National Commission on Correctional Health Care

Suicide Prevention Resource Guide National Response Plan for Suicide Prevention in Corrections

In Collaboration With The National Commission on Correctional Health Care is a nonprofit 501(c)(3) organization working to improve the quality of care in the nation’s jails, prisons, and juvenile detention and confinement facilities. NCCHC establishes standards for health services in correctional facilities, operates a voluntary accreditation program for institutions that meet those standards, produces and disseminates resource publications, offers a quality review program, conducts educational trainings and conferences, and offers a certification program for correctional health professionals. NCCHC is supported by the major national organizations representing the fields of health, mental health, law and corrections. Each of these organizations has named a liaison to the NCCHC board of directors. For more information, go to ncchc.org.

The American Foundation for Suicide Prevention is dedicated to saving lives and bringing hope to those affected by suicide. AFSP creates a culture that’s smart about mental health through education and community programs, develops suicide prevention through research and advocacy, and provides support for those affected by suicide. Led by CEO Robert Gebbia and headquartered in New York, and with a public policy office in Washington, DC, AFSP has local chapters in all 50 states with programs and events nationwide. Learn more about AFSP at afsp.org.

Project 2025 is a high-impact, collaborative initiative developed by the American Foundation for Suicide Prevention, aimed at achieving the organization’s bold goal of reducing the annual suicide rate in the U.S. 20 percent by 2025.

This publication represents the work of several national experts in suicide, mental health, corrections and correctional health care. The advice and suggestions offered here are in no way guaranteed to prevent all suicides. Some ideas may not be applicable or feasible at all facilities. Table of Contents

2 Forewords 4 Introduction 6 Assessment of Suicide Risk in Correctional Settings 16 Suicide Prevention and Treatment of Suicidal Behavior 22 Suicide Identification and Prevention Training Curriculum Guide 30 References and Resources 32 Facility Design: Creating a Physical Environment That Supports Well-Being 34 Case Study: Hudson County Correctional Center, New Jersey 36 Case Study: Middlesex Jail and House of Correction, Massachusetts 38 NCCHC Standard B-05 Suicide Prevention and Intervention 40 Acknowledgments and Thanks

To find this resource online, visit ncchc.org/suicide-prevention-plan.

© 2019 National Commission on Correctional Health Care

Suicide Prevention Resource Guide 1 FOREWORD National Commission on Correctional Health Care

The idea for the Suicide Prevention Resource Guide was conceived in August 2017 in a conference room in Chicago, where a group of mental health experts convened with National Commission on Correctional Health Care leadership for the inaugural Suicide Prevention Summit. The gathered participants were remarkable not only because of their collective expertise, but also because they were, in many ways, competitors, representing five major providers of correctional health care services. They came together determined to find solutions to a problem common to all correctional facilities. They discussed the complexities of suicide in corrections, shared their challenges and insights, considered possible process improvements, and discussed other ideas for keeping suicidal inmates safe. Most importantly, they agreed to keep meeting, collaborating and problem-solving.

In 2015, the American Foundation for Suicide Prevention launched its Project 2025, an ambitious initiative with the goal of reducing the annual suicide rate 20% by 2025. The project’s focus on corrections as one of four key areas with potential to save the most lives created a natural synergy with NCCHC’s ongoing suicide prevention efforts. The next Suicide Prevention Summit, cosponsored by AFSP, brought back the original participants, plus thought leaders from jails, universities, departments of corrections and the federal government to brainstorm next steps and start drafting an action plan.

The result is this Suicide Prevention Resource Guide, representing the collective knowledge of countless experts. The guide includes insight into assessing suicide risk, promising practices and guidelines for treating at-risk individuals, and guidance on developing a training curriculum – all through the lens of working with justice-involved patients within a correctional setting.

AFSP graciously supported this project financially, as well as provided perspective and subject-matter expertise. NCCHC provided our deep experience in correctional health care and nationally recognized standards to guide practice, as well as editing and production services.

The work of the AFSP–NCCHC partnership is not over. Together we will continue to work to reduce the incidence of suicide behind bars.

Deborah Ross, CCHP Brent Gibson, MD, MPH, CAE, CCHP-P Chief Executive Officer (interim) Chief Health Officer

2 NCCHC – AFSP FOREWORD American Foundation for Suicide Prevention

The American Foundation for Suicide Prevention is the nation’s leading suicide prevention organization, and Project 2025 is our bold initiative aimed at reducing the national suicide rate 20% by the year 2025. As part of this initiative, we have identified the corrections system as one of four critical areas through which we can save the most lives in the shortest amount of time.

According to the U.S. Department of Justice, suicide is the leading cause of death in jails, and the suicide rate in prisons continues to increase. Incarcerated people are particularly vulnerable to suicide for a variety of complex reasons. As such, we are partnering with the National Commission on Correctional Health Care to create a comprehensive guide to preventing inmate suicide in jails and prisons.

This guide provides a road map for navigating the complexities of suicide prevention in correctional settings. Research tells us that people in times of transition are at especially high-risk for suicide, and that there are particularly critical windows during which we can provide effective, life-saving suicide prevention interventions. Working together with NCCHC, we can educate both correctional staff and health care professionals who work in the correctional system about suicide risk and how to identify and care for the suicidal inmate-patient.

This Resource Guide is the result of the combined knowledge of our two organizations, and was developed with input from mental health experts from the nation’s largest jail and prison health care providers. Three areas have been identified as crucial for suicide prevention in a correctional setting – assessment, intervention, and training. In these pages, you will learn how to better identify and help inmates at risk for suicide, safely manage those identified as suicidal, and provide consistent, comprehensive training to all involved personnel.

Suicide can be prevented. By working together, we will save lives.

Robert Gebbia Christine Moutier, MD Chief Executive Officer Chief Medical Officer

Suicide Prevention Resource Guide 3 Introduction Assessment Treatment Training References Design Case Studies

Introduction

Suicide is a profoundly solitary act. The response to it, however, must not be. Suicide prevention requires a coordinated, multifaceted team effort. Nowhere is that more true than in jails and prisons.

Incarcerated men and women are a socially excluded population characterized by a multitude of personal and social problems and, often, mental health or substance abuse issues. Those risk factors for suicide are compounded by confinement, leaving some people feeling overwhelmed and hopeless. Tragically, too many of them die by suicide as a means of ending what feels like inescapable pain.

The goal of suicide prevention is to reduce risk before it becomes a crisis and, when necessary, defuse a crisis before it becomes fatal. The correctional mental health professional’s role is to help at-risk individuals find better mental health, hope, and reasons for living, and thus avert tragic and preventable suicides. That life-saving effort requires the cooperation, knowledge, observations and insights of the entire facility staff. Furthermore, suicide prevention is not a one-time event. It begins at intake and does not end until the individual returns to the community.

Fortunately, understanding of suicide risks and warning signs specific to incarcerated populations is expanding. Effective prevention strategies and interventions are being used today in correctional settings, and progress will continue to be made as knowledge continues to grow.

Through the Suicide Prevention Resource Guide, the National Commission on Correctional Health Care and the American Foundation for Suicide Prevention have joined forces to work toward reducing the incidence of suicide in jails and prisons. The guide focuses on three areas key to suicide prevention in corrections: assessment, intervention and treatment, and training. The aim is to educate the field on how to better identify and help inmates at risk for suicide, safely manage those identified as at high risk, and provide consistent, comprehensive training to all involved personnel.

Combining NCCHC’s knowledge of correctional mental health care with AFSP’s expertise in suicide prevention represents a unique opportunity to develop solutions that can effect real change – and save lives. In its Project 2025, AFSP identified corrections as one of four critical areas with the highest potential for preventing suicide, with the goal of reducing the suicide rate 20% by the year 2025.

Joining in the NCCHC–AFSP partnership are mental health experts serving some of the nation’s largest jail and prison systems, private health care providers, and leaders from within the corrections field – individuals who operate on the front lines of the suicide crisis and offer real-world perspective.

The result of this partnership to date is this Suicide Prevention Resource Guide. NCCHC and AFSP are deeply indebted to the cadre of experts who contributed writing, research, scholarship, review, critique, input, and wisdom to the resulting product.

We hope this guide proves useful in your facility’s quest to prevent inmate suicide. (See page 40 for a complete list of acknowledgments.)

4 NCCHC – AFSP While suicide is a profoundly solitary act, suicide prevention requires a coordinated, multifaceted effort.

Suicide Prevention Resource Guide 5 Introduction Assessment Treatment Training References Design Case Studies

Assessment of Suicide Risk in Correctional Settings

Understanding Suicide Risk When an individual is in a suicidal crisis, their thinking becomes Many people have thoughts of suicide limited and less flexible, and they feel without acting on those thoughts. tremendous pain and desperation. Fewer people make attempts, and In these moments, they don’t have deaths by suicide are less frequent. access to their usual coping abilities, and protective factors such as family, Preventing suicide requires ongoing assessment to identify The goal of suicide prevention is to friends, religion, and hope may be patients who are at heightened risk and need intervention. reduce risk for individuals before it stretched. becomes a crisis. There are many Only by identifying those individuals can resources be biological, psychological, social, Fortunately, tools and interventions appropriately directed to target interventions and save lives. and environmental factors that can exist that can help to prevent suicide. lead to suicidal behavior. Some They involve: treating mental health In correctional settings, however, valid and reliable suicide contributors that may combine to conditions; developing a plan for risk assessment has remained elusive for a number of increase the possibility for suicidal managing suicidal thoughts and behaviors; and limiting access to reasons, many of which will be discussed here. There is behavior over the course of one’s life include, but are not limited to: lethal means. Suicidal crises come no magic formula or definitive approach to suicide risk a mental health condition, including and go, and research shows that assessment, as understanding of this complex behavior alcohol and substance use disorders; the intensely painful moment of possible action is temporary, so among a complex patient population continues to evolve. a physical health condition or chronic pain; family history of mental health buying someone time to get through What follows are state-of-the-art recommendations based conditions or suicide; head trauma, it by limiting access to means, on advancements in the science and consensus among and early life trauma or abuse and helping them get through the experts. (physical or sexual). immediate crisis can save their life. On top of lifetime risk factors, current factors may include life stressors; current alcohol and substance use; Assessment: More current mental and physical health, Thorough Than Screening and access to care. Access to lethal means is the key factor leading to Screening and assessment, while death. both important to identifying individuals at risk for suicide, are

6 NCCHC – AFSP not the same thing. That is an An assessment includes a thorough important distinction, as the terms evaluation of the individual’s history are often mistakenly interchanged. Suicide Warning Signs and functioning across multiple domains, providing a more complete Screening is generally a one-time clinical picture. Assessments assist event used at intake for the early TAL in identifying key risk factors, identification of individuals at BEHAIR including mental health conditions potentially high risk for suicide. or psychological problems and their Screenings are usually brief, use severity, and aid in treatment planning. simple “yes/no” questions, and can Assessments typically integrate results be administered by health care from multiple sources, including professionals or trained custody staff. F psychological tests, clinical interviews, Screening results do not definitively H behavioral observations, clinical diagnose a specific condition or records, and collateral information. S disorder, but can indicate a need for further evaluation or preliminary A comprehensive assessment of intervention. suicide risk includes sufficient MD A description of the current behavior Screening tools for suicide risk that and justification for the interventions A have been validated in the community being provided to mitigate risk and are available that can be used in move the individual away from suicidal correctional settings with modification. thoughts and behaviors. (See box on page 11 for list of A H validated screening tools.) They can This section of the Suicide Prevention be used during the admission process Resource Guide focuses on to help identify immediate needs assessment, as it is assessments and in special situations, such as afsp.org/signs that inform health staff about the placement in restrictive housing/ targeted interventions required for segregation, following a court hearing, the individual patient. Assessment, proximate to a transfer or a change on the other hand, Assessment is not a one-time event, in security status. is an in-depth process involving but a process that should be ongoing a comprehensive examination throughout the at-risk patient’s conducted by a qualified mental incarceration. health professional (QMHP).

