psychiatric consultant is on duty for a number of hours per month depending on the number of inmates in- side the institution; such organization lacks a central coor- dination to provide guidelines for intervention and treat- ment, and every single professional is in charge of evalu- ating the best treatment for inmates.

Netherlands

Suicide prevention is underdeveloped in the Dutch penal institutions. Although the Ministry of Justice commis- sioned scientific research into screening of suicidal detain- ees (Blaauw & Kerkhof, 1999), the instrument is not being used as a screening instrument at intake in prisons and jails. It is only used after an inmate expresses suicidality. When- ever there is a suspicion of suicidality, the inmate is seen by a psychologist, who uses the screening instrument as a tool. Many psychologists have received special training in suicide prevention by Blaauw and Kerkhof. Some psychol- ogists offer postvention to officers after a suicide has taken place (Blaauw, Kerkhof, & Hayes, 2005; Blaauw, Kerkhof, Winkel, & Sheridan, 2001). It is well known that any pris- oner worries excessively. Worrying is related to hopeless- ness, depression, anxiety, sleeping problems, health com- plaints, and suicidality. Worrying by depressed and hope- less inmates is one of the warning signs or proximal risk factors for suicide that were studied in The Netherlands (Kerkhof & Van ’t Veer, 2004). In daily practice however, not much attention is being paid to suicidal worrying. Those admitting suicidal impulses are generally watched over more frequently and if necessary transferred to special departments for inmates with mental health problems. Treatment on these special wards is targeted at depression and other psychiatric conditions. Programs targeted at treatment of suicidal impulses among inmates are still non- existent.

UK

In the UK, most local prisons (where the large majority of suicides occur) have introduced first-night centers, where prisoners can be assessed and reassured, including by peer- support groups. Some of these centers have been specially

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built, ensuring appropriate facilities (such as private offi- ces, good access to telephones, etc.). Suicide prevention coordinators ensure that services within the prison are linked and that mental health in-reach nursing staff exper- tise is used to support ground staff in looking after at-risk prisoners. A thorough assessment is carried out on recep- tion, and referrals can also be made to assessment teams at any stage in the custodial process.

Many prisons have both “safe cells” and “care suites”, supported by prisoner Listener schemes (prisoners trained by The Samaritans) as well as by uniformed and specialist staff. It is also the dominant view in England and Wales that preventing suicide is the duty of all who work in pris- ons. Multidisciplinary teams carry out regular case reviews once an individual prisoner is referred to the ACCT (As- sessment Care in Custody and Teamwork Implementation) system. Physical education staff are increasingly involved in “healthy living” and other supportive initiatives as the emphasis shifts from a narrow focus on suicide prevention to a broader concern with promoting well-being. Some in- novative practices are emerging in men’s and women’s prisons, involving alternative therapies such as massage, yoga, and acupuncture. Deaths in custody are investigated by the Prisons and Probation Ombudsman (as well as by the Coroner) and specific thematic investigations have been conducted in establishments where more than one death occurs over a short period of time (Prisons and Pro- bation Ombudsman for England and Wales, 2003).

USA

At the sentencing stage in the USA, felony convictees re- ceiving sentences of any length may be placed in prisons. Some prisons receive those who are sentenced to a 120 day “shock sentence,” especially drug offenders for treatment. All accused persons in the USA who are found not guilty by reason of insanity (NGRI) under state jurisdiction will be committed to a state forensic hospital for treatment (rep- resenting only 1% of the inmates). Those who are found guilty but mentally ill (GBMI) in some states such as Mich- igan will be sentenced to prison but may be tagged for treat- ment. During the pretrial stage, all those who are adjudi- cated as incompetent to stand trial will be committed to a state forensic hospital until competency is restored. In the Federal system, those who are adjudicated as incompetent to proceed to trial will be committed to the Bureau of Pris- ons for treatment until competency is restored and then if restored proceed to trial. Because of the massive deinstitu- tionalization of the mentally ill from the state hospitals and the lack of systematic diversionary programs for the men- tally ill criminal offenders, the state prisons have become the de facto state hospitals. In the USA, prisoners have a constitutional right to receive medical and mental health care that meet minimal standards. In a key US Supreme Court case (Ruiz v. Estelle, 1980), the court outlined mini- mum requirements for mental health services in correction-

al settings: trained mental health professionals, systematic screening and evaluation, treatment, appropriate use of be- havior-altering medications, accurate recording, and sui- cide-prevention programs. Guidelines for clinically sound and legally defensible mental health care and suicide-pre- vention programs have also been established by the Amer- ican Correctional Association (ACA), American Psychiat- ric Association (APA), and National Commission of Cor- rectional Health Care (NCCHC).

Conclusion

International groups like the Task Force on Suicide in Pris- ons are a good opportunity to gain new insights in specific problems such as the prevention of suicide in high risk groups. In this case, the internet technology made the group very effective and produced findings that, for the first time, could be compared and analyzed. As expected, similar ser- vices are available in many countries but there are also many differences. These differences could be explained by (1) the availability of the resources, (2) the structure of the correctional and community services, but also (3) the dif- ferent paradigms about suicide prevention.

The real availability of resources might be a key expla- nation if we had compared countries with very differing levels of wealth, but that was not the case. Of course, un- developed countries would have less money to invest in their correctional systems, especially when, for example, they also have to think about services to offer in schools or hospitals for senior citizens. In more developed countries, the availability of resources might be more dependent on social and political considerations, like the relative open- ness of the tax-payers to pay attention to unpopular groups of citizens. That never-ending debate can have very real impacts on the general level of services in prisons. Remem- ber also that the USA is considered a wealthy nation and that it has a very high incarceration rate as well as a pool of very good researchers in the field of suicide prevention in prison. Nevertheless, it does not seem that the US has better services in prison than do other countries.

The structure of correctional and community services may explain more of the observed differences. In particular, the organization of mental health services, as well as the share of responsibilities, may well explain why there are more or less medical practitioners in prison or why an in- mate with mental health problems will or won’t be sent to a special unit. Prisons depend on the way the whole society organizes its health system, although specific partnerships may be negotiated between health and justice departments. In that sense, an effective organization of a specific service might not be easily exported to another country.

Differences between the eight countries that involve nonprofessional employees, the inmates themselves, or the outside community, may well be explained by the different paradigms that have been adopted in each country. Unfor-

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tunately, we were not in a position to obtain clear data on the theoretical, political, and philosophical paradigms that underpin suicide prevention processes, partly because there are enormous variations even within countries, but also be- cause officially stated paradigms often differ from actual practice. There have been few studies on this matter and it is a matter in need of researchers’ attention. Nevertheless, our data show that, in the field of suicide prevention, all correctional systems evolve around the availability of men- tal health services. That can be called the common and tra- ditional paradigm. However, we also see that these systems differ in the way they include (or not) the other partners of suicide prevention: correctional officers, other employees, peer inmates, chaplains or priests, and community workers. Circumstances, history, and national cultures may explain such diversity but it also may depend on the basic way we think about suicide prevention. Such implicit paradigms need to be analyzed in order for all organizations to be more efficient but, as mentioned earlier, we already know of some resistance, such as sharing responsibilities with peer inmates. Some other experiences involving the outside community mean that we would include citizens who are more used to criticizing the “prison system.&#

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