16 décembre 2003JOHN HOWARD SOCIETY OF ALBERTA
1999
EXECUTIVE SUMMARY
Suicide in correctional facilities is more prevalent than in the general population, and constitutes the leading cause of death for those in custody. There are several factors that have been found to be correlates of prison suicides, including the security of the facility, the crime committed that caused the inmate’s incarceration, and the phase of imprisonment the inmate is in.
Due to the fact that many of the inmates who commit suicide have feelings of depression and hopelessness, have been diagnosed with a mental disorder, or have expressed suicidal thoughts or behaviours in the past, efforts at adequate intervention and treatment need to be improved.
Researchers have devised theoretical profiles of "typical" inmate suicidal behaviour, but a profile alone is unable to provide corrections staff with a reliable method of distinguishing between suicidal and non-suicidal inmates. The communication and reporting of information needs to be improved, to allow for a more accurate picture of the effects of personal characteristics and of the institution on suicidal behaviours.
Risk factors exist that enhance suicidal intentions, and these factors are related to the circumstances of imprisonment or to the personal history of the inmate. Some examples of these factors include one’s view of incarceration, the effects of incarceration, the conditions in the correctional facility, one’s history, current family or life situation, the circumstances surrounding one’s incarceration, or one’s race.
Primary prevention efforts and secondary prevention efforts are both ways that correctional facilities have tried to reduce the rate of suicide. Correctional Service of Canada has also created a plan to combat suicides, entitled "The National Strategy for the Prevention of Suicide and Reduction of Self- Injury." Even though efforts are made to reduce the suicide rate in prisons, the task of suicide prevention remains a low priority for correctional institutions.
Correctional settings also try to come up with intervention programs. The key to intervention programs lies in the accurate communication of relevant information regarding the past or recent behaviour of suicidal inmates. The individual facts of each case suggests which method of intervention is most appropriate for the individual inmate.
Suicide treatment programs have been ineffective because they are based on the view that suicide is strictly a problem for doctors and medication to solve, but it is being recognized that greater significance needs to be given to the environment, and to the importance of providing activities to relieve stress. The issue of suicide must be recognized as a joint responsibility between staff, medical and psychiatric personnel, family and friends, and other inmates. Few jails and prisons have so far succeeded in consistently and effectively detecting and intervening in incidents of inmate suicidal behaviour.
While there is more that can be done, the fact is that prison and jail are brutally harsh environments that some simply are not able to cope with. After we have done all the prevention and intervention possible with the environmental constraints, will we then step back and look at prison itself ? Perhaps the solution to inmate suicide lies in more discriminate and appropriate use of incarceration, keeping less serious offenders in the community and making better use of mental health facilities for inmates with mental health concerns.
INTRODUCTION
Inmates in the custody of federal and provincial corrections facilities are considered a high suicide risk group. Many factors have been noted as to why the suicide rate in prisons is higher than the rate in the general population. These range from factors surrounding incarceration to personal attributes. Since prisons have such a significant suicide rate, attempts have been made to reduce the incidence of suicide. Prevention, intervention and treatment techniques have been used to reduce inmate suicide.
STATISTICAL OVERVIEW
Inmates are considered a high suicide risk group. In 1996-97, the adult inmate suicide rate was more than twice the suicide rate of the adult Canadian population (4.0 per 10,000 and 1.7 per 10,000 respectively) (Canadian Centre for Justice Statistics, 1998, p. 8), but has been noted as being up to 10 times as high as the national average (Canadian Press Newswire, 1996).