Suicide Prevention Resource Guide 7 Introduction Assessment Treatment Training References Design Case Studies

Understanding Incarcerated It is difficult to assess risk in a About “Suicide Watch” or Precautions population for whom impulses play Populations a large part. As an example, a suicide Patients assessed as at current risk for suicide must be placed on a risk screening completed during the Justice-involved individuals, as a level of suicide precautions consistent with their level of risk. All cells reception process may not identify whole, present certain characteristics housing suicidal inmates must be suicide-resistant. Decisions regarding the risk factors that characterize an that make suicide risk assessment the removal of a patient’s clothing, bedding, possessions (e.g., books, impulsive response to interpersonal and intervention particularly slippers/sandals, eyeglasses) and privileges should be commensurate conflict days later. complicated. To understand those with the level of suicide risk as determined on a case-by-case basis challenges, it is important to under- by the assessing qualified health care professional. stand the incarcerated population. Common risk factors are all too If the health care professional determines that a patient’s clothing Suicide Risk Assessment: needs to be removed for reasons of safety, the patient should always common. Research has identified A Process, Not an Event be issued a safety smock and safety blanket. All patients on suicide certain risk factors that heighten the precautions should be allowed access to a shower consistent with At present, there are no known risk for suicide. Those risk factors schedules in other special housing units. A safety mattress should validated suicide risk assessment are common and chronic among be issued to any patient on suicide precautions unless he/she utilizes instruments designed specifically incarcerated individuals, underscoring the mattress in ways in which it was not intended (e.g., attempting to for use in correctional settings. the need to provide prevention tamper with/destroy, utilize to obstruct visibility into the cell). The principles and approaches strategies for the entire incarcerated described below are based on a population. Patients on suicide precautions should not automatically be locked down; general population in the community. Justice-involved patients often they should be allowed all routine privileges (e.g., family visits, telephone As such, they are a useful starting calls, out-of-cell exercise) commensurate with their security status. have histories of trauma. Trauma is point for risk assessment of Finally, all patients on suicide precautions should be allowed to attend a risk factor for suicide. According to incarcerated individuals, while not court/parole hearings unless exigent circumstances exist in which a the National Center for Posttraumatic addressing the unique challenges patient is out of control and at immediate risk to self and others. Stress Disorder, about 4% of men discussed. and 10% of women in the United While each method provides a States will develop PTSD sometime A complicating factor is that Common characteristics of people foundation for conducting suicide in their lives, while approximately 6% individuals with histories of trauma with those challenges include risk assessment, additional of male inmates and 21% of female may not easily engage in open and impulsivity and recklessness. information is needed to develop an inmates meet criteria for PSTD. An honest discussions about their Impulsivity is marked by engaging assessment process appropriate for even larger number of incarcerated thoughts and feelings, especially in behavior without forethought. incarcerated populations and individuals have been exposed to with people they do not know. Recklessness is marked by engaging correctional settings. Until a validated traumatic events, including domestic in behavior without consideration of corrections-specific assessment violence, neglect, emotional abuse, Justice-involved patients can the danger or consequences of one’s instrument is developed, these physical abuse, assault, sexual abuse, be impulsive. Many incarcerated actions. Both result in unpredictable principles are to be used as guidelines. and sexual assault. Among female individuals have antisocial traits, and often sudden dangerous inmates, staff have estimated as expressed by their willingness to behaviors, including suicidal actions. Each of these methods highlights trauma exposure as high as 90%. violate the law, and many also that suicide risk assessment is a struggle with substance use disorders. process, not an event; is multifaceted;

8 NCCHC – AFSP and requires information from multiple Chronological Assessment of suicidal desire, suicidal capability, - Available means of killing sources. These methods also Suicide Events (CASE): The CASE suicidal intent, and mitigating oneself rely heavily on patient self-report, approach involves exploring the buffers/connectedness. - Currently intoxicated which can present challenges with chronology of suicidal ideation and - Substance abuse correctional populations. behavior with the patient and provides • Suicidal desire - Acute symptoms of mental recommendations for interviewing - Suicidal ideation illness Zero Suicide: The Zero Suicide techniques to help elicit disclosure of - Psychological pain • Suicidal intent initiative describes three components suicidal ideation. The CASE approach - Hopelessness - Attempt in progress of a full assessment and provides a involves three tasks: - Helplessness - Plan to kill self, method known foundation for treatment planning: 1. Gathering information related to - Perceived burden on others - Preparatory behaviors 1. Gather complete information the risk factors for suicide - Feeling trapped - Expressed intent to die about past, recent, and present 2. Gathering information related - Feeling intolerably alone • Buffers/connectedness suicidal ideation and behavior to the patient’s suicidal ideation • Suicidal capability - Immediate supports 2. Gather information about the and planning - History of suicide attempts - Social supports patient’s context and history 3. Making clinical decisions based - Exposure to someone else’s - Planning for the future (e.g., mental and physical health, on those data death by suicide - Engagement with helper family mental health history, - History of/current violence - Ambivalence for living/dying early trauma and abuse history, H.E.L.P.E.R: The H.E.L.P.E.R system to others - Core values/beliefs head injury) has three phases: 1) collection of - Extreme agitation/rage - Sense of purpose 3. Synthesize that information into data (information about the patient), a prevention-oriented suicide 2) analysis of that data, and risk formulation anchored in the 3) documentation. The H.E.L.P.E.R patient’s life context system includes the following: • Historical factors Collaborative Assessment and • Environmental factors Management of Suicidality (CAMS): • Lethality of the suicide thinking CAMS is an evidence-based, flexible and behaviors assessment and intervention model • Psychological factors based on a process of collaboration • Evaluation of suicide risk potential between the clinician and the patient. • Reporting of findings The goal is to identify drivers of suicidal ideation and behavior along National Suicide Prevention with reasons for living and reasons Lifeline: Under a grant from the for dying to discuss ambivalence Substance Abuse and Mental Health about suicide. This establishes a Services Administration, the National basis for collaborative solutions. Suicide Prevention Lifeline developed It functions as a tool for both a set of core principles and subcom- assessment and intervention. ponents for suicide risk assessment that includes four main areas to be probed during an assessment:

Suicide Prevention Resource Guide 9 Introduction Assessment Treatment Training References Design Case Studies

Approaches to Assessing • Express an understanding of the ambivalence in the patient’s Suicide Risk desire to die to relieve pain.

Clearly, the process of assessing Ensure reasonable privacy suicide risk involves more than and confidentiality during the completing a simple questionnaire screening and assessment with the patient. processes. Experience has Be collaborative, confident and demonstrated that it is not unusual compassionate. The Zero Suicide for an otherwise suicidal inmate to initiative emphasizes that screening deny suicidal ideation when and assessment of suicide risk must questioned in a physical environment attend to more than just the instru- that lacks privacy and confidentiality. ment being used or the questions The intake or reception area of any being asked. The qualified health care jail or prison is traditionally chaotic professional conducting a clinical and noisy, an environment where interview is encouraged to: staff feel pressure to process a high • Adopt a collaborative stance, number of inmates in a short period reflecting empathy and of time. Two key ingredients for genuineness. identifying suicidal behavior – time • Convey confidence that pain and privacy – are at a minimum. can be alleviated by alternative The ability to carefully assess the means and that the patient can potential for suicide by asking be empowered to use care and the inmate a series of questions, services to do so. interpreting their response (including • Treat the interview as an explo- gauging the truthfulness of their ration of what has happened denial of suicide risk), and observing When people to the patient, not as a task to their behavior is grossly compromised move beyond a suicidal complete or an examination of by an impersonal environment that crisis or attempt, they what is wrong with the patient. lends itself to something quite the • Indicate that when people move opposite. Efforts should be made to typically find ways to beyond a suicidal crisis or ensure privacy and confidentiality engage in their attempt, they typically find ways (from other inmates and non-health lives. to engage in their lives. More care personnel) when conducting than 90% of people who make suicide risk screening and a suicide attempt do not die by assessments. suicide even upon long-term follow-up.

10 NCCHC – AFSP Maximize rapport and self- disclosure. The Practical Art of In Screening and Assessment Instruments Suicide Prevention, C.S. Shea iden- tified the following approaches to The following list includes some of the screening tools with validated cut-scores. Available at: help establish rapport and encourage that have been validated on community populations integration.samhsa.gov/images/res/SBQ.pdf self-disclosure on the part of the (not corrections): • Patient Health Questionnaire – 9 (PHQ-9): patient: • Columbia Suicide Severity Rating Scale Used most often in primary care settings, this • Ask for specific descriptions (C-SSRS): Three versions are available for use. nine-item questionnaire has been validated in of behavioral incidents, not the The “Lifetime/Recent” version supports inquiry the identification of high-risk patients. Download patient’s opinions. into a patient’s lifetime history of suicidal ideation from: uspreventiveservicestaskforce.org/Home/ • Avoid judgmental or shame- and behavior as well as any recent suicidal ideation GetFileByID/218 inducing questions by framing and/or behavior. The “Since Last Visit” version of questions in a manner that is the C-SSRS screens for suicidal ideation and The following assessment instruments have been consistent with the patient’s behavior since the patient’s last visit. The “Screener” validated on community populations (not corrections) experience. version is a shortened form of the full version. and are entirely self-report based: • Assume the existence of suicidal Available at: cssrs.columbia.edu • Beck Scale for Suicide Ideation: Available for impulses and ask about them • Suicide Behaviors Questionnaire – Revised purchase at pearsonassessments.com/store directly, in a matter-of-fact tone. (SBQ-R): This 4-item questionnaire includes • Beck Hopelessness Scale: Available for • Frame questions regarding questions about suicidality over the lifespan as purchase at pearsonassessments.com/store frequency of behavior and well as future risk. It includes a scoring guide ideation in a manner that may overestimate their true frequency, so that the patient will respond with a more accurate estimation Whenever possible, previous A safety plan includes warning signs, One helpful instrument is the Reasons of their frequency, rather than treatment information should be ways the person can distract them- for Living Inventory, which assesses minimizing them. reviewed, along with objective data selves, who they can be with to life-maintaining beliefs. Areas of • Avoid blanket questions. Instead, from staff observations and incident distract themselves, people they can potential inquiry include the patient’s: ask about specific types of reports, and direct observation discuss their distress with, profes- • In-cell activities suicidal behavior and ideation of the patient during the clinical sionals and how to contact them, how • Distress tolerance skills separately. interview. Include family members, to limit access to lethal means, and • Emotion regulation skills if possible, as people may convey reasons for living. While this is an • Long-term goal orientation But don’t rely solely on self-report. their distress more directly to family. intervention, the development of the • Relationships with cellmates or plan provides a wealth of information others on the tier It is extremely important for a qualified Include discussion of coping health care professional (QHCP) to to support the assessment. A suicidal • Relationships with supports in strategies and other protective crisis is not a good time to develop the community balance patient self-report with the factors during the assessment collection of objective data related a plan. • Ability to ward off suicidal/self- interview. A critical ingredient to the to the patient’s suicide risk using all injurious impulses suicide risk assessment process (as information available to them. • Ability to ask for help well as clinical rationale for discharging • How the patient has handled the patient from suicide precautions) similar situations in the past is the development of a safety plan.

