1355076 - SAGE Publications, Inc. (US) ©clearly that such

1355076 - SAGE Publications, Inc. (US) ©
clearly that such placement will be contingent on bed space and
that the inmate can
expect the ability to use this strategy to become less frequent.
Another strategy is to make adjustments to segregation times,
whether through reductions
or staggered segregation schedules. Many disruptive inmates
owe tremendous amounts
of segregation time that have been accumulated over time. For
these inmates, it may be
helpful to make a deal whereby 15 days could be completed
rather than 6 months. Such
reward would be contingent on an absence of the maladaptive
behaviors for that time
period. Allowing inmates to receive 2 or 3 days' credit for each
adaptive day is also an
option. Effectiveness has also been shown in allow ing inmates
to be housed in
segregation during the week and in general population during
the weekend.
All of these strategies are designed to instill a sense of control
within the inmate-patient
based on behaving appropriately, that is, as specified in the
treatment plan. With an
opportunity to achieve rewards, the inmate-patient will learn
how to control some features
of his or her environment appropriately, which will lead to a
reduction in the experience of
punishment and perhaps generalize to other situations. Table

14.3 contains a sample BTP
that incorporates a sampling of the strategies described above.
Table 14.3
Combined Interventions
Although BTPs can be effective, their effectiveness may be
increased substantially when
they are combined with other treatment modalities including
medication and more
cognitively oriented interventions. These additional treatment
strategies might be helpful
in increasing impulse control, in overcoming skill deficits, or in
addressing underlying
mental health issues. For example, breathing exercises, deep
muscle relaxation,
challenging irrational assumptions, and/or behavioral skills
training (e.g., social skill
training or assertiveness training) may each assist the inmate in
gaining more control over
impulses. Pharmacological interventions with or without
hospitalization might be
appropriate where psychosis is involved, especially when
command hallucinations to act
aggressively towards oneself and/or others are involved (see
Chapter 7 for more
information about psychopharmacological interventions).
Linehan's (1993) book,
Cognitive-Behavioral Treatment of Borderline Personality
Disorder, provides an excellent
conceptual integration of a range of cognitive and behavioral
interventions, as well as the

file://view/books/9781452236315/epub/OEBPS/s978154430280
5.i809.html
use of psychotropic medications, for patients with borderline
personality disorder,
although the practical applicability of this treatment-intensive
approach to a general
population correctional setting is questionable.
Obstacles to Best Practice
In this section, some of the potential obstacles to developing
and implementing BTPs are
discussed.
Past Practices: Finding an Alternative to Punishment
Consistent with the admonition to be firm, fair, and consistent
in the treatment of inmates,
correctional systems have guidelines that mandate specific,
standardized procedures,
including the imposition of penalties, in response to
institutional rule violations. This
approach works in most situations with most inmates, at least
over the short term (Byrne
& Hummer, 2007). However, it is well documented that
punishment is not effective for
promoting long-term behavioral changes (e.g., Amos, 2004).
In fact, punishment of disruptive institutional behaviors
sometimes results in an ongoing
power struggle and an escalation of the problem behaviors. This
has largely to do with the
emphasis on controlling the behavior of an unwilling participant

and/or the emphasis on
punishing unwanted behavior rather than rewarding appropriate
behavior. Toch (2008)
suggests that behavioral management plans (i.e., behavior
control strategies implemented
by staff without inmate consent) that emphasize punishment
serve to intensify inmates'
resentment and solidify their resistance, even when they lead to
surface compliance. There
certainly is little reason to expect an “ah-ha” moment with the
extremely disruptive or
aggressive inmate unless the situational circumstances within
the institution change for
the inmate.
Therefore, in planning behavioral interventions, it is the task of
the mental health
professional to consult with and convince wardens and other
staff stakeholders that the
inmate is ultimately controlling things through disruptive
behaviors, and that a departure
from traditional responses, that is, a collaborative approach that
emphasizes positive
reinforcement, is necessary. Standards of care, such as those
offered by NCCHC (2008)
and the American Correctional Association (2004), as well as
features of settlement
agreements and consent decrees from other jurisdictions,
provide useful leverage for
moving correctional systems away from sole reliance on
traditional punitive custodial
practices and toward the development of more flexible and
effective behavioral treatment
strategies. A collaborative approach that appreciates and
incorporates both effective
custody and mental health practices tailored to the inmate's

functional level can result in
successful and long-lasting behavioral change for the inmate
and a smoother, more
efficient correctional operation.
Staff Resistance
There may be potential differences between the assumptions
under which mental health
providers approach offenders and the standard correctional
management approach. The
former focuses on individual differences, whereas the latter
stresses uniformity (i.e., equal
standards and treatment for all). These philosophies can
sometimes be difficult to
reconcile in practice; it is often difficult for correctional
workers to serve mental health care
and correctional functions simultaneously. In particular, mental
health care providers are
likely to prioritize the institution's rehabilitation missi on and a
positive approach (as
consistent with the learning theory emphasis on reward rather
than punishment), broadly
speaking. Most staff, particularly those in custody, must
consider safety and security as
paramount. As a result, they are likely to rely on short-term,
punishment-oriented
approaches, as dictated by institutional policy and applied
consistently and objectively;
and they are likely to resist deviations from these policies
suggested by mental health
clinicians.

Mental health care providers should bear in mind that BTPs
depend on the cooperation of
other staff, for whom the concept of the prisoner as patient, or
healthcare consumer, may
be utterly foreign. Hence, in formulating BTPs, it is vital to
bear in mind that staff must be
persuaded that BTPs have value and will benefit both the inmate
and the institution.
Additionally, staff must be reinforced for their cooperation.
Ideally, wardens and other
high-level administrators support these programs and recognize
staff for their
contributions.
Mental health, medical, and correctional staff may express
apprehension that meeting one
inmate's needs and making exceptions to standard correctional
practices via BTPs will
result in other inmates doing the same thing, the perceived
failure of the system, the
perception of inmates being in control, and the perception of
giving in. However, this
apprehension can easily be countered with the notion that when
these behaviors are not
properly treated, they can have a dramatic impact on facility
operations, including
increased staff injury and the canceling of visits, programs,
recreation, and other activities
important to inmates. Additionally, with regard to control
issues, it is the chronically
disruptive inmate who ultimately controls things anyway (e.g.,
provoking use of force,
compelling staff to expend more time in paperwork) through his
or her behavior. The key is
to accept that current punitive strategies are not effective with

this group of disruptive
offenders and to attempt strategies that may prove more
effective.
Cost-Benefit
The time and labor investments in BTPs are greater over the
short term, that is, during the
baseline and early implementation phases, whereas the reward
to staff, in terms of
improved behavior, may take considerable time. For example,
assessment is continuous
and requires ongoing observation and recording of the target
behavior(s), so that the
effectiveness of the intervention, once introduced, can be
determined. During the earlier
phases of the program, there may be no improvement in
behavior or even an exacerbation
of the problem, until and unless the inmate-patient responds
favorably to the changed
circumstances, that is, the intervention. Hence, staff should be
prepared to exercise
patience and consistency, and rewards (positive reinforcement)
for staff involvement (e.g.,
through awards, letters of commendation placed in personnel
files) should be built into
these programs.
Obtaining Informed Consent
Finally, there is the challenge of obtaining the inmate-patient's
cooperation in the BTP.
Without the inmate's cooperation, any attempt at behavioral

change would be considered
a traditional behavior management plan, and as previously
noted, with such plans there is
the danger of increasing inmate resistance, the frequency of
disruptive behaviors, and an
adversarial relationship between staff and inmates. If the inmate
can be persuaded to
become an active partner in the treatment process; can see value
in developing alternative,
more acceptable behavioral patterns; and can be convinced to
work collaboratively with
staff, then behavioral change through BTPs becomes possible
and more likely to succeed.
Hence, if the inmate's cooperation cannot be obtained, perhaps
because maintaining the
control that exercising the problem behavior affords him or her
is extremely reinforcing, or
because no adequate reinforcement for more appropriate
behavior can be found, it is
recommended that a BTP be introduced on a much smaller scale.
Perhaps in this instance,
a first step would be to build trust through a small verbal
agreement such as providing out-
of-cell time for a shift of adaptive behaviors. Whereas formal
signed contracts may not be
needed if a verbal agreement can be obtained, it is important to
ensure that the inmate is
involved in the plan. As previously noted, improperly designed
behavioral interventions can
exacerbate problem behaviors.
Summary and Conclusions
This chapter has focused on disruptive inmate behaviors as well
as possible motivations
for these behaviors. It has reviewed treatment strategies
designed to ensure safety and