The suicide rate in federal facilities has not shown any really dramatic changes over recent years. From 1990-96, an average of 15 federal prisoners per year committed suicide (Canadian Press Newswire, 1996). In 1989-90, the number of suicides totalled 13 (Canadian Centre for Justice Statistics, 1990, p.141), and for 1993-94, the number of suicides in federal facilities climbed to 24, and accounted for 49% of deaths in federal prisons (Correctional Services Canada, 1994, p. 6). This rate has fallen in recent years. In 1995-96, the number of suicides was only 17, and in 1996-97, it dropped even further to 10 which accounted for 21% of federal inmate deaths (CCJS, 1998, p. 8). The numbers are slightly higher for provincial correctional facilities. Provincial inmate suicides totalled 21 in 1989-90 (CCJS, 1990, p. 141) and in 1993-94, suicides totalled 23 and accounted for 46% of deaths (Correctional Services Canada, 1994. p. 6). In 1996-97, the suicide number climbed to 27, and constituted 61% of inmate deaths. Suicide constitutes the leading cause of death for those in custody.
Several observations have been made concerning suicide among individuals in custody :
both maximum and medium security institutions have higher rates of suicide than minimum security institutions, and remand centres show the highest rates(Staff member, personal communication, Correctional Service of Canada, February 2, 1999) ;
the majority of those who commit suicide are men : for 1991-97, 92 males committed suicide while only one female committed suicide (Correctional Services Canada, 1998) ;
age does not correlate with suicide rate ;
a higher rate of suicide is evident in inmates convicted of crimes against another person than inmates convicted of property crimes ;
a higher rate of suicide is associated with both low and high levels of education, but no significant relationship is found between suicide and I.Q. ;
suicide does not correlate with sentence length ;
those in the initial phase of imprisonment show the highest rate of suicide ; and
hanging is consistently the most common method employed, followed by slashing and overdose (Task Force on Suicide in Canada, 1994 ; Conacher, 1993 ; National Task Force, 1987).
SUICIDAL BEHAVIOUR AND RISK FACTORS
Behaviour
Given what is supposed to be a lack of privacy and an inaccessibility of methods of committing suicide within the penitentiary environment, the persistence and comparatively high rate of suicide in jails and prisons has prompted increased efforts to develop a means of early identification of inmate suicidal behaviour. A previous psychiatric history (attempted suicide, depression, psychiatric treatment) can be a key factor in the cause of inmate suicide. In 1993-94, 7 of the 24 federal inmates who committed suicide were known to be depressed, 14 of the 24 were thought to have experienced hopelessness, 7 of the 24 were diagnosed as either psychotic or schizophrenic, 6 of the 24 had been diagnosed as suicidal currently or in the past, and half experienced suicidal thoughts or suicide attempts in the past (Laishes, 1994, p. 13-14). These numbers may vary slightly from year to year, but these elements are always present to some degree or another. These figures show that there is often inadequate intervention and treatment of inmate suicidal behaviour. Attempts at suicide and the expression of suicidal thoughts and intentions are the most common ways to identify potential suicides (Conacher, 1996, p. 74), and should thus be considered more seriously and with more care.
While researchers have devised theoretical profiles of "typical" inmate suicidal behaviour, the practical application of these profiles by corrections staff has revealed limitations. Corrections staff are unable to be provided with enough detailed information about the inmate and the particular characteristics of the prison environment to allow a consistent, pro-active prediction of suicidal behaviour. A profile alone, however accurate, will not provide corrections staff with a reliable method of distinguishing between suicidal and non-suicidal inmates. There must also be standardized reporting and communication of information about the inmate’s history and proper training of corrections staff in the detection and intervention of suicidal behaviour. In order to accurately detect whether or not an inmate is suicidal, factors must be considered that range from the inmate’s personal and social background to the effects of the institutional experience itself.
Risk Factors
Many factors have been identified that influence an inmate’s motivation to commit suicide, and these factors are related either to the circumstances of imprisonment or to the personal history of the inmate. Factors relating to circumstances of imprisonment include :
the view of incarceration as a punishment and disgrace ;
denial of membership in decent, law-abiding society ;
loss of control over life ;
loss of privacy ;
loss of family and friends ;
concern over a transfer, appeal, or parole decision ;
the closed social system of the prison (for example, the "cons" versus the authorities) ; and
an atmosphere of violence, fear and distrust (Correctional Services Canada, 1994 ; National Task Force, 1987).