Suicide Prevention Resource Guide 11 Introduction Assessment Treatment Training References Design Case Studies

Conduct comprehensive training Take time to establish rapport and Open communication allows for the While that approach can often support for health and custody staff. All trust. Conversations about suicidal patient to experience support from safety, it removes the patient’s ability staff members who work with inmates thoughts, despair, and hopeless- multiple relationships. It also allows to develop or practice the skills should receive both initial and ness are difficult even in the best for health care staff to alert family and necessary to cope with distress. For recurring suicide prevention training therapeutic contexts. Correctional friends to high-risk times, warning many patients, it intensifies feelings of that includes, but is not limited to, settings are far from therapeutic and signs and other factors that may be shame, triggers traumatic memories, the following topics: avoiding negative are challenging with respect to privacy identified by those social supports increases feelings of hopelessness, attitudes to suicide prevention, why and confidentiality. Effective suicide but may not be shared with clinical and erodes therapeutic connections correctional environments are risk assessment requires that the staff. Family and friends should be with health staff. The underlying mes- conducive to suicidal behavior, risk assessment be conducted in a private encouraged to contact facility staff sage is that the patient is incapable factors to suicide, high-risk suicide and confidential setting, not cell-front. whenever they have concerns. of keeping safe. Understandably, periods, warning signs and symptoms patients may be hesitant to reveal Balance safety and autonomy. (verbal and behavioral cues) and Health staff can feel pressure to be suicidal thoughts when they know identifying suicidal inmates despite efficient and may feel rushed to Most models of health care and the result of doing so. the denial of risk. complete an assessment rather than wellness share the foundational to connect with a patient experiencing assumption that patient health is Decisions about whether or not to Use the Suicide Identification and distress. Despite good intentions, maximized when patients are auton- place a patient on “suicide watch” Prevention Training Curriculum Guide health staff may “signal” to the patient omous, engaged, and able to make need to be made based on a thor- on page 22 as the foundation for that there is insufficient time to dive informed decisions about their care. ough evaluation of risks, protective study and staff training. in to his or her experience. Suicidal In correctional settings, health staff factors, contexts, and patient char- individuals can be sensitive to these Provide adequate staffing. must balance support for patient acteristics. There is no one formula Many dynamics and shut down in the midst autonomy with support for patient that will work for every patient. correctional facilities function with of an assessment. (and often institutional) safety. Often Qualified health care professionals staff vacancies. Shortages in mental there are two choices for patients need to weigh all factors to determine health staffing do not support Communicate with family members and supports, experiencing suicidal thoughts: how best to support patient safety thoughtful, attentive, and compre- especially when they return to general population with a while also providing care in the least hensive suicide risk assessments. convey concern. It is important for plan for follow-up, or be placed in restrictive environment possible to Instead, cursory screenings may be any incarcerated individual at risk for a single cell under observation on maintain that safety. conducted just to ensure that at least suicide to be able to access social suicide watch. Both options are far Conduct suicide reviews/ some evaluation of risk is completed. supports. Early on in the evaluation from ideal. Vacancies in custody staff can result of these patients, it is important to psychological autopsies under in systemic and dangerous barriers work with them to identify individuals Typically, suicide watch is highly protection from litigation. In some to patients’ access to care. who can be relied upon for support. restrictive and very uncomfortable. facilities, clinical mortality reviews Whenever possible, health care staff Patients are placed alone in a cell, and psychological autopsies – critical Without sufficient staff, the risk for should obtain releases of information clothed in a tear-proof smock, with quality improvement processes – can inmate suicide will remain high in to be able to contact family and a tear-proof mat, and observed be hindered or diluted by litigation correctional settings, exacerbated friends to discuss patient needs. continuously by another individual. fears. by inmate isolation, lack of access to Finger food is provided without mental health staff, and decreased utensils. monitoring by custody staff.

12 NCCHC – AFSP It is important for any incarcerated individual at risk for suicide to be able to access social supports.

Suicide Prevention Resource Guide 13 Introduction Assessment Treatment Training References Design Case Studies

However, the litigiousness surround- ing inmate deaths and the media attention those lawsuits attract can create a degree of hesitancy about fully discussing and documenting the specifics of an inmate suicide. Fear of litigation might make full transparency seem like a liability and legal risk rather than a quality improvement opportunity. To fully examine the event and understand where improvements are needed, staff must be able to study events in an open and transparent way.

Guidance may be needed on how to conduct thoughtful, relevant, and transparent reviews that inform quality improvement and procedural changes without putting the correctional system at undue risk for liability and litigation.

Collect and share data on suicide. Sharing suicide data among facilities is essential to the field’s increased understanding of this complex behavior and the unique risks and protective factors specific to incarcerated and justice-involved populations.

See The Need for a Corrections- In NCCHC’s 2018 Standards for • An administrative review is The purpose of these reviews is “to Specific Suicide Risk Assessment Health Services for jails and prisons, conducted in conjunction with determine the appropriateness of Process on page 15 for more standard A-09 Procedure in the custody staff clinical care; to ascertain whether information. Event of an Inmate Death requires • A psychological autopsy is changes to policies, procedures, the following: performed on all deaths by or practices are warranted; and to • A clinical mortality review is suicide within 30 days identify issues that require further conducted within 30 days study.” The intent is to improve care and prevent future deaths.

14 NCCHC – AFSP The Need for a Corrections-Specific Suicide Risk Assessment Process

In order to create a clinically comprehensive, Development of a corrections-specific list of risk effective, efficient, corrections-specific suicide risk factors that can be analyzed with sufficient statistical assessment process, a structured risk assessment power will require collaboration across multiple guide needs to be developed. Ideally, this guide correctional agencies. It will likely be necessary would be informed by relevant risk and protective to develop a national database of information that factors specific to justice-involved and incarcerated can be used to better determine which factors populations, along with prompts for exploring impact the likelihood of completed suicide. relevant issues during an interview. The following data points are likely to assist Development of such a guide will require research, in better understanding of suicide among the data collection, and shared findings, as well as inmate-patient population: training and statistical analysis. It will also require • Date of incarceration determination of whether one guide can provide • Date and time of suicide support for valid risk assessment in both jails • Demographics: age, ethnicity, gender, marital and prisons, or if two separate sets of factors or status, education, diagnoses risk assessment processes are needed for those • Crime and custody information: type of crime • Other risk factors: recent self-injury, recent distinct populations. (violent, nonviolent property, drug, etc.); type change in physical health, recent conflicts with of pending charges; incarceration status; peers or officers, recent bad news, recent Currently, little research is available on the risk and security level, housing location, and type of suicide in facility, recent transition protective factors that may be unique to incarcerated cell; length of time in segregation or length • Protective factors: family support, frequent individuals. At a minimum, the following need to of time pending in segregation (if applicable); visits, role in caring for a loved one, positive peer be identified: length of time remaining on sentence; recent relationship(s), actively involved in programming, • Historical (static) risk factors change in any of those factors strong religious/spiritual beliefs, recent future • Clinical (dynamic) risk factors • Suicide characteristics: method; objects used; orientation, recent goal orientation, treatment • Institutional/situational risk factors precautions against discovery (no, little/passive, compliance, recent use of positive coping • Protective factors and coping skills or yes); active substance use (if yes, type of skills, safety plan substance); toxicology conducted with results • Management/treatment at the time of suicide: Unfortunately, collection of the data required for a • Lifetime historical risk factors: substance on mental health caseload, when added to clearer understanding of risk factors and suicidal abuse, impulsivity, suicidal or self-injurious caseload, on psychotropic medications, recent behavior are not usually shared among correctional behaviors, trauma/abuse, psychiatric change in medications, date of last mental systems for reasons that include legal liability risks, treatment, family/close friend suicide health contact, date last released from suicide negative press, and fear of blame. Each system is • Clinical risk factors: recent presentation precautions limited to analyzing its own suicide data, and the of agitation/severe anxiety, hopelessness, ability to aggregate information is lost. No individual psychological turmoil, alienation, depressive Those data can be collected from information in correctional system is capable of generating the symptoms, psychotic symptoms, suicide plan, patient records as well as findings from mortality amount of data needed. sudden change in mental status, sudden reviews and psychological autopsies. onset stressor, one or more mental health conditions

Suicide Prevention Resource Guide 15 Introduction Assessment Treatment Training References Design Case Studies

Suicide Prevention and Treatment of Suicidal Behavior

Understanding Self-Injury’s frustration and indecision. There can be a tendency to consider self- Connection to Suicide injurious behavior as driven by manipulative intent, thereby suggesting Nonsuicidal self-injury (NSSI) is a that the individual is not suicidal. significant problem in jails and prisons. Collaborative, interdisciplinary Despite the word “nonsuicidal” in the strategies for the management and term, there tends to be a significant The correctional mental health professional’s role is to treatment of inmates who self-injure overlap between NSSI and suicidal or threaten to harm must be devel- help patients manage their mental health, identify hope, ideation and behavior. It is important oped and implemented, regardless to regard self-injury and threats of and recognize reasons for living, and thus avert tragic of the perceived motivation of such self-harm as a legitimate target of and preventable suicides. behavior. ongoing suicide prevention, manage- At its core, intervention and treatment for suicidal ideation, ment, and treatment efforts. One way to reframe the misguided interpretation of behavior as simply suicidal behavior and nonsuicidal self-injury should be: Some patients who initially engage manipulative rather than reflecting in NSSI may miscalculate the lethality private and confidential, evidence-based, collaborative, suicide risk is to understand that at of the behavior, while others who and patient-centered. a moment of crisis, many people at chronically self-injure can become risk for suicide lose their usual, more suicidal over time. Research indicates effective coping strategies, and While much of the information in this guide is specifically that many suicide victims had therefore engage in behaviors that geared toward qualified mental health professionals, it is previously engaged in self-injurious may appear manipulative but come behavior, displayed problems with important that administrative and custody staff also under- from a place of desperation and impulse control, or expressed stand the factors that affect intervention and treatment, thinking that is inflexible and hopelessness or suicidal thoughts. so that all disciplines can work collaboratively. constricted. Episodes of self-injury are emotion- For the purposes of these guidelines, ally charged events not only for Before delving in to the specifics of suggested intervention therefore, the term NSSI will be methods, it is important to review some basic principles those who engage in this behavior used in conjunction with the but also for the health and custody and realities to keep in mind when working with correctional term suicidal to describe at-risk staff members involved in managing patients. populations. such episodes. The time and effort expended in managing these cases is considerable and fraught with

16 NCCHC – AFSP The Need for Privacy Administrative officials and custody staff can help ensure that therapeutic and Confidentiality services to suicidal and NSSI patients can be provided in an area The physical and social environment that is conducive to treatment. At a in which treatment is provided plays minimum, the location should have a prominent role in the success of adequate lighting and ventilation, therapeutic interventions. For suicidal essential furniture, and privacy. patients, those interventions have traditionally been delivered within the context of suicide risk assessment prior to, during, and immediately The Importance of after the individual’s placement on Self-Care and Support suicide watch. In the correctional setting, such intervention typically Mental health professionals are at occurs at cell front, lacking privacy high risk for professional burnout or confidentiality. Moreover, suicide due to their exposure to anger and watch is often conducted in areas despair in an environment that is that do not constitute a therapeutic not always conducive to treatment. environment. In addition, a significant portion of Qualified mental health the clientele suffers from serious professionals (QMHPs) should, mental illness and is often resistant to the degree possible, deliver to therapeutic intervention. That potent assessments and treatment to combination can cause unhelpful or suicidal inmates in a location that even dangerous emotions within the offers privacy and confidentiality professional, who needs to guard against, acknowledge, and respond and is physically separate from the appropriately. Please keep the suicide watch cell/room. Therapeutic following in mind as you work with interventions are to be considered suicidal and NSSI patients. separate and distinct from routine daily risk assessments.