security through a collaborative approach designed to reduce
these behaviors. The
challenge for correctional staff is to reshape inmate demands
into something acceptable
to the institution through the reinforcement of appropriate,
adaptive behaviors. Most
systems can find the balance between care and safety in the
service of change and good
outcomes, as long as there is collaboration and clear
communication. It is clear that in
addition to those who meet typical criteria for serious mental
illness, there is a small group
of inmates with personality disorders or other mental health
symptoms whose extreme
behaviors require unique interventions based on behavioral
principles. Although these
interventions may be time- and labor-intensive and may meet
initial resistance from
correctional staff, their long-term benefits may warrant their use
with some offenders
when more traditional correctional management techniques
prove ineffective.
While the “mad” versus “bad” dilemma has a long history in
corrections, behaviors
attributed to either must be addressed collaboratively and based,
at least in part, on
behavioral principles. Recent standards of care, legal cases, and
heightened awareness
are moving correctional facilities toward making
accommodations for those whose
mental illness or symptoms (e.g., impulsivity) prohibit them
from progressing within the
framework of traditional correctional practices. This is leading
to best practices as
detailed in this chapter. Although several obstacles still exist,

mental health professiona
Management of Suicidal
and Self-Harming
Behaviors in Prisons:
Systematic Literature
Review of Evidence-Based
Activities
Emma Barker, Kairi Kõlves, and Diego De Leo
The purpose of this study was to systematically analyze existing
literature testing
the effectiveness of programs involving the management of
suicidal and self-harming
behaviors in prisons. For the study, 545 English-language
articles published in peer
reviewed journals were retrieved using the terms ‘‘suicid�,’’
‘‘prevent�,’’ ‘‘prison,’’ or
‘‘correctional facility’’ in SCOPUS, MEDLINE, PROQUEST,
and Web of
Knowledge. In total, 12 articles were relevant, with 6 involving
multi-factored suicide
prevention programs, and 2 involving peer focused programs.
Others included changes
to the referral and care of suicidal inmates, staff training,
legislation changes, and a
suicide prevention program for inmates with Borderline
Personality Disorder. Multi-

factored suicide prevention programs appear most effective in
the prison environment.
Using trained inmates to provide social support to suicidal
inmates is promising. Staff
attitudes toward training programs were generally positive.
Keywords best practice, inmates, prison, suicidal behavior
INTRODUCTION
Research has consistently shown higher
suicide rates in prisons and jails worldwide,
when compared to the general population
(Dooley, 1990; Hayes, 1994; Hayes &
Blaauw, 1997). The prison environment
presents many predictors of suicidal beha-
viors which are unique from the general
population. Risk factors of suicidal
behaviors in prisons could be divided into
four distinct categories:
. Demographic risk factors including
being a young male, having prior crimi-
nal history, low education level, White
race, and being of single marital status
(Daniel & Fleming, 2006).
. Clinical factors including personal and
family history of psychiatric problems,
and dysfunctional family lives including
parental substance abuse and violence
(Laishes, 1997), and Axis I and Axis II
Color versions of one or more of the figures in
the article can be found online at www.tandfonline.

com/usui.
Archives of Suicide Research, 18:227–240, 2014
Copyright # International Academy for Suicide Research
ISSN: 1381-1118 print=1543-6136 online
DOI: 10.1080/13811118.2013.824830
227
psychiatric disorders (Daniel & Fleming,
2006).
. Psychosocial factors such as poor cop-
ing methods, stressful life events, past
suicide attempts, receiving a new charge
or conviction, and experiencing shame
or guilt (Daniel & Fleming, 2006), and
family conflict (Laishes, 1997).
. Institutional factors such as overcrowded
conditions, bullying and harassment,
recent disciplinary action (Kovasznay,
Miraglia, Beer et al., 2004), being in a
new environment (Winkler, 1992),
sentences of life imprisonment, being
held on remand (Fazel, Cartwright,
Norman-Nott et al., 2008), lack of staff
supervision, isolation, and sensory depri-
vation of suicidal inmates (Daniel, 2006).
Rising prison suicide rates since the
1980’s have seen an increase in the study
of suicide in prisons (Daniel, 2006), and
the introduction of new suicide prevention

programs (SPP’s) and policies. For example,
the World Health Organization (WHO) in
collaboration with the International Associ-
ation for Suicide Prevention (IASP) released
the guideline ‘‘Preventing suicide. In Jails
and Prisons’’ in 1999. However, despite
the increased attention, there still seems to
be lack of evidence-based activities and
programs focusing on reducing suicidal
behaviors in prisons.
The aim of current review is to system-
atically analyze existing literature on suicide
prevention activities in prisons, which have
been tested for their effectiveness.
Methodology
A search was conducted of English-
language, peer reviewed articles published
between 1990 and 2012. The search
terms applied in SCOPUS, MEDLINE,
PROQUEST, and Web of Knowledge
were ‘‘suicid�,’’ ‘‘prevent�,’’ ‘‘prison,’’ or
‘‘correctional facility.’’ The initial search
of the databases returned a total of 538
articles, with another 7 articles being added
after checking the reference lists of the
articles retrieved by the search. These 545
articles were then limited to 99 after con-
sideration of the titles (Figure 1). The
abstracts of these 99 articles were then read
and reviewed according to the following
criteria:

Studies that present an overview of
suicide prevention activities in the
correctional setting, and include an
analysis of effectiveness measured in
incidence of suicidal behaviors or a
changing of staff=inmates attitudes.
Studies were excluded if they did not
appropriately test the impact of suicide
prevention activities (i.e., solely presenting
numbers of suicides occurring while the
suicide prevention program was in place
without any comparison to numbers before
program implementation), if they were too
outdated, were not focused specifically on
suicide prevention within prisons, or if
they simply provided an overall summary
of various suicide prevention recommen-
dations without any support of the effec-
tiveness of these recommendations.
RESULTS
A total of 12 articles fulfilled the selected
criteria and are presented here in more
detail (see Table 1 for a summary). Out
of the 12 studies, 7 were conducted in
the United States, 2 in the United Kingdom
and 1 in Canada, Austria, and Australia. Six
of these studies involved multi-factored
suicide prevention programs. Two of the
studies were peer focused suicide preven-
tion activities. The other four studies
included changes to the referral and care
of suicidal inmates in prison mental
health services, risk management skills

based training for prison staff, changes in
Managing Suicide and Self-Harm in Prisons
228 VOLUME 18 � NUMBER 3 � 2014
legislation and a specific suicide prevention
program targeted at inmates with Border-
line Personality Disorder.
Multi-Factored SPPs
In 1986, the Galveston County Jail in
the US implemented an SPP based on the
principles listed by Felthous (1994), includ-
ing screening new inmates, giving specific
attention to inmates during risky periods
such as the 3 days before and after a court
hearing, providing psychological support
for inmates, and avoiding the isolation of
suicidal inmates. The study also noted that
the use of trained inmates to provide com-
pany for inmates housed in isolation should
FIGURE 1. Flow chart of the identification, screening,
eligibility assessment, and inclusion of articles.
E. Barker, K. Kõlves, and D. De Leo
ARCHIVES OF SUICIDE RESEARCH 229