The characteristics frequently evident in the personal histories of the inmates included :
deprived family background typified by abuse and/or criminality ;
history of violence ;
distress about a financial problem ;
a history of psychiatric treatment, hospitalization or outpatient ;
current physical or mental health problems ; and
drug and/or alcohol abuse (Correctional Services Canada, 1994 ; Conacher, 1993 ; National Task Force, 1987).
There are further factors which researchers have found which can contribute to the suicidal behaviour of inmates. Inmates are more likely to commit suicide in the relatively early stages of custody, mostly in the first three months, and approximately half of all suicides in prison occur during the first 6 months of the sentence (Task Force on Suicide in Canada, 1994, p. 27). Alcohol and drug use plays a role in suicide. In 1993-94, alcohol and/or drugs were "confirmed or suspected" of being involved in half of inmate suicide cases (Laishes, 1994, p. 14). Also, the vast majority of inmates who commit suicide have a history of drug or alcohol abuse. One study found that as many as two-thirds of individuals have a history of alcohol abuse, and 54% a history of drug abuse (Task Force on Suicide in Canada, 1994, p. 27).
Being placed in isolation or dissociation units has also been shown to increase the risk of suicide. Isolation can increase the likelihood of suicide by altering an inmate’s mental state. Inmates are unable to communicate and release their suicidal feelings to others, and this intensifies their feelings.
The crime for which the inmate has been incarcerated is also seen as a risk factor. Inmates whose crimes were crimes against the person are at a higher risk of committing suicide than those whose crimes were property crimes. Crimes such as violent and sexual crimes produce the highest rates of suicide. This is especially true if the person feels guilt over hurting or injuring the victim (Conacher, 1996, p. 75).
First Nations peoples have proven to have a higher inmate suicide rate than the non-Aboriginal inmate population. Aboriginal people in the general population are 2 to 3 times more likely than non-Aboriginal people in the general population to commit suicide, and in prison, this number is even higher (Choosing Life, 1994, p. 1). For example, female Aboriginal inmates aged 20-29 are 3.6 times more likely than Canadian females in general to commit suicide (Grossmann, 1992, p. 409). A major factor contributing to the high inmate suicide rate among Aboriginals in Canada is the over- representation of Aboriginal people in correctional facilities. Although Aboriginal people represent 3% of the population in Canada, they make up 16% of total provincial/territorial admissions, and 15% of federal admissions (CCJS, 1998, p. 7). The location of correctional facilities are also thought to have an impact on Aboriginal inmates. These facilities are located far away from family and friends, thus causing a sense of loss in many inmates. This sense of loss contributes to many Aboriginal inmates committing suicide. Recently though, facilities have been built for Aboriginal inmates. These new facilities are in closer proximity to reserves, and thus in closer proximity to family and friends. The suicide rates at these new facilities should be examined over the next few years to see if they lower the suicide rate of Aboriginal inmates.
Many of these factors can provide a motivation and play a role in whether or not a person commits suicide. These factors should not be ignored when trying to create programs and methods to reduce the rate of suicide in correctional institutions.
PREVENTION, INTERVENTION AND TREATMENT
Prevention
There are two types of suicide prevention efforts which can be undertaken by correctional facilities. These are primary prevention efforts and secondary prevention efforts (Conacher, 1993). Primary prevention techniques are those efforts that reduce overall suicide rates, such as changes in the environment or courses for staff, educating them about suicidal behaviour. Primary prevention requires advance planning, policy changes and higher staffing levels. Secondary prevention efforts are aimed at individuals who have already been identified at risk, whether through attempts, or through feelings expressed (Roger & Lariviere, 1998). These efforts might include "special facilities to house suicidal inmates and allow special observation,...measures to recruit family and friends to help authorities identify those who may be suicidal, and the use of ?inmate observation aides’”(Conacher, 1993, p. 26).
Correctional Services Canada has formulated a plan entitled “The National Strategy for the Prevention of Suicide and Reduction of Self-Injury.” This plan was formulated to combat suicides within correctional facilities. The key points of this plan focus on staff training, early identification of potential suicides, information sharing, and quick intervention and support for people affected by an inmate’s suicide (Correctional Services Canada, 1994, p. 6). Although the Correctional Service of Canada has made attempts at reducing inmate suicide, the task of suicide prevention has remained a much lower priority for prison officials than the tasks of control and containment.