Photo: Tampa Bay Times

Suicide Prevention Resource Guide 17 Introduction Assessment Treatment Training References Design Case Studies

Remain vigilant for cynicism, or bond between the patient and • Transparently work in the patient’s the management of suicidal patients hypervigilance, apathy, and mental health professional is positively best interest that are promulgated without input other warning signs of stress, correlated with treatment outcome. • Remain clear about the necessary from QMHPs tend to be concrete, and actively seek supervision, QMHPs must be aware of their own elements of suicide-specific specific, and rigid, mental health consultation, and peer support to beliefs and how they could hinder treatment professionals necessarily adhere to prevent burnout and its adverse the ability to structure treatment in • Refer patients to other profes- more general, flexible, and case- consequences. Working with suicidal a collaborative fashion. sionals when appropriate specific clinical guidelines. Flexibility patients and those who engage in • Seek professional consultation in the application of both correctional Do not acquiesce to patients’ persistent self-injury exposes mental • Carefully document clinical directives and therapeutic interven- demands for fear that they may health professionals to trauma. decisions and actions tions is required for effective man- attempt or die from suicide. Proactive self-care is essential for Under agement and treatment of self-harm optimal patient care, and for main- pressure from a patient, it is possible Become a “behavioral consultant” and suicidal behavior. Of course, taining empathy, work satisfaction, to lose perspective and feel com- to educate team members from development of any policy, procedure, and efficacy. pelled to abandon the treatment plan, other disciplines. Custody and and/or directive regarding the man- resulting in reactive and chaotic health staff may not fully understand agement of suicidal patients should Pay close attention to negative Remember, as a qual- treatment. the unique clinical factors in self- exemplify collaboration between feelings toward a patient and ified mental health professional, injurious and suicidal behavior. custody and mental health staff. immediately seek consultation or you exercise due diligence and Furthermore, while correctional supervision if negative feelings proper care when you: Seek input and consultation from policies and procedures regarding persist. It is not uncommon to supervisors and colleagues. The become frustrated with, or even assessment, management, and resentful toward, certain patients. treatment of suicidal patients is a Such feelings can undermine the stressful, high-stakes challenge for delivery of effective treatment to the most QMHPs. They are often under very patients most in need of help. pressure from administrative officials Research also has demonstrated to make quick decisions (e.g., whether that negative feelings on the part of the patient is at true risk or “just health care professionals can be manipulating”), and pressured by detected by patients and contribute custody personnel to restrict both to increased suicide risk. If negative the frequency and the duration of feelings are strong or persistent, the suicide watches. Therefore, peer mental health professional is obligated consultation or clinical supervision to refer the patient to a colleague. is always helpful in clinical decision Make sure that personal attitudes making and treatment planning about suicide and suicidal patients related to suicidal patients. Moreover, do not undermine the therapeutic consultation with a colleague has alliance. proven most helpful to those mental One of the most consistent health professionals who have been findings in psychotherapy research the subject of civil litigation as the is that a strong therapeutic alliance result of patient suicide.

18 NCCHC – AFSP When possible, meet as multi- The model should directly target techniques, mindfulness exercises, Help the patient review his or her disciplinary treatment teams, so suicidal ideation and behavior, and problem-solving skills. Evaluation reasons for living and reasons for that qualified mental health profes- emphasize patient adherence to the for and treatment with medication is dying, and then capitalize on the sionals and other appropriate staff treatment protocol, and focus on an important component for some therapeutic alliance to inspire the members can review all patients cognitive and behavioral skill deficits patients. patient’s motivation to live. Virtually receiving suicide-specific treatment. with the opportunity to rehearse all suicidal patients engage in an Such meetings are rich sources of new skills. While each patient and Note: A safety plan is not a “no-suicide internal debate over the decision to ideas and suggestions regarding each situation is unique and complex, contract.” As they are generally used, take their own life. In every therapeutic therapeutic interventions and man- the following are agreed-upon no-suicide contracts ask patients to relationship, the patient’s sense of agement strategies, and can be an principles for working with suicidal promise to stay alive without providing caring and support by the provider excellent forum in which to consider and NSSI patients. guidance on how to do that. They can help move the patient toward barriers to treatment and brainstorm are, therefore, not recommended by their own innate reasons to fight the strategies to address them. The first therapeutic encounter experts in the field. suicidal urge and to remain alive. with the patient should be highly Gaining the patient’s own engagement Find peer support, consultation, structured and involve creation The first encounter might also include against ambivalence will help him or and/or supervision in the of a safety plan. A safety plan, a narrative, the patient’s perspective her more fully embrace life and the immediate aftermath of a death by sometimes called a crisis response on the suicidal crisis, in which he or use of other coping strategies. suicide. Sadly, research indicates plan, is a prioritized, written list of she is asked to tell a story associated that more than one in five mental coping strategies and sources of with the most recent episode of Explore the patient’s perception health professionals will lose a support developed by the QMHP in suicidal thoughts or behavior. That of his or her identity and patient to suicide in the course of collaboration with the patient. As narrative serves as a foundation for otherwise remain culturally their career. The experience can be discussed in the Assessment section treatment planning and a model for competent. Ethical and clinical shocking, disheartening, and surreal, of this guide, the safety plan should understanding how best to deactivate standards require qualified mental and must be addressed with be guided by the mental health the patient’s wish to die. health professionals to remain compassion, respect, and a reparative staff in conjunction with the patient culturally aware in the treatment Subsequent sessions, if available, approach. to address relapse prevention and of all patients. This is especially can be less structured but should initiate a risk management plan. important with regard to suicidal focus on developing a dynamic The risk management plan should individuals, with recognition of treatment plan into which the patient describe signs, symptoms, and the both within-group and individual Therapeutic Intervention has substantial input. Later sessions circumstances in which the risk differences. If unfamiliar with the should concentrate on restructuring Principles for suicide is likely to recur, how patient’s culture, seek relevant attitudes and beliefs that are support- recurrence of suicidal thoughts can training or education. However, ive of suicidal or NSSI behaviors. Although NCCHC does not endorse be avoided, and actions the patient don’t assume that an individual The final session should be devoted any specific therapeutic approach or staff can take if suicidal thoughts identifies with a specific cultural to the consolidation of skills and for suicidal patients, it is imperative do occur. group based on observed that all therapeutic interventions are further refinement of the treatment characteristics. founded on an evidence-based and Based on the person’s condition, plan, including safety planning and clinically useful treatment model. capacity, and assessment, safety relapse prevention. planning can include conceptual- ization of reasons for living, crisis management skills, relaxation

Suicide Prevention Resource Guide 19 Introduction Assessment Treatment Training References Design Case Studies

Consider a behavioral Treatment Plans plan, at a minimum, patients • Cognitive therapy for suicide management plan for inmates discharged from suicide precautions prevention (CT-SP) Address safety planning as the who frequently engage in NSSI should be seen within 24 to 72 hours • Brief cognitive behavioral first and foremost clinical issue to behavior. Such plans use positive and periodically thereafter based therapy for suicide prevention address. A treatment plan targeting “reinforcers” along with certain upon clinical judgment and caseload (BCBT-SP) the reduction of suicidal ideation and restrictions to increase the frequency requirements. Provide psychoeducation. behavior, as well as NSSI, should of behaviors incompatible with NSSI flow directly from a collaborative and replace the self-destructive Regardless of the therapeutic model behavior with new, more effective used, the following psychoeducation suicide risk assessment performed Longer-Term Treatment in collaboration with the patient. behaviors and cognitive approaches. is essential: A behavioral management plan This approach is far superior to “no Help the patient identify valuable • Help patients better understand should begin with very short-term suicide contracts” or “contracting for coping skills to respond differently suicide risk factors as well expectations. Then, as the absence safety,” neither of which is clinically when confronted by a situation or as protective factors that can of NSSI is witnessed over time, efficacious nor legally defensible. crisis that would normally promote insulate them from suicidal urges timeframes are expanded for the • Educate them about their mental suicidal ideations or behavior. Review treatment plans during administration of reinforcers. For health diagnosis, if warranted Evidence-based treatment literature every therapeutic encounter. behavioral management plans • Teach them to recognize warning clearly indicates that effective Local or agency policy may prescribe to succeed, the multidisciplinary signs and precipitating factors strategies for preventing or coping the timeframes for updating suicide- treatment team must ensure that leading to suicidal behavior with future crisis situations (i.e., specific treatment plans. However, goals and objectives are attainable, • Use bibliotherapy – a therapeutic relapse prevention) are essential it is recommended that those reviews reinforcers are delivered in accordance approach that uses storytelling to achieving successful outcomes. occur during each therapeutic with timelines, and all staff are fully or the reading of specific books That can involve the use of guided encounter and that treatment plans committed to the plan’s consistent as therapy – combined with imagery coupled with rehearsal of are updated as needed. execution. journaling as an adjunct to suicide-specific coping strategies. treatment Develop a stabilization plan that Provide a schedule of follow-up Consider CBT interventions in • Indicate resources available promotes constructive activities, for patients released from suicide the treatment of suicidal and when they are in crisis reframes negative thoughts, and precautions. Due to the strong NSSI patients. The most significant enlists the support of others. correlation between suicide and prior Maintain up-to-date, advancements in the treatment of Stabilization planning is a critical suicidal behavior, in order to safeguard thorough, and suicide-specific suicidal individuals have come from step in the development of a larger the continuity of care for suicidal documentation in the health the cognitive-behavioral therapy suicide treatment plan. Stabilization individuals, all patients discharged record. (CBT) tradition. Indeed, brief CBT Complete documentation is plans typically focus on direct from suicide precautions should interventions have produced perhaps the single most important management of suicidal thoughts, remain on mental health caseloads consistent evidence of their superiority means to decrease the risk of means restriction, self-soothing and receive regularly scheduled to other suicide-specific treatment malpractice litigation following a coping strategies, distraction follow-up assessments by mental approaches. The following CBT-based suicide. It is strongly recommended techniques, physical activities, and health personnel until their release interventions have been demonstrated that, at a minimum, clinical notes methods for seeking support. Such from custody. Although there is not to be effective: include the patient’s diagnosis, plans are designed to increase the a nationally acceptable schedule • Dialectical behavior therapy mental status, and current suicide patient’s ability to cope with current for follow-up, unless otherwise (DBT) risk, as well as information concerning and future crises. specified in an individual treatment