T
A
B
L
E
1
.
S
u
ic
id
e
P
re
v
e
n
ti
o
n
P
ro
g
ra
m
s
in
P
ri
s
o
n
s
a
n

d
C
o
rr
e
c
ti
o
n
a
l
F
a
c
il
it
ie
s
A
u
th
o
r
C
o
u
n
tr
y
/
P
ri
s

o
n
a
n
d
p
e
ri
o
d
A
c
ti
v
it
y
/
In
te
rv
e
n
ti
o
n
E
v
a
lu
a
ti
o
n

m
e
a
s
u
re
M
a
in
fi
n
d
in
g
s
F
el
th
o
u
s,
1
9
9
4
U
n
it
ed
S

ta
te
s,
G
al
v
es
to
n
C
o
u
n
ty
Ja
il
1
9
8
6
–
1
9
9
4
S
u
ic
id
e
p

re
v
en
ti
o
n
p
ro
g
ra
m
w
as
im
p
le
m
en
te
d
w
h
ic
h
in
cl
u
d
ed
sc
re
en
in

g
o
f
in
m
at
es
,
p
sy
ch
o
lo
g
ic
al
su
p
p
o
rt
,
o
b
se
rv
at
io
n
an
d
d
is
b

ar
m
en
t
o
f
d
an
g
er
o
u
s
o
b
je
ct
s,
cl
ea
r
an
d
co
n
si
st
en
t
g
u
id
el
in
es

an
d
h
o
sp
it
al
iz
at
io
n
.
C
h
an
g
es
in
su
ic
id
e
n
u
m
b
er
s.
O
v
er

th
e
p
er
io
d
o
f
1
9
8
6
–
1
9
9
4
,
n
o
su
ic
id
es
o
cc
u
rr
ed
at
th
e

ja
il
.
T
h
is
is
a
re
d
u
ct
io
n
fr
o
m
7
su
ic
id
es
in
th
e
te
n
ye
ar
p
er

io
d
b
ef
o
re
th
e
p
ro
g
ra
m
w
as
im
p
le
m
en
te
d
.
H
ay
es
.
L
.,
1
9

9
5
L
o
u
is
ia
n
a,
U
n
it
ed
S
ta
te
s,
E
la
yn
H
u
n
t
C
o
rr
ec
ti
o

n
al
C
en
te
r
M
u
lt
i-
fa
ct
o
re
d
S
P
P
co
n
ta
in
in
g
si
x
m
ai
n
co
m
p
o

n
en
ts
in
cl
u
d
in
g
:
st
af
f
tr
ai
n
in
g
,
in
ta
k
e
sc
re
en
in
g
=
as
se
ss
m
en
t,

ap
p
ro
p
ri
at
e
h
o
u
si
n
g
o
f
su
ic
id
al
in
m
at
es
,
ap
p
ro
p
ri
at
e
su
p
er

v
is
io
n
d
ep
en
d
in
g
o
n
su
ic
id
e
ri
sk
,
in
te
rv
en
ti
o
n
p
ro
ce
d
u
re
s,
an
d

ad
m
in
is
tr
at
iv
e
re
v
ie
w
af
te
r
a
su
ic
id
e.
C
h
an
g
es
in
su
ic
id
e
n

u
m
b
er
s
in
E
la
yn
H
u
n
t
C
o
rr
ec
ti
o
n
al
C
en
te
r
an
d
su
ic
id
e
ra

te
s
ac
ro
ss
th
e
st
at
e.
O
n
ly
o
n
e
su
ic
id
e
at
th
e
fa
ci
li
ty
si
n
ce

p
ro
g
ra
m
im
p
le
m
en
ta
ti
o
n
,
si
g
n
if
ic
an
t
re
d
u
ct
io
n
in
st
at
e
su

ic
id
e
ra
te
s
fr
o
m
2
3
.1
p
er
1
0
0
,0
0
0
b
et
w
ee
n
1
9
8
4
an
d
1

9
9
2
to
1
2
.4
p
er
1
0
0
,0
0
0
in
1
9
9
3
.
C
o
x
&
M
o
rs
ch
au

se
r,
1
9
9
7
S
ta
te
o
f
N
ew
Y
o
rk
,
U
n
it
ed
S
ta
te
s,
1
9
8
5
–

1
9
9
6
S
P
P
u
si
n
g
co
-o
rd
in
at
io
n
st
ra
te
g
ie
s
an
d
ri
sk
-m
an
ag
em

en
t
co
m
p
o
n
en
ts
.
In
cl
u
d
ed
st
af
f
co
-o
p
er
at
io
n
,
st
ru
ct
u
re
d
sc
re
en

in
g
,
su
p
er
v
is
io
n
an
d
o
b
se
rv
at
io
n
o
f
at
-r
is
k
in
m
at
es
,
sp
ec
ia
l

sa
fe
ce
ll
s,
im
p
ro
v
ed
st
af
f
tr
ai
n
in
g
,
cr
is
is
in
te
rv
en
ti
o
n
m
en
ta
l

h
ea
lt
h
se
rv
ic
es
,
in
v
es
ti
g
at
io
n
o
f
su
ic
id
es
an
d
st
af
f
d
eb
ri
ef
in

g
.
C
h
an
g
es
in
su
ic
id
e
n
u
m
b
er
s.
F
ee
d
b
ac
k
fr
o
m
p
ar
ti
ci
p

an
ts
as
to
th
e
ch
an
g
e
in
n
at
u
re
o
f
re
la
ti
o
n
sh
ip
s
b
et
w
ee
n

p
ri
so
n
s
an
d
m
en
ta
l
h
ea
lt
h
ag
en
ci
es
.
S
in
ce
im
p
le
m
en
ta
ti
o
n
o

f
th
e
p
ro
g
ra
m
su
ic
id
e
n
u
m
b
er
s
d
ro
p
p
ed
fr
o
m
2
6
in
1
9
8

4
to
9
in
1
9
9
6
.
F
u
rt
h
er
m
o
re
,7
8
%
o
f
p
eo
p
le
w
h
o
re
sp
o
n

d
ed
to
a
su
rv
ey
co
n
d
u
ct
ed
af
te
r
im
p
le
m
en
ta
ti
o
n
re
p
o
rt
ed
im

p
ro
v
ed
co
n
n
ec
ti
o
n
s
w
it
h
m
en
ta
l
h
ea
lt
h
se
rv
ic
es
.
H
ay
es
,
L

.,
1
9
9
7
U
n
it
ed
S
ta
te
s,
C
o
u
n
ty
D
et
en
ti
o
n
C
en
te
r
S

P
P
im
p
le
m
en
te
d
w
h
ic
h
in
v
o
lv
ed
st
af
f
tr
ai
n
in
g
,
id
en
ti
fi
ca
ti
o

n
=
sc
re
en
in
g
o
f
su
ic
id
al
in
m
at
es
,
b
et
te
r
st
af
f
co
m
m
u
n
ic
at
io
n

,
im
p
ro
v
ed
su
p
er
v
is
io
n
,
im
p
ro
v
ed
sa
fe
h
o
u
si
n
g
an
d
ap
p
ro

p
ri
at
e
st
af
f
in
te
rv
en
ti
o
n
.
C
h
an
g
es
in
su
ic
id
e
n
u
m
b
er
s.

In
th
e
1
8
m
o
n
th
s
af
te
r
th
e
im
p
le
m
en
ta
ti
o
n
o
f
th
e
S
P
P
,
n
o
fu

rt
h
er
su
ic
id
es
w
er
e
re
co
rd
ed
.
230 VOLUME 18 � NUMBER 3 � 2014
F
ru
eh
w
al
d
,
F
ro
tt
ie
r,
E

h
er
,
R
it
te
r,
&
A
ig
n
er
,
2
0
0
0
A
u
st
ri
a,
1
9
4
7
–
1
9
9
6

C
h
an
g
es
in
le
g
is
la
ti
o
n
ai
m
ed
at
re
d
u
ci
n
g
p
ri
so
n
su
ic
id
es
sa

w
fe
w
er
lo
n
g
-t
er
m
se
n
te
n
ce
s,
m
o
re
fr
eq
u
en
t
re
le
as
es
o
n

p
ar
o
le
an
d
sp
ec
ia
l
m
an
ag
em
en
t
o
f
m
en
ta
ll
y
il
l
o
ff
en
d
er
s,
in
cl
u

d
in
g
in
cr
ea
se
in
m
en
ta
l
h
ea
lt
h
st
af
f.
R
ef
o
rm
s
p
ro
d
u
ce
d
a
lo
w

er
in
g
o
f
th
e
p
ri
so
n
p
o
p
u
la
ti
o
n
w
h
ic
h
w
as
ex
p
ec
te
d
to
lo
w

er
su
ic
id
e
ra
te
s.
C
h
an
g
es
in
su
ic
id
e
ra
te
s
B
et
w
ee
n
1
9
4
7
an
d