Intervention
It has often been documented that the majority of suicide attempts in Canadian correctional institutions do not culminate in death, but the rate for attempted suicides versus successful suicides is not known. This is because of the differences in reporting practices across institutions. Many institutions report such acts as body mutilation as a suicide attempt whereas, in actuality, it may not have been an attempted suicide. It is therefore unknown whether official intervention is adequate.
Correctional settings generally provide custodial rather than therapeutic care for suicidal inmates. Breakdowns in communication whereby custodial staff were unaware that an inmate had been designated a suicide risk by therapeutic staff, delays in transfers to clinical facilities, understaffed and inadequate psychiatric facilities and insufficient surveillance of high risk suicidal inmates have consistently hampered efforts at effective inmate suicide intervention.
Communication of information regarding the past or recent behaviour of suicidal inmates needs to be encouraged within institutions and between jurisdictions and institutions. The reporting of information about suicidal inmates has been found to include numerous deficiencies, such as reporting periods, definitions, categories of incident, time-frames, causes of the incident, sex, age, race, employment history of the victim, methods and weapons involved, length of incarceration, form of imprisonment and type and severity of injury. While most local corrections facilities have developed reporting formats, many lack the detail needed for efficiently communicating information about suicide incidents, and so have been open to misinterpretation. A standard data collection form, universally enforced, would promote standardized reporting. A central collating agency, such as the Canadian Centre for Justice Statistics, would also be necessary so data could be standardized and the analysis and feedback of study results made more readily accessible. However, because the collation of data on inmate suicidal behaviour would not in itself contribute to the prevention of suicide, a thorough and continuing study of the data collected needs to be encouraged and the results shared among jurisdictions. The communication of information is not only relevant to intervention issues, but is also important in relation to the treatment of suicidal inmates.
All suicide risks must be treated seriously, and treated on an individual basis. An interdisciplinary approach needs to be developed so that inmate suicide will not be viewed as strictly a security matter or as entirely a medical problem. Suicide intervention requires a decision to either isolate the individual with supervision, or to place the inmate in fuller association with others. The individual facts of each case would be what suggests to staff members which method would be appropriate. Self- help and peer group assistance, inmate watch and supervision by staff are further practical measures to intervene in a suicidal crisis in the early stages. All incidents of self-inflicted injury or attempted suicide should be reported to the institutional psychiatrist, psychologist or health care staff.
Treatment
Many of the issues and circumstances affecting the treatment of inmate suicidal behaviour are inextricably linked to those involved in its intervention and prevention. Since effective, pro-active intervention and prevention procedures and programs are not yet standard features within correctional facilities, any discussion of inmate suicide treatment tends to focus primarily on the problems and inadequacies. From this, however, it is possible to get an insight into what improvements are needed and what would constitute appropriate, effective treatment for suicidal inmates.
Inmates have been generally expected to cope with prison life in competent and socially constructive ways. Too often, however, the inmate has been confronted by a hostile or indifferent custodial environment in which denial of personal problems and manipulation of others are the primary ingredients in coping with daily life. Consequently, the "survivors" of penitentiary life become tougher, more aggressive and less able to feel empathy for themselves or others ; the "non-survivors," meanwhile, become weaker, more vulnerable and less able to control their lives. A prevailing inmate attitude is one of "doing one’s own time ;" it places a taboo on admitting feelings and sharing them with others. Stoicism is valued and expressions of fear are equated with a stigma of "weakness." Maintaining distance from staff is also a dominant theme within "doing time." Adding to this has been the view, held by both inmates and their custodians, that proper treatment and humane compassion are seen as incompatible with security and correctional concerns. There have been indications that guards tend to dismiss incidents of self-injury as attention-seeking gestures ; as a result they either go unreported or recorded in a subjective manner which downplays their seriousness. A more positive response by guards to inmates attempting suicide needs to be developed, and proper counselling must be ensured.