20 NCCHC – AFSP When Psychiatric Medication Is Indicated

Qualified mental health professionals may not have received formal train- ing nor otherwise have expertise in psychopharmacology. However, psychiatric medication may be included in the care of many patients. Two main principles need to be kept in mind regarding psychotropic medications: Suicidal patients who show significant symptoms of mental illness should be referred for psychiatric medication consultation. The position of most forensic experts is that failure to do so would reflect nonadherence to the professional standard of care in such situations. QHMPs must be aware of any psychotropic medication the suicidal patient has been prescribed by a psychiatric provider so they can remain vigilant therapeutic interventions employed as a suicide risk assessment template well trained, and closely supervised. for adverse side effects associated and the patient’s treatment progress rather simply as a progress note. Note that the NCCHC standards do with specific medications, as well to date. If the QMHP determines Communication with facility staff, not endorse the use of other inmates as for evidence that the patient is that there is no foreseeable suicide family, and supports should also be in any way (e.g., suicide watch noncompliant with the medication risk at the time of the clinical visit, documented. companions, suicide-prevention regimen. he or she must be sure to document aides) to provide exclusive supervision Consider the use of peer support. the factors that led to that decision. of acutely and nonacutely suicidal For purposes of litigation, the The Federal Bureau of Prisons and inmates. The presence of another clinician will always be judged by some state correctional systems inmate companion/aide does not their last clinical entry into the health (e.g., Indiana) make extensive use of take the place of required observations record. As such, the clinical decision inmate peers in the care and treatment by facility staff. to discharge a patient from suicide of suicidal and NSSI patients. Those precautions should be documented inmates must be carefully screened,

Suicide Prevention Resource Guide 21 Introduction Assessment Treatment Training References Design Case Studies

Suicide Identification and Prevention Training Curriculum Guide

Suicide Prevention and health care personnel in a classroom environment, and not as Training Saves Lives a web-based (e-learning) training module. The NCCHC Standards for Health Services for jails and prisons standard on Suicide Prevention and Suicide is a leading cause of death in correctional facilities, Intervention (B-05) identifies the How To Use This Guide key components of a correctional and a rising cause of death in the community. An effective suicide prevention program. The This guide provides a basic structure suicide prevention program can save lives. In addition, first component is training: “All staff to assist any system or facility in a suicide prevention program can promote a healthy members who work with inmates are developing a training strategy that trained to recognize verbal and aligns with its needs and priorities, environment for justice-involved people and the staff who behavioral cues that indicate potential and is consistent with key components work with them, and can lessen certain legal risks to suicide and how to respond appro- of standard B-05 Suicide Prevention systems and individuals. priately. Initial and at least annual and Intervention. It is a curriculum training is provided.” development guide, intended as an outline to help facilities develop a When staff understand that training full training curriculum in-house. can enable them to save lives, they are more likely to master the content Please refer to the Assessment and and necessary skills. Treatment sections for important information to include in training.

Avoid Web-Based Learning Who Needs Training? Suicide prevention is all about Everyone attitude and collaboration, principles that are lost sitting alone in a chair As indicated in the NCCHC standards, at a computer terminal or laptop. all staff members who work with Therefore it is strongly recommended inmates must be trained in suicide that any suicide prevention training prevention. Everyone should be be provided jointly to custody staff provided at least a basic knowledge

22 NCCHC – AFSP about risk factors, warning signs, what to do if they think someone may be at risk, and the overall suicide prevention plan. One never knows who a suicidal person may talk with and who may be in a position to identify someone at risk. When staff understand that Since a correctional environment encompasses a broad range of training can enable professionals, the goals and content them to save lives, of training must match the roles and they are more likely to baseline knowledge of a variety of master the content trainees. These can be divided into four broad groups: custody staff (line and necessary security and custody administrators), skills. qualified health care professionals, qualified mental health professionals, and executive leadership – those who set administrative regulations, policies, and procedures that apply across a facility or system.

While some training needs overlap, each group has its own priorities and roles in suicide prevention.

1. Custody staff are the eyes, ears, and leaders of every correctional and detention facility, the first to see and first to respond. Every member of the custody staff must possess the necessary

Suicide Prevention Resource Guide 23 Introduction Assessment Treatment Training References Design Case Studies

knowledge and skills to recognize 3. Qualified mental health measures that have the potential At the facility level, the responsible the warning signs that signal an professionals (QMHPs) need to to reduce risk throughout an health authority (RHA) and/or opportunity to prevent a suicide. possess up-to-date knowledge entire system. Executive leader- responsible mental health authority, Training should focus on and skills necessary to assess ship is in a position to promote in conjunction with the correctional increasing each staff member’s and treat potentially suicidal or suicide prevention across a administrator, ensures that training is ability to do three crucial things: self-harming individuals in a system when making decisions available to both health and custody • Recognize and respond manner that ensures that appro- about environmental design, staff, and that training is completed. effectively to warning signs of priate safety precautions are in programming, staffing, and impending suicide or self-harm place. Research is continually operations. (See Strategies for At both the system and facility levels, • Intervene to interrupt a suicidal expanding our understanding Primary Prevention of Suicide correctional leadership is responsible act in progress of suicide; mental health profes- on page 25.) for ensuring that custody staff • Recognize when an individual sionals must regularly update complete required suicide prevention needs to be referred for mental their knowledge and skills training. health care and ensure the accordingly. Training should Training: A Shared Systems that contract with a vendor referral is made in a timely and enable them to skillfully: Responsibility for health services must ensure that effective manner • Interview and build a the lines of responsibility for training therapeutic alliance with Leadership at the system, facility, are always clear. 2. Qualified health care vulnerable inmates while and clinical program levels must professionals (QHCPs) are eliciting the information share responsibility for overseeing on the front line of health care; necessary to determine if an effective training program, as inmates who die by suicide have the individual is acutely or well as assessing its impact. Training = Knowledge, often recently been treated nonacutely suicidal Skills, and Attitudes for primary medical problems, • Perform and document Training should enable them to: • Develop and implement a system- including chronic disorders, a thorough suicide risk Training increases knowledge and wide suicide prevention plan substance use disorders, or assessment skills, while at the same time shaping • Enumerate risk factors and pain conditions. Training should • Formulate and implement a attitudes; therefore, the format must warning signs of suicide risk provide health staff with the treatment plan that addresses be structured to address each of • Facilitate the treatment of knowledge and skills to: safety and treatment needs those three areas. Preservice and individuals deemed to be at risk • Screen for suicide risk in the using the least restrictive annual training are essential in order At the system level, the responsible course of providing primary means consistent with clinical to establish a baseline, measure mental health authority and/or the care guidelines and institutional progress, provide feedback, and responsible mental health clinician • Recognize the warning signs of policies enhance retention. a mental health crisis, including is responsible for ensuring that risk of suicide or self-injury 4. Executive leadership, those the clinical elements of a training • The knowledge component of • Recognize signs and symptoms individuals responsible for program are consistent with training relies on a combination of common mental health creating regulations, policies, appropriate practice guidelines and of oral and visual content conditions and procedures, need training NCCHC standards. presentation, supplemented • Refer patients in need of mental focused on the public health with written materials, matched health services in a timely and dimensions of suicide prevention, to the baseline understanding effective manner including primary preventive and needs of the learners.

24 NCCHC – AFSP • The skills component requires Strategies for Primary Prevention of Suicide in Correctional Facilities practice and constructive feedback, using methods such Primary prevention strategies reduce suicide risk 6. Promote resilience as role-play for officers and factors and promote protective factors across an entire • Educate and reach out to inmates about coping mentored evaluations for health incarcerated population. This impact occurs directly with stress and asking for help professionals. (such as increasing opportunities for offenders to - Inmate education and outreach can include • Joint training exercises in which connect with others) and indirectly (such as promoting classroom, written and other means of teaching correctional and health staff hope). Given that the majority of deaths by suicide in the incarcerated persons about suicide prevention, participate together can promote United States occur in persons not known to have a with an emphasis on the opportunity for each attitude a confident toward sui- mental illness, the need to emphasize primary prevention incarcerated person to experience himself or cide prevention among all staff is great. herself as part of a community whose members and underscores that suicide can make a difference to others. prevention involves a holistic, Options to consider include: - Promote peer-to-peer outreach such as the DVD multidisciplinary approach. 1. Create a healthy correctional community presentation, “Suicide is Forever: Recognizing Requiring custody and health • Each facility is like a “village behind walls.” & Preventing Suicide,” produced by offenders care personnel to sit together in • Provide safe housing for offenders in the Missouri Correctional system. a classroom environment is not • Reduce emotional/physical trauma • Educate inmates about life skills and coping skills only symbolically appropriate, • Promote gender and cultural awareness • Provide work skills development and opportunities but instills the philosophy that • Support healthy activities and daily routine • Educate inmates about basic money all professionals, regardless of management (to reduce financial crises) credentials or agency affiliation, 2. Promote connectedness have an equal responsibility for • Ensure that each incarcerated person, especially 7. Promote general health and physical functioning inmate suicide prevention and those housed alone, can maintain regular contact • Encourage healthy physical activities can learn from one another’s with family and other sources of support, regardless • Ensure restorative sleep backgrounds, insights, and of administrative status or financial resources. • Ensure healthy nutrition experiences. • Reduce isolation of offenders • Control noise levels • Lower barriers to primary care Effective training answers three 3. Lower barriers to seeking mental health care - Ensure that offenders have access to effective questions: What (knowledge), how • Reduce stigma management of (skills), and why (attitude). Every • Ensure confidentiality - Chronic pain training activity should start by • Maintain an effective referral system - Chronic illness ensuring that each trainee under- stands why the content is relevant to 4. Reduce access to the means of suicide their professional role. The curriculum • Focus on locations where offenders are isolated should be designed so that every fact taught assists trainees in 5. Reduce the harmful use of alcohol and drugs mastering at least one new skill. • Provide addictions treatment that include a full Practice, feedback, and mentoring spectrum of treatment options and follow NCCHC will impart the confidence needed to guidelines put newly learned skills into action.