1
9
9
6
th
e
p
ri
so
n
su
ic
id
e
ra
te
s
in
cr
ea
se
d
fr
o
m
4
8
.6
p
er
1
0

0
,0
0
0
to
2
9
4
.4
p
er
1
0
0
,0
0
0
,
d
es
p
it
e
th
e
re
d
u
ct
io
n
in

p
ri
so
n
p
o
p
u
la
ti
o
n
an
d
in
cr
ea
se
d
m
en
ta
l
h
ea
lt
h
st
af
f.
F
re
em

an
&
A
la
im
o
,
2
0
0
1
U
n
it
ed
S
ta
te
s,
C
o
o
k
C
o
u
n
ty
D
ep

ar
tm
en
t
o
f
C
o
rr
ec
ti
o
n
s,
1
9
9
0
–
2
0
0
1
.
Im
p
le
m
en
te
d

m
u
lt
i-
fa
ct
o
re
d
S
P
P
in
cl
u
d
in
g
m
en
ta
l
h
ea
lt
h
sc
re
en
in
g
,
in
p
at

ie
n
t
ca
re
fo
r
su
ic
id
al
in
m
at
es
,
fo
ll
o
w
u
p
tr
ea
tm
en
t
o
n
ce
st
ab

il
iz
ed
,
re
lo
ca
ti
o
n
in
to
g
en
er
al
p
o
p
u
la
ti
o
n
,
co
m
m
u
n
it
y
li
n

k
ag
e
u
p
o
n
re
le
as
e,
st
af
f
tr
ai
n
in
g
.
C
h
an
g
es
in
su
ic
id
e
ra
te
s.

S
in
ce
im
p
le
m
en
ta
ti
o
n
su
ic
id
e
ra
te
s
d
ro
p
p
ed
to
fe
w
er
th
an

2
su
ic
id
es
fo
r
ev
er
y
1
0
0
,0
0
0
ad
m
is
si
o
n
s.
E
cc
le
st
o
n
&
S
o

rb
el
lo
,
2
0
0
2
A
u
st
ra
li
a
Im
p
le
m
en
ta
ti
o
n
o
f
S
P
P
ta
rg
et
ed
at

su
ic
id
al
in
d
iv
id
u
al
s
w
it
h
B
P
D
.
P
ro
g
ra
m
in
cl
u
d
ed
fo
u
r
m
o

d
u
le
s
w
h
ic
h
ai
m
ed
to
te
ac
h
o
ff
en
d
er
s
m
o
re
ad
ap
ti
v
e
co
p
in
g

sk
il
ls
,
re
d
u
ce
su
ic
id
e
an
d
se
lf
-h
ar
m
b
eh
av
io
r
an
d
ad
d
re
ss
u

n
d
er
ly
in
g
cr
im
in
o
g
en
ic
n
ee
d
s.
A
n
al
ys
is
o
f
B
P
D
sy
m
to
m
at
o
lo

g
y
b
ef
o
re
an
d
af
te
r
p
ar
ti
ci
p
at
io
n
th
ro
u
g
h
a
d
ep
re
ss
io
n
,
an

x
ie
ty
an
d
st
re
ss
sc
al
e
an
d
th
ro
u
g
h
q
u
al
it
at
iv
e
an
al
ys
is
o
f
th

er
ap
is
t
n
o
te
s.
M
o
st
p
ar
ti
ci
p
an
ts
ex
p
er
ie
n
ce
d
a
d
ec
li
n
e
in
B

P
D
sy
m
p
to
m
s
d
u
ri
n
g
th
e
p
ro
g
ra
m
,
h
o
w
ev
er
2
o
f
th
e
g
ro

u
p
s
(A
an
d
D
)
h
ad
le
ss
g
ro
u
p
ex
p
er
ie
n
ce
th
an
th
e
o
th
er
s
an

d
re
co
rd
ed
an
in
cr
ea
se
in
d
ep
re
ss
io
n
an
d
an
x
ie
ty
d
es
p
it
e
an
d
ec

ea
se
in
st
re
ss
.
H
al
l
&
G
ab
o
r,
2
0
0
4
C
an
ad
a,
S
o
u
th
er
n

A
lb
er
ta
P
en
al
In
st
it
u
ti
o
n
,
1
9
9
6
–
1
9
9
9
.
P
ee
r-
fo
cu
se
d

su
ic
id
e
p
re
v
en
ti
o
n
tr
ai
n
in
g
w
h
ic
h
fo
cu
se
d
o
n
tr
ai
n
in
g
in
m
at
es

in
li
st
en
in
g
sk
il
ls
,
su
ic
id
e
p
re
v
en
ti
o
n
,
ri
sk
as
se
ss
m
en
t
sk
il
ls

,
ef
fe
ct
iv
e
an
d
ac
ti
v
e
li
st
en
in
g
,
an
d
n
o
n
-v
er
b
al
co
m
m
u
n
ic
at
io

n
sk
il
ls
.
C
h
an
g
es
in
su
ic
id
e
n
u
m
b
er
s
o
v
er
th
e
p
er
io
d

o
f
th
e
p
ro
g
ra
m
an
d
as
se
ss
m
en
ts
fr
o
m
in
m
at
es
an
d
st
af
f
o
n

p
ro
g
ra
m
ef
fe
ct
iv
en
es
s.
S
u
ic
id
e
n
u
m
b
er
s
lo
w
er
ed
fr
o
m
4
in

th
e
5
ye
ar
p
er
io
d
b
ef
o
re
im
p
le
m
en
ta
ti
o
n
to
2
d
u
ri
n
g
th
e

5
ye
ar
p
er
io
d
o
f
th
e
st
u
d
y.
B
o
th
su
ic
id
al
in
m
at
es
an
d
v
o
lu
n
te

er
s
fo
u
n
d
th
e
p
ro
g
ra
m
to
b
e
v
er
y
u
se
fu
l.
C
o
rr
ec
ti
o
n
al
o
ff

ic
er
s
w
er
e
le
ss
p
o
si
ti
v
e,
h
o
w
ev
er
,
p
ro
fe
ss
io
n
al
st
af
f
co
n
si
d

er
ed
th
e
p
ro
g
ra
m
to
b
e
(C
on
ti
n
u
ed
)
T
A
B
L
E
1
.
C
o

n
ti
n
u
e
d
A
u
th
o
r
C
o
u
n
tr
y
/
P
ri
s
o
n
a
n
d
p
e
ri
o
d

A
c
ti
v
it
y
/
In
te
rv
e
n
ti
o
n
E
v
a
lu
a
ti
o
n
m
e
a
s
u
re
M
a
in
fi

n
d
in
g
s
ac
ce
ss
ib
le
an
d
h
el
p
fu
l.
K
o
v
as
z
n
ay
,
M
ir
ag
li
a,
B
ee
r,