Too much of corrections policy has failed to seriously consider the social dimension of inmate suicide and, as a result, suicide treatment programs have not been effective because they are based on the view that suicide is strictly a medical problem for doctors to solve. However, it is being recognized more and more that greater significance needs to be given to the environment in which inmates and staff are expected to live and work, and to the importance of providing constructive activities to help inmates cope with anxiety and stress. The treatment and prevention of inmate suicide needs to be a joint responsibility, involving inmates, corrections staff, families, visitors and the administration, as well as consideration of the physical environment. Medical personnel need to recognize and accept a wider view of their tasks and responsibilities, including specific training in dealing with the inmate problems created by incarceration. Among the major difficulties that need to be overcome in order for corrections staff to respond more positively to incidents of inmate suicide are the lack of staff continuity, insufficient time for staff to spend with prisoners in an involved manner, and a lack of training, particularly in interpersonal relationships.
Nurses have played an important part in assessing and treating inmate suicidal behaviour, as they have been responsible for documenting the initial medical history of all inmates within 24 hours of admission. They advise corrections physicians and custodial staff early in the process about any inmate judged to be at risk of suicide because of apparently severe emotional crisis and, therefore, requiring counselling, medical or psychiatric help. There is also a need for nurses to visit inmates in the housing units, for by being more visible to the inmates, there is an increased chance that inmates will discuss their concerns and problems with the nurses. Nurses are not only medical staff, they also perform the tasks of case-finder, counsellor, group therapist, suicidologist, caretaker and crisis intervener.
One of the more expedient treatment methods for suicidal behaviour has been the use of medications. However, the side effects of these drugs has also been known to aggravate suicidal tendencies. The depressant drugs used to alleviate emotional crisis or chronic psychosis induce a state of passivity, reduce agitation and aggression, as well as the mood swings associated with severe psychotic disturbances. However, because these drugs generally have medical side effects, anti- depressants have been used to eliminate the side effects. As a result, inmates treated with these drugs swing between euphoria and depression and, under such influences, depressives who are already potentially suicidal often make suicide attempts.
An effective method for dramatically reducing incidents of suicide is the implementation of inmate peer support programs (Roger & Lariviere, 1998). Drumheller’s Samaritans program in Alberta and Leclerc’s V.I.V.A. program in Quebec are two notable examples of inmate peer support programs. Because fellow inmates are often the first to recognize a distressed or suicidal inmate, and the fact that inmates may confide more readily to inmate peers, these types of programs do have a “beneficial effect...by reducing the incidence of self-injury or suicide and improving the overall prison environment” ( p. 19). Although very few inmate peer support groups currently operate in Canadian institutions, the Correctional Service of Canada intends to implement more programs in its medium and minimum security institutions over the course of the next year.
CONCLUSION
While literature on inmate suicide indicated that suicidologists have long been in disagreement over what the causes and best prevention strategies would be for inmate suicide, they have agreed that few jails and prisons have succeeded in consistently and effectively detecting and intervening in incidents of inmate suicidal behaviour. Ironically, the highest risk of suicide is in maximum security and remand facilities, where it is less likely that programs such as Samaritans will be implemented due to security issues. The very factors that relate to suicide risk are those that make suicide prevention difficult to implement. One of the common themes within the inmate suicide issue has been the increasing acknowledgement by corrections officials and suicidologists that profiles alone, however accurate, will not reduce the incidence of inmate suicide. There must also be standardized reporting and communication of information about the inmate’s history, proper training of corrections staff in suicide detection and intervention and a move toward a more inter-disciplinary approach to intervention and prevention of inmate suicide. While there is more that can be done, the fact is that prison and jail are brutally harsh environments that some simply are not able to cope with. After we have done all the prevention and intervention possible with the environmental constraints, will we then step back and look at prison itself ? Perhaps the solution to inmate suicide lies in more discriminate and appropriate use of incarceration, keeping less serious offenders in the community and making better use of mental health facilities for inmates with mental health concerns.
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