Suicide Prevention Resource Guide 25 Introduction Assessment Treatment Training References Design Case Studies

Facts: Choose Wisely factors and warning signs of suicide helpful in making system-level An Effective Curriculum and how to refer and intervene as programmatic decisions. One note of caution: While certain first responders. An emphasis on The most important measure of an As another example, QMHPs need to facts are essential, irrelevant infor- demographic correlates of suicide effective training curriculum is the be up-to-date about recent research mation can distract from overall is of little relevance to those tasks, results it produces in a specific group findings that can aid them in differen- learning. Choose facts and information while training that emphasizes of trainees. For example, a curriculum tiating acute from nonacute suicide that support enhancing the skills awareness and monitoring for unusual that results in custody or health care risk, while QMHPs need to hone their relevant to the trainee’s role and behavior changes is essential. staff referring more individuals for skills at identifying and referring “need to know.” Executive leadership, on the other emergency mental health care before patients who may be at any level of hand, would likely find information self-harm occurs is an effective risk. Line security staff, for instance, about the rates of suicide in various curriculum. So is one that results in need to know how to spot the risk demographic groups to be extremely mental health professionals more

Suicide Risk Despite Denial

A critical ingredient to suicide prevention training for all Recent research has found that a sizable percentage of personnel is the basic understanding that we should not inmates (between 30 and 40%) reported that it would be rely exclusively on the direct statements of inmates who “unlikely” for them to report any current suicidal ideation deny that they are suicidal and/or have a prior history of to a mental health clinician. The principal reason why suicidal behavior, particularly when their behavior, actions suicidal inmates do not report their ideation is because and/or history suggest otherwise. For example, consider of the conditions of suicide precautions, namely, the an inmate who is on suicide precautions for attempting sterile housing and loss of privileges and possessions. suicide the previous day. He is now naked except for a This same research suggests that suicide risk assessments suicide smock, given finger foods, and on lockdown should not rely on a patient’s self-report of suicidal status. The mental health professional approaches the ideation, and “patients with strong and acute and chronic cell and asks the inmate through the food slot (within risk factors, even in the absence of reported suicidal hearing distance of others on the unit): “How are you ideation, should be taken seriously and appropriate feeling today? Still feeling suicidal?” interventions to prevent suicide should be taken.”

Why would a suicidal inmate deny being suicidal? If an inmate’s simple denial of being suicidal was the Possible answers include: only criteria utilized to assess suicide risk, then it would • Perceived punitive aspects of suicide precautions be unnecessary to ask any other questions during the • Desire to end their life and not be stopped intake screening or assessment process, nor would • Inability or unwillingness to articulate their thoughts we need a mental health professional to make an • Fear of being ridiculed and/or ostracized by other assessment because any staff member could listen to inmates an inmate deny they were suicidal and assume they • Lack of privacy when the questions are asked were not. • Manner in which the questions are asked

26 NCCHC – AFSP thoroughly completing suicide risk leadership should be seen as areas • Explain how to collaborate with assessments. Training that results to emphasize, while not undermining mental health staff in monitoring A Word About in leadership making systemwide the need to work across disciplines. individuals with lifetime risk and operational decisions that reduce Effective training balances the two. during high-risk periods such Language and address risk factors (such as as transition points When talking about suicide, access to means of suicide) or elevate Training may need to be adapted to avoid using terms like “commit protective factors (such as ways to meet the needs of specific subgroups Referral suicide” or “successful attempt.” stay in touch with family) is effective. under each heading. For example, • Cite policies and procedures for Those phrases perpetuate under the mental health professionals obtaining emergency evaluations heading, training for psychiatric suicide’s stigma and moral providers will emphasize different Housing judgment. Preferred terms are “ended one’s life” or “died Content Outline for topics and skills than training for • Verify that housing used for by suicide,” according to Suicide Prevention Training nurses or administrative program suicide watch is suicide resistant the American Foundation for managers, though certain content and clear of items that could Suicide Prevention. Below are suggested learning and skills, such as interviewing raise the risk of self-harm objectives for each group of training techniques for eliciting disclosure of • Emphasize that isolation participants. These objectives follow suicidal thinking, are common to all undermines suicide prevention, • Explain procedures for docu- the key components of a suicide clinical training. Use these learning and restrictive housing should be mentation and communication prevention program listed in NCCHC objectives as a guide, and customize avoided to the extent possible in at shift change Standard B-05 Suicide Prevention as needed. persons known to be at elevated • Describe how to obtain and Intervention. By creating risk emergency clinical services for learning modules around these an inmate when indicated objectives, trainers can be confident Monitoring Learning Objectives • Explain policies and that they are covering the most • Describe the procedures and procedures for verbal/written important points for each group of for Custody Staff circumstances for providing communications with mental trainees. constant observation for persons health staff, transferring Upon completion of suicide determined to be acutely suicidal This outline emphasizes the prevention training, custody staff authorities, and outside facilities • Describe the procedures and • Review the institutional suicide components that most closely match should be able to: circumstances for providing the needs of specific groups of staff, prevention plan Identification intermittent (staggered) watch although some shared training • Describe common warning for those determined to be Intervention experience is highly desirable to nonacutely suicidal promote effective collaboration, and signs of suicide and nonsuicidal • Apply relevant policies and self-injury procedures in the event of a can serve as a guide when allocating Communication training time and resources. Training • Identify common signs and suicide attempt in progress symptoms of mental health • Demonstrate interpersonal skills • Locate and use safety equipment needs to balance role-specific that can de-escalate crises and components with a multidisciplinary conditions (such as cut-down tool) • Recognize behavioral signs of lower barriers to mental health • Demonstrate ability to perform component. The items highlighted care for patients specifically for custody, qualified medical conditions that require CPR and use an AED when health care professionals, qualified immediate medical care medically necessary mental health, and executive

Suicide Prevention Resource Guide 27 Introduction Assessment Treatment Training References Design Case Studies

Learning Objectives • Review policies and procedures for communicating with custody for Qualified Health Care staff when referring individuals Professionals for routine or emergency mental health care Upon completion of suicide prevention • Provide systematic follow-up with training, QHCPs should be able to: patient after the referral or visit

Identification Intervention • Describe warning signs of suicide • Provide medical intervention, and nonsuicidal self-injury including CPR and use of an • Identify signs and symptoms of AED when indicated, in the event mental health conditions of a suicide attempt • Recognize behavioral signs of medical conditions that can Review mimic mental disorders • Review institutional suicide Referral prevention plan • Explain institutional policy on • Review procedures for making postsuicide review a mental health referral in a manner that ensures safety and Evaluation continuity of care • Demonstrate development of a Learning Objectives for • Demonstrate use of suicide risk safety plan as part of a compre- Treatment Qualified Mental Health assessment tools to augment the hensive treatment plan clinical assessment of individuals • Collaborate with mental health Professionals who are have been referred for Monitoring professionals to ensure continuity mental health evaluation of care for individuals who receive Upon completion of suicide • Clarify the purpose for placing • Explain how suicide risk crisis care prevention training, QMHPs should acutely suicidal individuals on be able to: assessment is used to determine constant watch, and nonacutely Communication an individual’s risk level suicidal persons on staggered Identification (See Assessment of watch • Demonstrate interviewing and Suicide Risk in Correctional Settings, Treatment Planning (See Suicide interpersonal skills that lower page 6) Prevention and Treatment of Communication barriers to mental health care, • Describe the risk factors and Suicidal Behavior, page 16) such as stigma • Examine the importance of warning signs for suicide and • Discuss effective interventions • Communicate medical meeting safety and treatment nonsuicidal self-injury consistent with licensure, information and behavioral needs of individuals at elevated • Explain how screening, qualifications, and relevant observations to mental health risk of suicide assessment, evaluation, and clinical guidelines professionals when making a • Review institutional policies ongoing monitoring are used to • Describe how treatment of referral relevant to communicating with identify individuals at elevated mental health conditions impacts custody and health staff risk of suicide suicide risk

28 NCCHC – AFSP • Explain the need for both oral Review • Describe ways to mitigate the Housing and written communication with • Review the institutional suicide impact of a suicide event on the • Demonstrate that adequate inmate and custody staff prevention plan organization suicide-resistant housing is • Discuss the importance of available to meet the needs for Intervention postevent review or psychological emergency care of acutely and • Demonstrate ability to perform autopsy Learning Objectives for nonacutely suicidal inmates or assist with CPR and AED use • Conduct a psychological autopsy Executive Leadership • Ensure that individuals have when medically necessary easy access to mental health Debriefing Executive leadership plays a key care (including crisis/emergency Reporting • Explain the role of the mental role in promoting suicide prevention care) to meet their needs in a • Explain institutional policies on health professional in a across systems when making high- safe manner reporting of crisis care, suicide postevent debriefing level decisions. • Provide appropriate ongoing watch, or postevent summaries monitoring whenever inmates Upon completion of suicide are housed in relatively isolated prevention training, executive settings leadership should understand the importance of: Notification Be Aware of High-Risk Times and Situations • Confirm that policies and Identification personnel are in place to provide It is important to understand that suicide can occur at any time, so • Explain the importance of timely notification of appropriate focusing too narrowly on the “typical” risks and times can be dangerous. providing a physical environment authorities and family members However, certain times and situations are particularly high-risk for that allows for privacy and in the event of a death by suicide inmates who may be suicidal. According to NCCHC standard B-05 confidentiality during the intake or serious suicide attempt Suicide Prevention and Intervention, those high-risk situations are: screening process • Upon admission (e.g., 2 to 14 days following incarceration) • Identify opportunities for primary Reporting • Following new legal problems (e.g., within 48 hours of a court suicide prevention across the • Ensure adequate data collection appearance, new charges, additional sentences, institutional institution and reporting in the event of a proceedings, denial of parole) • Explain the importance of death by suicide • After admittance to segregation or single-cell housing internal and external statistical • After the receipt of bad news regarding self or family (e.g., serious data in making decisions about Review illness, the loss of a loved one) operational, programmatic, and • Utilize review results to inform • After suffering humiliation (e.g., sexual assault) or rejection resource allocation issues that operational and correctional • Pending release after a long period of incarceration may impact suicide prevention decision-making • Review risk factors and warning Other high-risk situations include: signs for suicide and institutional Debriefing • Anniversary dates procedures for identification • Describe debriefing procedures • Decreased staff supervision and intervention for individuals for custody staff and inmates • Pending release from custody, especially if the inmate lacks a viable at risk discharge plan due to lack of family, employment, housing, and other stabilizing resources.

Suicide Prevention Resource Guide 29 Introduction Assessment Treatment Training References Design Case Studies

References and Resources

Assessment

American Foundation for Suicide Prevention. https://afsp.org Miller, N. A., & Najavits, L. M. (2012). Creating trauma-informed correctional care: A balance of goals and environment. European Journal of Psychotraumatology, 3. doi: 10.3402/ejpt. American Psychiatric Association. (2003). Practice guideline for the assessment and treatment v3i0.17246 of patients with suicidal behaviors. American Journal of Psychiatry, 160(11 Suppl.), 1-60. National Center for PTSD. https://www.ptsd.va.gov Baranyi, G., Cassidy, M., Fazel, S., Priebe, S., & Mundt, A. (2018). Prevalence of posttraumatic stress disorder in prisoners. Epidemiological Review, 40(1), 134-145. National Commission on Correctional Health Care. (2018a). Standards for health services in jails. Chicago, IL: Author. Bostwick, M. J., Pabbati, C., Geske, J. F., & McKean, A. J. (2016). Suicide attempt as a risk factor for completed suicide: Even more lethal than we knew. American Journal of Psychiatry, National Commission on Correctional Health Care. (2018b). Standards for health services in 173, 1094–1100. doi: 10.1176/appi.ajp.2016.15070854 prisons. Chicago, IL: Author. Commonwealth of Massachusetts. Executive Office of Public Safety, Department of National Suicide Prevention Lifeline. (2007). Suicide risk assessment standards. https:// Corrections. Governor’s Commission on Corrections Reform. (2005). Dedicated external suicidepreventionlifeline.org/wp-content/uploads/2016/08/Suicide-Risk-Assessment- female offender review. Boston, MA. http://www.mass.gov/eopss/docs/doc/research- Standards-1.pdf reports/gccr-13-review-final.pdf Noonan, M. (2016a). Mortality in local jails, 2001-2014 – statistical tables (NCJ 250169). Jobes, D. A. (2012). The Collaborative Assessment and Management of Suicidality (CAMS): Washington, DC: Bureau of Justice Statistics. https://www.bjs.gov/index.cfm?ty= An evolving evidence-based clinical approach to suicide risk. Suicide and Life-Threatening pbdetail&iid=5868 Behavior, 42(6), 640-653. Noonan, M. (2016b). Mortality in state prisons, 2001-2014 – statistical tables (NCJ 250150). Hayes, L. M. (2013). Suicide prevention in correctional facilities: Reflections and next steps. Washington, DC: Bureau of Justice Statistics. https://www.bjs.gov/index.cfm?ty= International Journal of Law and Psychiatry, 36, 188-194. pbdetail&iid=5867 Hayes, L. M. (2016). Training curriculum and program guide on suicide detection and prevention Shea, S. C. (2002). The practical art of suicide assessment: A guide for mental health in jail and prison facilities: Instructor’s manual. Mansfield, MA: National Center on Institutions professionals and substance abuse counselors. Lexington, KY: Mental Health Presses. and Alternatives. White, T. W. (1999). How to identify suicidal people: A systematic approach to risk assessment. Ivanoff, A., Jang, S. J., Smyth, N. J., & Linehan, M. M. (1994). Fewer reasons for staying alive Philadelphia, PA: Charles Press. when you are thinking of killing yourself: The brief reasons for living inventory. Journal of ZeroSuicide. https://zerosuicide.sprc.org/toolkit/identify/screening-and-assessing-suicide- Psychopathology and Behavioral Assessment, 16, 1-13. doi: 10.1007/BF02229062 risk#footnote2_qcsd5s8