&
W
ay
,
2
0
0
4
N
ew
Y
o
rk
P
ri
so
n
s.
Im
p
ro
v
ed
su
ic
id
e
p
re
v

en
ti
o
n
p
ro
ce
ss
es
in
cl
u
d
in
g
an
im
p
ro
v
ed
p
ro
ce
ss
fo
r
th
e
re
v

ie
w
o
f
su
ic
id
es
,
u
p
d
at
ed
cl
in
ic
al
p
o
li
ci
es
an
d
p
ro
ce
d
u
re
s,

im
p
ro
v
ed
o
b
se
rv
at
io
n
ce
ll
s
an
d
st
af
f
tr
ai
n
in
g
.
G
ra
d
u
al
ch
an
g

es
in
su
ic
id
e
ra
te
s.
A
u
th
o
r
n
o
te
s
th
at
su
ic
id
e
ra
te
s
h
av
e
b
ee
n

g
ra
d
u
al
ly
d
ec
re
as
in
g
th
ro
u
g
h
o
u
t
th
e
st
at
e
si
n
ce
m
ea
su
re
s

w
er
e
im
p
le
m
en
te
d
.
R
at
es
re
ac
h
ed
a
lo
w
p
o
in
t
o
f
1
0
.2
p

er
1
0
0
,0
0
0
in
2
0
0
1
.
Ju
n
k
er
,
B
ee
le
r,
&
B
at
es
,
2
0
0
5

U
n
it
ed
st
at
es
,
F
ed
er
al
B
u
re
au
o
f
P
ri
so
n
s
M
ed
ic
al
R
ef

er
ra
l
ce
n
te
r
S
P
P
u
si
n
g
in
m
at
e
o
b
se
rv
er
s
to
m
o
n
it
o
r
in
m

at
es
at
-r
is
k
o
f
su
ic
id
e.
A
n
al
ys
is
o
f
th
e
n
u
m
b
er
o
f
su
ic
id
e

w
at
ch
es
an
d
th
e
m
ea
n
h
o
u
rs
sp
en
t
o
n
su
ic
id
e
w
at
ch
b
ef
o
re

an
d
af
te
r
p
ro
g
ra
m
im
p
le
m
en
ta
ti
o
n
.
N
o
n
-s
ig
n
if
ic
an
t
d
ec

re
as
e
in
th
e
n
u
m
b
er
o
f
w
at
ch
es
re
q
u
es
te
d
o
v
er
th
e
p
ro
g
ra
m

co
u
rs
e.
M
ea
n
ti
m
e
sp
en
t
o
n
su
ic
id
e
w
at
ch
w
as
si
g
n
if
ic
an
tl
y

d
ec
re
as
ed
.
S
h
aw
&
H
u
m
b
er
,
2
0
0
7
U
n
it
ed
K
in
g
d
o
m
,

p
ri
so
n
s
m
en
ta
l
h
ea
lt
h
se
rv
ic
es
.
R
ec
en
tl
y
im
p
le
m
en
te
d
su
ic

id
e
p
re
v
en
ti
o
n
st
ra
te
g
ie
s
in
cl
u
d
in
g
th
e
A
ss
es
sm
en
t,
C
ar
e
in

C
u
st
o
d
y
an
d
T
ea
m
w
o
rk
A
p
p
ro
ac
h
(A
C
C
T
).
T
h
is
m
ea
n
s
th
at

an
y
st
af
f
m
em
b
er
ca
n
re
fe
r
an
in
m
at
e
to
re
ce
iv
e
an
as
se
ss
m

en
t
an
d
p
la
n
o
f
ca
re
.
C
h
an
g
es
in
su
ic
id
e
ra
te
s.
S
ig
n
if
ic
an
t
re

d
u
ct
io
n
in
su
ic
id
e
ra
te
s
fr
o
m
1
2
7
p
er
1
0
0
,0
0
0
in
2
0
0

4
to
9
0
p
er
1
0
0
,0
0
0
in
2
0
0
6
.
A
.
H
ay
es
,
S
h
aw
,
L

ev
er
-G
re
en
,
P
ar
k
er
,
&
G
as
k
,
2
0
0
8
E
n
g
la
n
d
an
d
W
al
es

,
5
p
ri
so
n
si
te
s.
R
is
k
M
an
ag
em
en
t
S
k
il
ls
B
as
ed
T
ra
in
in
g
p

ro
g
ra
m
w
as
ad
ap
te
d
to
fi
t
th
e
p
ri
so
n
en
v
ir
o
n
m
en
t
an
d
w
as

p
ro
v
id
ed
to
p
ri
so
n
st
af
f.
T
h
e
p
ro
g
ra
m
in
v
o
lv
ed
4
m
o
d
u
le

s
d
el
iv
er
ed
th
ro
u
g
h
le
ct
u
re
s,
v
id
eo
s,
v
id
eo
-t
ap
ed
ro
le
p
la
ys

an
d
fe
ed
b
ac
k
o
n
th
e
ro
le
p
la
ys
.
S
ta
ff
co
m
p
le
te
d
q
u
es
ti
o
n
n

ai
re
s
b
ef
o
re
an
d
af
te
r
tr
ai
n
in
g
,
an
d
ag
ai
n
at
a
6
–
8
m
o
n
th

fo
ll
o
w
u
p
.
T
h
e
p
ro
g
ra
m
re
su
lt
ed
in
im
p
ro
v
ed
st
af
f
at
ti

tu
d
es
to
w
ar
d
s
su
ic
id
e
p
re
v
en
ti
o
n
,
an
d
in
cr
ea
se
d
k
n
o
w
le
d
g

e
an
d
co
n
fi
d
en
ce
fo
r
ri
sk
id
en
ti
fi
ca
ti
o
n
.
T
h
e
v
id
eo
ta
p
in
g

o
f
ro
le
p
la
ys
w
as
n
o
te
d
as
th
e
le
as
t
h
el
p
fu
l
p
ar
t
o
f
th
e
p
ro

g
ra
m
.
232 VOLUME 18 � NUMBER 3 � 2014
not replace staff observation, and that
closed-circuit television (CCTV) should not
replace personal observation and interac-
tion at least every 15 minutes (Felthous,
1994). According to Felthous (1994)
inmates should be disarmed from poten-
tially dangerous items depending on suicide
risk, and suicide prevention procedures
should be applied consistently, with clear
outlines as to the responsibilities of invol-
ved persons (Felthous, 1994). Finally,
inmates who were psychotically disturbed
were provided access to psychiatric hospi-
talization when possible. Although the
author notes the empirical testing of prison
SPP’S is difficult to achieve, the impact of
the application of these principles can be
seen by the reduction in suicide deaths
(Felthous, 1994). During the period from
1986 (when the program was implemented)
to 1994 (when the article was published) no
suicide deaths occurred in the jail, com-
pared to seven suicides between 1976 and
1986 before the program began. This vast
reduction is despite the jail population
having more than doubled since 1986
(Felthous, 1994).

Similar to the previous study, Hayes
(1995) reported on the effectiveness of
the SPP at the Elayn Hunt Correctional
Centre (EHCC) in Louisiana, US. The
prison acts as both an intake and assess-
ment point for male offenders committed
to the Louisiana Department of Public
Safety and Corrections, and as a permanent
housing facility for sentenced prisoners.
The SPP tested at EHCC addressed the
six main components of a successful pro-
gram as listed by Hayes (1995), including
staff training, intake screening=assessment,
appropriate housing of suicidal inmates,
appropriate levels of supervision according
to active suicide risk, intervention proce-
dures in the event of an attempt (staff first
aid and availability of an ambulance for
transportation to hospital), and adminis-
trative review following a suicide. Between
the period of 1983 and 1994, 57,091
inmates were processed through the EHCC
adult reception and diagnostic center
(ARDC), only one of whom completed sui-
cide (Hayes, 1995). This was coupled with a
significant reduction in suicide in prisons
all across the state after the introduction
of a departmental suicide review committee
in 1992, to aid in coordinating suicide pre-
vention practices across the state’s 11
prison facilities and to supplement internal
investigations. Since the introduction of
this committee, Louisiana’s suicide rates
dropped from a rate of 23.1 per 100,000

between 1984 and 1992 to 12.4 per
100,000 inmates during 1993 (Hayes, 1995).
A large metropolitan County Deten-
tion Centre (CDC) in the US experienced
nine suicides within 24 months, a much
higher rate than the national average
(Hayes, 1997). Reasons for this high rate
were attributed to lack of staff supervision,
inadequate response time by medical staff,
hazardous cell conditions, and inadequate
staff training (Hayes, 1997). Following
these nine suicides, a comprehensive sui-
cide prevention program was implemented
to resolve these shortcomings, including
improved staff training through the intro-
duction of 8 hour suicide prevention train-
ing sessions as well as 2 hours of refresher
training each year, identification=screening
of all inmates on intake and for all inmates
identified as being suicidal during their
incarceration, improved communication
between staff, the availability of suicide
resistant housing, and appropriate staff
intervention and use of first aid and cardio-
pulmonary resuscitation (CPR) when sui-
cide attempts occur (Hayes, 1997). In the
18 months following the nine inmate sui-
cides and the implementation of the new
suicide prevention program, no further
suicides were recorded (Hayes, 1997).
Also in the US, Freeman and Alaimo
(2001) provided an outline of an effective
SPP applied in the Cook County Depart-
ment of Corrections (CCDOC), the third