30 NCCHC – AFSP Treatment Training

Brown, C. K., Have, T. T., Henriques, G. R., Xie, S. X., Hollander, J. E., & Beck, A. T. (2005). Barry, L. C., Wakefield, D. B., Trestman, R. L., & Conwell, Y. (2016). Active and passive suicidal Cognitive therapy for the prevention of suicide attempts. Journal of the American Medical ideation in older prisoners. Crisis, 37(2), 88-94. DOI: 10.1027/0227-5910/a000350 Association, 294, 563-570. Centers for Disease Control and Prevention. (n.d.) Strategic direction for the prevention of Bryan, C. J., & Rudd, D. M. (2018). Brief cognitive behavioral therapy for suicide prevention. suicidal behavior: Promoting individual, family, and community connectedness to prevent New York, NY: Guilford. suicidal behavior. https://www.cdc.gov/violenceprevention/pdf/Suicide_Strategic_Direction_ Full_Version-a.pdf Fagan, T. J., Cox, J., Helfand, S. J., & Aufderheide, D. (2010). Self-injurious behavior in correctional settings. Journal of Correctional Health Care, 16, 48-66. Cheatle, M. D. (2011). Depression, chronic pain, and suicide by overdose: On the edge. Pain Medicine, 12(Suppl. 2), S43-S48. doi: 10.1111/j.1526-4637.2011.01131.x Galynker, I. (2017). The suicidal crisis. New York, NY: Oxford Press Hirsch, J. K., Duberstein, P. R., & Unützer, J. (2009). Chronic medical problems and distressful Jobes, J. A. (2016). Managing suicidal risk: A collaborative approach (2nd ed.). New York, NY: thoughts of suicide in primary care patients: Mitigating role of happiness. International Guilford. Journal of Geriatric Psychiatry, 24, 671-679. doi: 10.1002/gps.2174 Junker, G., Beeler, A., & Gates, J. (2005). Using trained observers for suicide watch in a federal Insomnia and suicide attempts. (2016, October). Suicide Prevention Resource Center. correctional setting: A win-win solution. Psychological Services, 2, 20-27. https://www.sprc.org/news/insomnia-suicide-attempts Linehan, M. M., Korslund, K. E., Harned, M. S., Gallop, R. J., Langu, A., & Neasciu, A. D. (2015). National Commission on Correctional Health Care. (2016). Substance use disorder treatment Dialectical behavior therapy for high suicide risk in individuals with borderline personality for adults and adolescents (position statement). https://www.ncchc.org/substance-use- disorder. JAMA Psychiatry, 72, 475-482. disorder-treatment-for-adults-and-adolescents National Action Alliance for Suicide Prevention: Transforming Health Systems Initiative Work National Commission on Correctional Health Care. (2018a). Standards for health services in Group. (2018). Recommended standard care for people with suicide risk: Making health care jails. Chicago, IL: Author. suicide safe. Washington, DC: Education Development Center. https://theactionalliance.org/ sites/default/files/action_alliance_recommended_standard_care_final.pdf National Commission on Correctional Health Care. (2018b). Standards for health services in prisons. Chicago, IL: Author. National Commission on Correctional Health Care. (2018a). Standards for health services in jails. Chicago, IL: Author. Townsend, M., & Morgan, K. (2017). Essentials of psychiatric mental health nursing concepts of care in evidence-based practice (7th ed.). Philadelphia, PA: F. A. Davis. National Commission on Correctional Health Care. (2018b). Standards for health services in prisons. Chicago, IL: Author. Way, B., Kaufman, A., Knoll, J., & Chlebowski, S. (2013). Suicidal ideation among inmate-patients in state prison: Prevalence, reluctance to report, and treatment preferences. Behavioral Stanley, B., Brown, G. K., Brenner, L. A., Galfalvy, H. C., Currier, G. W., Knox, K. L., . . . Sciences & the Law, 31, 230-238. Green, K. L. (2018). Comparison of the safety planning intervention with follow-up vs usual care of suicidal patients treated in the emergency department. JAMA Psychiatry, 75, 894-900. Yaseen, Z. S., Galynker, I. I., Cohen, L. J., & Briggs, J. (2017). Clinicians’ conflicting emotional responses to high suicide-risk patients—Association with short-term suicide behaviors: A prospective pilot study. Comprehensive Psychiatry, 76, 69-78.

Suicide Prevention Resource Guide 31 Introduction Assessment Treatment Training References Design Case Studies

FACILITY DESIGN Creating a Physical Environment That Supports Well-Being

A comprehensive physical plant glazed window openings. Technology and furniture must be carefully selected be given to those inmates who have assessment is an essential component should be used to support the phys- to prevent any opportunity for an limited access to movement, programs, of a carefully thought-out suicide ical observation of inmates by staff. inmate to affix a ligature. Where small and other amenities, including those prevention plan. While it is not gaps or voids may be present, they under suicide precaution. possible to design a “suicide-proof” should be filled with tamper-resistant cell, best practices for planning and security-grade caulking or grout. Excessive noise, which is prevalent design can mitigate the risk. These Physical Characteristics Many manufacturers today provide in correctional institutions, can lead practices relate to operations, products that are designed to be to sleep loss and fragmentation. Careful review of all of the physical appropriate fixtures and furnishings, suicide resistant. Such noise should be mitigated attributes of the environment is and the environmental quality through the strategic use of acoustical required to identify unsuspected or of cells and living units. These materials. Observation cells should mundane objects that inmates could practices must be considered as have natural light and exterior views, utilize as ligature devices. Visibility working in concert, not individually. Environmental Aspects as there is evidence that greater is critical when monitoring suicidal exposure to daylight can reduce inmates. Inmate cells should be The environmental quality of a space stress and depression, and the glazed to the greatest extent possible, has a profound impact on health and absence of windows has been linked Planning Considerations allowing staff to view the interior of a wellness. Although this is important to higher rates of anxiety. Windows cell in its entirety. Floor drains and air to consider for all inmates and staff in also provide the feeling of connection It is essential for staff to be able to vents, plumbing and lighting fixtures, a correctional facility, priority should to the outside world, which can be perform their duties in a safe and beneficial to mental health restoration efficient manner. Thoughtful consid- and recovery. eration must be given to how staff will perform their rounds, respond to The buildings in which we work and emergencies, and maintain visual and reside must support the mission audial control of their surroundings. and activities that take place within Obstacles that impede efficient them. By eliminating features and movement and visibility should be characteristics of a space that might avoided, which will affect the location be considered vulnerabilities with of staff and nurse workstations in regard to safety, and including relation to observed cells, corridor features that have been shown to locations and connections, and improve wellness, we can be assured that the design of a facility meets Photo: Hudson County Correctional Center the mission of health and safety.

32 NCCHC – AFSP Suicide Prevention Resource Guide 33 Introduction Assessment Treatment Training References Design Case Studies

CASE STUDY Hudson County Correctional Center, New Jersey

Six deaths in nine months – four of procedures and staff training. Edwards Transforming Health Care An innovative move was to place the them suicides –at Hudson County found that 90% of the people entering nurses station inside the medical Correctional Center in Kearney, NJ, the facility had a mental health and/ Also Prevents Suicides housing unit. Stepdown housing is rocked the facility staff, county officials, or substance abuse issue, and all in the same unit, on the other side of Ultimately, Edwards and his team fellow inmates, and the community of the individuals to recently die by the nurses station. This close contact identified numerous changes aimed and made headlines in the region. suicide had had such problems. ensures better patient care and at transforming the culture around Most suicides were happening soon strengthens teamwork among health inmate health care as a whole, not Hudson County wasn’t the only jail after arrival, sometimes by “frequent staff and correctional officers. The only suicide prevention. The 30-year- to experience a rise in suicides. fliers” and by those arrested on cells also have a nurse call button old facility was ill-equipped to handle Fueled by drug addiction, mental nuisance charges. He also found for more proactive care. the needs of a population with illness, and, often, a combination that the nurses performing intake complex health, mental health, and of the two, suicide had been on the screening needed additional training “Jails usually design the infirmary substance abuse needs. So, during rise in jails across New Jersey for to assess for suicide risk, and that like an isolation unit,” says Edwards. this same period, the jail built a several years. staff in general needed to improve “Now, with all of these pieces in the modern medical housing unit with their skills at crisis assessment and same housing unit, people get to Director of Corrections Ronald a variety of cells/beds for infirmary intervention. know each other. There are more eyes Edwards, MAS, was determined to care and other special needs. watching and more ears listening.” turn this trend around. Director since A crucial step was to convene an Suicide prevention was integral to The nurses were given whistles to August 2017, and deputy director informal task force with medical, the design of the 54-bed unit. help keep them safe should a patient for a year before that, Edwards had mental health, and corrections act out. Improved design features are not been in charge very long, but personnel, as well as advisors from straightforward and commonsense. after 25 years with the jail he had a the community: people who worked Edwards brought in Dennis Sandrock, All cells in the unit now have ligature- good sense of what did – and didn’t at the local psychiatric hospital, PhD, CCHP, regional mental health resistant components: bunk, stool, – work. He knew that tweaking the crisis centers, and suicide helplines. director of the jail’s health services wall-mounted desk, toilet, light fixture, policies and procedures was not They met monthly to brainstorm on vendor at the time, to help with vents. Lighting has been improved. enough, nor was refresher training solutions and develop plans. the effort. Sandrock reviewed and for correctional officers. Radical The cells doors have larger windows strengthened policies, procedures, change was needed. for greater two-way visibility. The and training on suicide prevention, three suicide observation cells have and developed separate training The first step was to examine the a camera with monitors at the nurses modules geared to mental health circumstances surrounding the cases, station and custody control room staff and to nursing staff. Over a as well as the jail’s assessment for additional “eyes-on” capability. three-week period, each of the 43 nurses took part in a four-hour,

34 NCCHC – AFSP off-site training session. “We wanted the nurses to feel that they were Change – Cultural, Structural, and Procedural – Essential to Suicide Prevention helping to solve the issues and save people’s lives,” says Edwards. At Hudson County Correctional Center, these improvements have been implemented: • Updated suicide prevention policies and procedures To sharpen the patient-centered • Granted the desk sergeant authority to place individuals at risk (based on a brief questionnaire) on close focus, staff are instructed to greet observation until they can see a mental health counselor patients in a personal manner, • Expanded the mental health staff with additional counselors introducing themselves by name. • Hired counselors who are bilingual (primarily Spanish) Edwards also identified a high level • Greatly expanded availability of interpreter services in the medical unit of burnout among the mental health • Added a second emergency response code: 911 is called immediately for nonresponsive inmates professionals and worked to improve • Strengthened medical grievance and ombudsman programs the environment for them.