largest pre-trial detention system in the
country. This program included the mental
health screening of all new detainees
(utilizing structured questionnaires, clinical
observation, and previous staff member
experience to detect high risk individuals),
staff member training, inpatient care and
monitoring of suicidal inmates, emergency
procedures such as close observation and
the use of medical restraints for highly sui-
cidal inmates, and follow up treatment
once inmates were stabilized (Freeman &
Alaimo, 2001). The care of inmates per-
sisted after they were released back into
the general prison population; with a crisis
team available at all times (Freeman &
Alaimo, 2001). Finally, the SPP introduced
new training procedures for correctional
officers with regards to better identification
of the mental health needs of the prison
population. One unique factor of this pro-
gram was the community linkage of detai-
nees who were suicidal. This involved the
petition to the court to have inmates who
remained suicidal on release, committed
to a state hospital for further treatment.
Since 1990, after the implementation of
the SPP at CCDOC, suicide rates were
reduced to less than 2 per 100,000 admis-

sions at the prison (Freeman & Alaimo,
2001). This low rate is impressive consider-
ing departments which hold pre-trial
inmates have been shown to generally have
higher incidences of suicide than those
which detain inmates on longer sentences
(Blaauw, Kerkhof, & Hayes, 2005). How-
ever, authors did not provide a baseline
rate for CCDOC, though it was noted that
suicide rates across New York State
showed an average of 42.2 suicides per
100,000 admissions between 1988 and
1997 (Freeman & Alaimo, 2001).
Two of the studies involved multi-
factored SPP’s implemented in prisons
across New York. The first, by Cox &
Morschauser (1997), focused on a multi-
factored SPP addressing increasing prison
suicide rates in New York Prisons between
1983 and 1984. The program was named
the ‘‘Local Forensic Suicide Prevention
Crisis Service Program’’ and was imple-
mented in 57 counties, with revisions made
in 1993 to keep the program up to date
(Cox & Morschauser, 1997). This program
included many components seen in previ-
ously mentioned programs such as inmate
screening, supervision of high risk inmates,
and staff training. In addition, it included
details of the review process after a suicide
occurs to prevent future incidents, and
staff debriefing to provide support for
staff involved in the incident (Cox &
Morshauser, 1997). Cox and Morschauser

(1997) report that the program had great
success across the state, with a decrease
in suicide numbers from 26 in 1984 to 9
in 1996, despite a doubling in the jail popu-
lation. Strengthened relationships between
prisons and mental health agencies were
also reported by 78% of respondents
(Cox & Morshauser, 1997).
The second, more recent, study from
New York focused on a program imple-
mented by NYS Department of Correc-
tional Services (DOCS), Bureau of
Forensic Services (BFS), and the Central
New York Psychiatric Centre (CNYPC).
Similar to other studies, measures included
an improved process for the review of
suicides, with each completed suicide
undergoing a psychological autopsy and a
special investigation, and quality assurance
reviews for both completed suicides and
serious non-fatal attempts (Kovasznay,
Miraglia, Beer et al., 2004). Clinical Policies
and procedures were improved through
changes to the inmate service level classi-
fication process, the admittance of inmates
into the observation unit, methods to
engage reluctant inmates with appropriate
treatment, and modification of observation
cells for enhanced safety (Kovasznay,
Miraglia, Beer et al., 2004). Despite fluctua-
tions, suicide showed an overall declining
trend (dropping from 15.8 per 100,000 in
1993 and 24.4 per 100,000 in 1994 to
10.2 per 100,000 in 2001, 19.4 per

234 VOLUME 18 � NUMBER 3 � 2014
100,000 in 2002). Kovasznay, Miraglia,
Beer et al. (2004) suggest that it is related
to these measures implemented as well as
quality assurance reviews, an increase in
mental health staff in prisons, and the col-
laboration between DOCS and mental
health agencies.
Peer Focused Prevention Activities
The potential for using other inmates
as suicide prevention has come to attention
due to suggestions that inmates are more
able to relate to the experiences of their
peers, therefore being more likely than staff
to gain the trust of other inmates (Laishes,
1997). The SAMS in the Pen, peer SPP was
implemented in a medium security facility
in Southern Alberta, Canada. The program
was created by collaboration between the
prison and the Samaritans of Southern
Alberta (SAMS; an inmate suicide preven-
tion group). Training was provided to
selected inmates covering topics such as
the concept of befriending, effective and
active listening, nonverbal communica-
tions, the nature of mental illness, suicide
prevention and intervention, and policies
and procedures of SAMS (Hall & Gabor,
2004). After participation in the program,

the general inmate population, as well as
SAMS volunteers, perceived the program
to be quite helpful, however correctional
staff were not as certain about the effec-
tiveness (Hall & Gabor, 2004). Professional
staff (parole officers, mental health work-
ers, chaplains) were more impressed than
correctional officers about the accessibility
of the program and its helpfulness (Hall
& Gabor, 2004). The program appeared
to have potential for suicide prevention,
with suicide deaths lowering from four
suicides in the 5-year period before
implementation, to two completed suicides
during the 5-year period of the program
(1995–2000). Unfortunately, due to low
absolute numbers it was not possible to
demonstrate effectiveness statistically.
However, Hall and Gabor (2004)
concluded that the comments from parti-
cipants and the low suicide rate over the
duration of the program indicated the pro-
grams potential for suicide prevention.
The Inmate Observer Program (IOP)
implemented at a Federal Bureau of
Prisons Medical Referral center, specifically
aimed to prevent the negative effects of
isolation through the use of inmate obser-
vers in the correctional setting (Junker,
Beeler, & Bates, 2005). During the 24-week
study period, 82 suicide watches were
initiated for 37 individuals who were placed
on suicide watch in an inpatient restricted
housing unit. These inmates were obser-

ved through direct observation by trained
inmate observers as well as staff obser-
vation through CCTV and rounds by staff
(Junker, Beeler, & Bates, 2005). The num-
bers of suicide watches in the 12-week per-
iod prior to the program were compared to
the 12 weeks following, with watches being
reduced from 48 to 33 (31.25% reduction),
however this reduction was not significant
(p ¼ 0.096) (Junker, Beeler, & Bates,
2005). Nevertheless, one group of inmates,
those with personality disorders had signifi-
cantly fewer watches than before program
implementation (p ¼ 0.033). The mean
hours on suicide watch was then analyzed
before and after initiation of the program.
Before implementation, inmates spent an
average of 108.88 hours on suicide watch,
which was reduced significantly to 64.5
hours after implementation (p ¼ 0.036)
(Junker, Beeler, & Bates, 2005).
Other Studies
In 1975, law reforms in Austria
imposing fewer long term sentences, more
suspended sentences, more frequent release
on parole, and special requirements for the
management of mentally ill offenders
(those not guilty by reason of insanity,

highly dangerous and mentally ill offenders,
and alcohol and drug addicted offenders)
were expected to lower prison suicide rates
(Fruehwald, Frottier, Eher et al., 2000). The
reform also saw an increase in staff, impro-
ved staff training, and better facilities to
treat mentally ill inmates. Fruehwald, Frot-
tier, Eher et al. (2000) analyzed the statisti-
cal reports from the Ministry of Justice
between 1947 and 1996 to get an overview
of annual suicide rates over this time per-
iod. It was found that despite the measures
implemented to reduce suicide and a lower-
ing of the prison population, the rates of
suicide increased significantly since 1947
(6 suicides or 48.6 per 100,000 in 1947, to
20 suicides or 294.4 per 100,000 in 1996).
Authors stated that this increase may be
partly attributed to the fact that the reform
saw only highly dangerous or violent offen-
ders incarcerated; a population which has
been shown to have increased suicide risk.
Furthermore, despite the reduced prison
numbers, the housing arrangement of pris-
oners remained much the same, which may
have still given inmates the impression of
unpleasant overcrowded conditions
(Fruehwald, Frottier, Eher et al., 2000).
Eccleston and Sorbello (2002) pre-
sented an Australian program adapted from
Dialectical Behavior Therapy (DBT), which
was piloted in Victoria, called RUSH (Real
Understanding of Self-Help). The program
aimed to teach offenders with Borderline

Personality Disorder (BPD) more adaptive
coping skills, to reduce suicide and self-
harming behavior, and reduce recidivism
by addressing underlying criminogenic
needs (Eccleston & Sorbello, 2002). Five
groups participated in the program, with
group A comprising inmates who were
highly vulnerable to suicide, group B com-
prising violent offenders, group C, vulner-
able and first time offenders under the
age of 25, and groups D and E, protection
offenders. Quantitative evaluations were
conducted before and after participation
in the program using the depression,
anxiety, and stress scale (DASS) (Lovibond
& Lovibond, 1995). It was found that the
majority of participants experienced a
decline in Borderline Personality Disorder
symptoms during the program, particularly
groups B, C, and E (Eccleston & Sorbello,
2002). Interestingly, groups A and D
showed a reduction in stress, but an
increase in depression and anxiety. The
author noted that this may be attributed
to the fact that these participants had less
group experience than the other groups,
and therefore had more difficulty identify-
ing feelings of depression and anxiety on
entering the program. This prediction was
supported by participant feedback, with
those inmates who had little group experi-
ence admitting that they had denied symp-
tomology when completing the initial
questionnaire (Eccleston & Sorbello, 2002).
Qualitative analysis of facilitator therapy

notes showed that most participants had
high levels of motivation and commitment,
actively demonstrated the RUSH skills,
established group cohesion quickly and
regularly confirmed the programs useful-
ness during the program and in formal
feedback administered during the last
session (Eccleston & Sorbello, 2002). Cor-
rectional officers perceived the program to
be useful; indicating anecdotally that the
self-harming and dysfunctional behavior
had declined in participants.
To address criticism of staff suicide
prevention training in England and Wales,
a well-known suicide prevention training
package called Skills-Based Training on
Risk Management (STORM) was adapted
to fit the prison setting (Hayes, Shaw,
Lever-Green et al., 2008). The program
was evaluated at two adult male establish-
ments and one juvenile offender establish-
ment, through measurement of staff
attitudes to the training (using the adapted
Attitude to Suicide Prevention Scale). Fur-
thermore, a measure of knowledge about
suicide was developed for the study, and
a measure of self-efficacy was used to
236 VOLUME 18 � NUMBER 3 � 2014
evaluate staff confidence in their abilities

and satisfaction with the training. Results
of surveys completed before and after the
training showed a significant improvement
in scores for attitudes, knowledge, and con-
fidence (Hayes, Shaw, Lever-Green et al.,
2008). The majority of staff were satisfied
with the program with 78% enjoying the
course, 95% saying they would recommend
it to colleagues and 94% finding the skills
and techniques learned to be relevant to
the prison setting. The videotaping of role
plays was perceived to be the least helpful
part of the training, with only 42% of
participants reporting satisfaction with this
activity. Follow up surveys issued 6–8
months after program completion had
poor response rates (38%) making inter-
group comparisons difficult (Hayes, Lever-
Green et al., 2008).
Another paper from the United
Kingdom by Shaw and Humber (2007),
specifically focused on improvements to
prison mental health services in the UK.
The article presented the introduction of
suicide prevention procedures, namely the
Assessment, Care in Custody and Team-
work (ACCT) process, in which any staff
member can seek mental health services
for an inmate who appears to be at risk
of suicide. After being identified, these
individuals will be monitored, assessed,
and provided with a plan of care, all of
which will be supervised by a case manager
(Shaw & Humber, 2007). After the
implementation of these procedures there

was a decline in the prison suicide rate
from 127 per 100,000 in 2004 to 90 per
100,000 in 2006. Shaw and Humber
(2007) noted that this cannot yet be con-
sidered a definite trend as prison suicide
rates may fluctuate.
DISCUSSION
Prison SPP’s are difficult to empirically
asses, and as the study by Fruehwald,
Frottier, Eher et al. (2000) indicated, the
success of SPPs may rest partly on the
characteristics of the individual prisons
being analyzed. Despite this, the current
literature shows that multi-factored suicide
prevention programs focusing specifically
on reducing unique risk factors for suicide
in prison have the potential to lower the
incidence of suicide. Programs are most
likely to succeed when implemented as
prisoners arrive and are maintained until
inmates leave the facility. Effective multi-
factored programs may include screening
and assessment of inmates on intake,
improved staff training, post intake obser-
vation for suicide risk, monitoring and
psychological treatment of suicidal inmates,
limited use of isolation and increased social
support, and adequate and safe housing
facilities for at-risk individuals (Cox &
Morschauser, 1997; Felthous, 1994;
Freeman & Alaimo, 2001; Hayes, 1995;
1997; Kovasznay, Miraglia, Beer et al.,
2004). Procedures implemented after a

suicide or serious suicide attempt, such as
internal and external review processes
and staff debriefing and support can also
aid in preventing further incidents and
lower the burden of these events on staff
(Cox & Morshauser, 1997). Successful
SPPs in the prison environment do not
appear to be limited to multi-factored
programs. While still in the early stages of
development, programs aimed at pro-
viding support and observation of suicidal
prisoners through the use of trained
inmates may help to prevent suicides
and limit the negative effects of isolation
(Hall & Gabor, 2004; Junker, Beeler, &
Bates, 2005). However, despite positive
results, these inmate observers must be
carefully selected and trained, and inmate
observation must be coupled with frequent
observation by trained staff members
(Junker, Beeler, & Bates, 2005). If inmates
are not carefully selected there exists the
risk of volunteers misusing the program
to facilitate social visits, illegal activities or
transferring information (Hall & Gabor,
2004).
All except one of the programs evalu-
ated (Fruehwald, Frottier, Eher et al., 2000),

achieved positive outcomes. Three of the
studies reported decreases in suicide rates
(Freeman & Alaimo, 2001; Kovasznay,
Miraglia, Beer et al., 2004; Shaw &
Humber, 2007), while four studies obser-
ved changes in suicide numbers (Cox &
Morschauser, 1997; Felthous, 1994; Hayes,
1997; Hall & Gabor, 2005). One study
found both changes in numbers at the
particular prison where the program was
implemented as well as changes in rates
state-wide after the introduction of a
committee to co-ordinate the states suicide
prevention practices (Hayes, 1995). The
study which evaluated staff attitudes to an
improved training program retrieved posi-
tive results (Hayes, Shaw, Lever-Green
et al., 2008), as did the study analyzing
the mean number of hours prisoners spent
on suicide watch before and after imple-
mentation of a peer observer SPP (Junker,
Beeler, & Bates, 2005). Eccleston and
Sorbello (2002) found that the SPP targeted
specifically at individuals with BPD gener-
ally achieved a decline in BPD symptoms
during participation in the program. The
study by Fruehwald, Frottier, Eher et al.
(2000) found that suicide rates continued
to rise after the implementation of new
policies and procedures regarding suicide
prevention. However, this was the only
study that analyzed a longer period (50
years) across a whole country (Fruehwald,
Frottier, Eher et al., 2000). Furthermore,
the author partly attributed the rise to the
fact that the change in legislation resulted

in mainly highly violent offenders, who
are known to have a higher risk of suicide,
being housed in the prison (Fruehwald,
Frottier, Eher et al., 2000). The main find-
ing of the current literature review was that
there may be potential to reduce the occur-
rence of prison suicides, however this
appears to depend on programs addressing
all four major categories of risk specific to
prison suicides including demographic,
clinical, psychosocial and institutional
factors, through the use of comprehensive
multi-factored prevention programs. Fur-
thermore, the review indicates that the
progression of suicide prevention practices
around the world varies greatly from one
country to the next, with innovative SPP’s
such as the use of trained inmate observers
achieving positive results when carefully
implemented.
Limitations
The studies presented in this literature
review have several limitations which
should be noted. Due to the nature of
prison suicides, and the inability to use
controls to empirically test programs by
withholding treatment from some indivi-
duals (Felthous, 1994), most studies in this
review had to rely solely on changes in sui-
cide numbers or rates (Cox & Morschauser,
1997; Felthous, 1994; Freeman & Alaimo,
2001; Hayes, 1997, 1995) or perceived
changes in attitudes from staff and inmates

(Hayes, Shaw, Lever-Green et al., 2008). It
is noted that prison suicide numbers are
always fluctuating, meaning that small
changes may be difficult to attribute to
the implementation of a SPP (Shaw &
Humber, 2007). Other limitations include
small sample or group sizes due to partici-
pant attrition in follow-ups (Hayes, Shaw,
Lever-Green et al., 2008) or during the
course of the program (Eccleston &
Sorbello, 2002), problems with program
implementation due to the prison environ-
ment, prisoner behavior and attitudes, and
the complexity of some parts of the pro-
gram (Eccleston & Sorbello, 2002) and
poor generalizability of results from the
prison mental health setting to other prison
environments (Junker, Beeler, & Bates,
2005).
The current systematic literature
review was not without limitations itself.
238 VOLUME 18 � NUMBER 3 � 2014
Firstly, the review was limited to articles
published in English, which may have
resulted in the exclusion of some studies.
In fact, the majority of the studies included,
and all multi-factored SPPs were from the
US, and all of the studies came from
Westernized nations. Furthermore, there

may be unpublished reports that were not
found through our searches. Some studies
which were included in the systematic
review were not able to evaluate their
programs through changes in suicide rates
or numbers, meaning they depended on
personal perceptions which might be
less reliable. Finally, there is a possibility
of publication bias and studies which
retrieved undesirable results have not been
published.
CONCLUSIONS
Prison suicide is a major problem world-
wide, with prisons constantly showing
higher suicide rates than the general
population (McArthur, Camilleri, & Webb,
1999). This indicates the need for effective
suicide prevention programs in the prison
environment. Findings of the review dem-
onstrate that well known therapies or
programs such as DBT and the STORM
training package may be successfully
adapted for use in the prison setting,
indicating the potential to similarly adapt
other existing therapies or programs. Those
suicide prevention programs utilizing vari-
ous methods such as initial screening, staff
training, increased observation and moni-
toring, safer physical environments, mental
health services including external hospitali-
zation, reduced use of isolation, and post
suicide debriefing and staff support have
been found to be the most effective at
reducing suicidal behaviors in prisons.

Despite the effectiveness of multi-factored
programs it is important in the future to
continue considering the unique charac-
teristics of the prison environment by
including innovative methods such as the
use of trained inmates as observers to
reduce the problem of understaffing in
prisons.
The review highlights the lack of
current research and the need for future
studies analyzing the effectiveness of sui-
cide prevention practices in prisons. The
known general fluctuation of prison suicide
rates and the fact that the article analyzing
suicide prevention measures over the long
term was the only one to return negative
results, indicates the importance of studies
covering longer periods of time to lend
strength to current positive findings.
AUTHOR NOTE
Emma Barker, Kairi Kõlves, and Diego
De Leo, Australian Institute for Suicide
Research and Prevention; National Centre
of Excellence in Suicide Prevention; and
World Health Organization Collaborating
Centre for Research and Training in
Suicide Prevention, Griffith University,
Queensland, Australia.
Correspondence concerning this article
should be addressed to Diego De Leo,
AISRAP, Griffith University, Mt. Gravatt

Campus, Mt. Gravatt, QLD 4122, Australia.
E-mail: [email protected]
FUNDING
This review was supported by the Queens-
land Corrective Services.
REFERENCES
Blaauw, E., Kerkhof, A. J., & Hayes, L. M. (2005).
Demographic, criminal, and psychiatric factors
related to inmate suicide. Suicide and Life Threatening
Behavior, 35, 63–75.
Cox, J. F., & Morschauser, P. C. (1997). A solution
to the problem of jail suicide. Crisis, 18, 178–184.
Daniel, A. (2006). Preventing suicide in prison: A
collaborative responsibility of administrative,
custodial and clinical staff. Journal of the American
Academy of Psychiatry and the Law, 34, 165–175.
Daniel, A., & Fleming, J. (2006). Suicides in a state

correctional system, 1992–2002: A review. Journal
of Correctional Health Care, 12, 24–35.
Dooley, E. (1990). Prison suicide in England and
Wales, 1972–87. British Journal of Psychiatry, 156,
40–45.
Eccleston, L., & Sorbello, L. (2002). The RUSH pro-
gram—Real understandings of self-help: A suicide
and self-harm prevention initiative within a prison
setting. Australian Psychologist, 37, 237–244.
Fazel, S., Cartwright, J., Norman-Nott, A., &
Hawton, K. (2008). Suicide in prisoners: A sys-
tematic review of risk factors. Journal of Clinical
Psychiatry, 69, 1721.
Felthous, A. R. (1994). Preventing jailhouse suicides.
Bulletin of the American Academy of Psychiatry and the
Law, 22, 477–488.
Freeman, A., & Alaimo, C. (2001). Prevention of
suicide in a large urban jail. Psychiatric Annals, 31,

447–452.
Fruehwald, S., Frottier, P., Eher, R., Ritter, K., &
Aigner, M. (2000). Fifty years of prison suicide
in Austria: Does legislation have an impact? Suicide
and Life-Threatening Behavior, 30, 272–281.
Hall, B., & Gabor, P. (2004). Peer suicide prevention
in a prison. Crisis, 25, 19–26.
Hayes, A. J., Shaw, J. J., Lever-Green, G., Parker, D.,
& Gask, L. (2008). Improvements to suicide pre-
vention training for prison staff in England and
Wales. Suicide and Life Threatening Behavior, 38,
708–713.
Hayes, L. M. (1994). Prison suicide: An overview
and a guide to prevention (Part 1). Crisis, 15,
155–158.
Hayes, L. M. (1995). Prison suicide: An overview and
a guide to prevention (Part 2). The Prison Journal,
75, 431–456.

Hayes, L. M. (1997). From chaos to calm: One jail
system’s struggle with suicide prevention. Beha-
vioral Sciences and the Law, 15, 399–413.
Hayes, L. M., & Blaauw, E. (1997). Prison suicide: A
special issue (Editorial). Crisis, 18, 146–147.
Junker, G., Beeler, A., & Bates, J. (2005). Using
trained inmate observers for suicide watch in a
federal correctional setting: A win-win solution.
Psychological Services, 2, 20–27.
Kovasznay, B., Miraglia, R., Beer, R., & Way, B.
(2004). Reducing suicides in New York state cor-
rectional facilities. Psychiatric Quarterly, 75, 61–70.
Laishes, J. (1997). Inmate suicides in the correctional
service of Canada. Crisis, 18, 157–162.
Lovibond, S. H., & Lovibond, P. F. (1995). Manual
for the Depression Anxiety Stress Scales (2nd ed.).
Sydney: Psychology Foundation.
McArthur, M., Camilleri, P., & Webb, H. (1999).

Strategies for managing suicide & self-harm in prisons.
Report for the Australian Institute of Criminology:
Trends & Issues in crime and criminal justice
(no. 125).
Shaw, J., & Humber, N. (2007). Prison mental health
services. Psychiatry, 6, 465–469.
Winkler, G. E. (1992). Assessing and responding
to suicidal jail inmates. Community Mental Health
Journal, 28, 317–326.
World Health Organization (1999). Preventing suicide in
jails and prisons. Geneva, Switzerland: Author.
240 VOLUME 18 � NUMBER 3 � 2014
Copyright of Archives of Suicide Research is the property of
Taylor & Francis Ltd and its
content may not be copied or emailed to multiple sites or posted
to a listserv without the
copyright holder's express written permission. However, users
may print, download, or email
articles for individual use.

1355076 - SAGE Publications, Inc. (US) ©clearly that such

Recommended

Recommended

More Related Content

More from AnastaciaShadelb

More from AnastaciaShadelb (20)

1355076 - SAGE Publications, Inc. (US) ©clearly that such