“This approach changed the Many initiatives are ongoing: atmosphere immediately,” says • Provide thorough four-hour suicide assessment training for every nurse Edwards. Health care grievances • Conduct 24/7 receiving screening by an RN, with a health assessment by an RN within 4 hours have dropped by about 67% in • Check the electronic health record of every new arrival for medical, mental health, and substance use two years. He also credits a new history, including past prescription medications ombudsman program with addressing • Provide a suicide blanket to all new intakes until cleared all problems cited by inmates even • Provide evidence-based medical care for detoxing patients if they don’t rise to the level of a • When possible, pair up patients on suicide watch and/or leave the cell door open grievance. • Reduce suicide watch shifts to two hours (vs. eight), and require officers to remain on their feet during those shifts While all of this was happening, the • Certify all correctional officers in cardiopulmonary resuscitation jail switched to a new health services • Address staff burnout and improve interpersonal communication between caregivers and patients vendor, and Edwards says the buy-in to the suicide-prevention culture was immediate. He points to several cases where suicide was averted due to efforts by staff. “Everybody understands: we are a team,” he says. “We work together to heal these people and save lives.”

Suicide Prevention Resource Guide 35 Introduction Assessment Treatment Training References Design Case Studies

CASE STUDY Middlesex Jail and House of Correction, Massachusetts

After an inmate at the Middlesex Jail A number of proactive measures mental health. The posters provide The required number of hours of and House of Correction died by were recommended and put in place. a phone number that is manned 24/7 suicide prevention training has suicide, his phone records revealed Many of them were relatively easy to by jail staff trained to respond doubled, both for new hires and that in the days leading up to his institute, but are proving to have big immediately and appropriately to for all staff. And additionally, the death, he had placed an alarmingly impact on the culture and practices such concerns. Middlesex Sheriff’s Office has high number of calls to his family – within the facility. worked with the National Institute calls that went unanswered. Calls go to an in-house dispatcher of Corrections (NIC) to host crisis One of those things is the placement who fills out a form so that all pertinent intervention team (CIT) training open Now, the jail has set up a system to of posters in visiting areas and other information is gathered. He or she to offices across the Commonwealth. monitor records for unusual activity, public spots, urging family members then contacts mental health or such as high numbers of unconnected and friends to contact jail officials if medical staff, who immediately see “Mental health has become so much calls or hang-ups, that might provide they are worried about a loved one’s the inmate and determine if further more important in our training,” says a clue to an inmate’s state of mind, mental health evaluation or assessment Superintendent Osvaldo Vidal. “The indicate a crisis and, potentially, is needed. entire staff is very aware of mental save a life. health issues and the risks for suicide. An automated recording with a Everyone is much more apt now That is one way that the Billerica, similar message is now included to report it or call for mental health Mass., facility has boosted its at the beginning and end of every follow-up if they see something suicide prevention efforts, after phone call so that both incarcerated concerning.” a comprehensive audit of its individuals and their loved ones processes, policies and procedures know that help is available and how Another cultural change is the conducted by a leading expert in to access it. awareness of times and situations suicide prevention in corrections that can put people at particular whom Middlesex Sheriff Peter “Families can play a key role in risk for suicidal behavior, such as Koutoujian brought in as a proactive suicide prevention,” says Special after receiving an update about their measure. Not willing to accept the Sheriff Shawn Jenkins. “We have case, sentence or denial of parole. cold comfort that some suicides are been surprised by the numbers of Jail staff are now more cognizant not preventable, Koutoujian called phone calls we receive. Many family that a visit or phone call from an for a deeper dive. “Even one suicide members have told us how much attorney, law enforcement officer or is one too many,” he says. they appreciate having a place to other outside agent can mean bad call, and it helps us immeasurably.” news for the inmate, signaling the need for closer observation.

36 NCCHC – AFSP The department improved suicide prevention screening by adding a much more thorough assessment of mental health to the intake process and increased the level of privacy for the interviews, allowing individuals to speak more openly.

Simple structural improvements also have been implemented. To create suicide-resistant cells, hooks were removed, holes in metal bedframes were filled, sharp-edged sprinklers were replaced with flushed sprinkler heads, and suicide-resistant beds are now placed in the middle of the cells to improve visibility.

A suicide is “The measures seem to be working,” Jenkins reports. “We have had a lot not a routine of phone calls, but we have not had matter; it’s a any completed suicides or significant attempts since this all went into great loss. effect.” Sheriff Koutoujian told the New England Center for Investigative Reporting, “A suicide is not a routine matter; it’s a great loss.”

Suicide Prevention Resource Guide 37 NCCHC STANDARD B-05 Suicide Prevention and Intervention

Suicides are prevented when possible by implementing prevention Discussion efforts and intervention. Although many suicides are unpredictable, a suicide prevention program can help reduce risks. Inmates may become suicidal at any point during their stay, Compliance Indicators but high-risk periods include the following: 1. The responsible health authority and facility administrator approve the a. Upon admission (e.g., 2 to 14 days following incarceration) facility’s suicide prevention program. b. Following new legal problems (e.g., within 48 hours of a court appearance, 2. A suicide prevention program includes the following: new charges, additional sentences, institutional proceedings, denial of a. Facility staff identify suicidal inmates and immediately initiate parole) precautions. c. After admittance to segregation or single-cell housing b. Suicidal inmates are evaluated promptly by the designated health d. After the receipt of bad news regarding self or family (e.g., serious illness, professional, who directs the intervention and ensures follow-up as the loss of a loved one) needed. e. After suffering humiliation (e.g., sexual assault) or rejection Acutely suicidal c. inmates are monitored by facility staff via constant f. Pending release after a long period of incarceration observation. Nonacutely suicidal d. inmates are monitored by facility staff at In addition, juveniles in an adult correctional setting and inmates in the early unpredictable intervals with no more than 15 minutes between checks. stages of recovery from severe depression may be at risk. 3. The use of other inmates in any way (e.g., companions, suicide- prevention aides) is not a substitute for staff supervision. A treatment plan should be developed or revised for any inmate expressing 4. Treatment plans addressing suicidal ideation and its reoccurrence are suicidal ideation. This treatment plan should be developed by the mental developed. health staff in conjunction with the patient to address relapse prevention and 5. Patient follow-up occurs as clinically indicated. initiate a risk management plan. The risk management plan should describe 6. All aspects of the standard are addressed by written policy and defined signs, symptoms, and the circumstances in which the risk for suicide is likely procedures. to recur; how recurrence of suicidal thoughts can be avoided; and actions the patient or staff can take if suicidal thoughts do occur. Definitions Acutely suicidal (active) inmates are those who are actively engaging in self- Key components of a suicide prevention program include the following: injurious behavior and/or threaten suicide with a specific plan. a. Training. All staff members who work with inmates are trained to recognize verbal and behavioral cues that indicate potential suicide and how to Nonacutely suicidal (potential or inactive) inmates are those who express respond appropriately. Initial and at least annual training is provided. current suicidal ideation (e.g., expressing a wish to die without a specific b. Identification. The receiving screening form contains observation threat or plan) and/or have a recent history of self-destructive behavior. and interview items related to potential suicide risk. If a staff member identifies someone who is potentially suicidal, the inmate is placed on suicide precautions and is referred immediately to mental health staff (see E-02 Receiving Screening).

38 NCCHC – AFSP c. Referral. There are procedures for referring potentially suicidal inmates i. Intervention. There are procedures addressing how to handle a suicide and those who have attempted suicide to qualified mental health attempt in progress, including appropriate first-aid measures. professionals or facilities. The procedures specify a time frame for j. Notification. Procedures state when correctional administrators, outside response to the referral. authorities, and family members are notified of attempted or completed d. Evaluation. An evaluation, conducted by a qualified mental health profes- suicides. sional, determines the level of suicide risk, level of supervision needed, k. Reporting. Procedures for documenting the identification and monitoring and need for transfer to an inpatient mental health facility or program. of potential or attempted suicides are detailed, as are procedures for Patients are reassessed regularly to identify any change in condition reporting a completed suicide. indicating a need for a change in supervision level or required transfer l. Review. There are procedures for mental health, medical, and administrative or commitment. The evaluation includes procedures for periodic follow-up review, including a psychological autopsy, for completed suicides. For assessment after the individual’s discharge from suicide precautions. details, see A-09 Procedure in the Event of an Inmate Death. e. Treatment. Strategies and services to address the underlying reasons m. Debriefing. There are procedures for offering timely debriefing to all (e.g., depression, auditory commands) for the inmate’s suicidal ideation affected personnel and inmates. Debriefing is a process whereby are to be considered. The strategies include treatment needs when the individuals are given an opportunity to express their thoughts and feelings patient is at heightened risk for suicide as well as follow-up treatment about an incident (e.g., suicide or attempt), develop an understanding interventions and monitoring strategies to reduce the likelihood of relapse. of stress symptoms resulting from the incident, and develop ways to f. Housing. Unless constant supervision is maintained, a suicidal inmate is deal with those symptoms. Debriefing can be done by an in-house not isolated but is housed in the general population, mental health unit, response team or outside consultants prepared to handle these highly or medical infirmary and located in close proximity to staff. All cells or stressful situations. rooms housing suicidal inmates are as suicide-resistant as possible (e.g., without protrusions that would enable hanging). An active approach to the management of suicidal inmates is recommended. g. Monitoring. There are procedures for monitoring an inmate identified In facilities where 24-hour mental health staff coverage is not present, designated as nonacutely suicidal. Unpredictable, documented supervision is health and/or custody staff should be able to initiate suicide precautions maintained, with irregular intervals no more than 15 minutes apart. until the qualified mental health professional on call can be contacted for Although several protocols exist for monitoring suicidal inmates, when an further orders. Only designated qualified mental health professionals should acutely suicidal inmate is housed alone in a room, continuous monitoring be authorized to remove an inmate from suicide precautionary measures. by staff should be maintained. Other supervision aids (e.g., closed circuit television, inmate companions or watchers) can supplement, but never A suicide or suicide attempt can be a stressful event for staff and other substitute for, direct staff monitoring. inmates. Where feasible, persons trained in debriefing procedures should h. Communication. Procedures for communication between mental health, be used. Practical guidelines on the debriefing process are available from medical, and correctional personnel regarding inmate status are in place organizations such as the International Critical Incident Stress Foundation. to provide clear and current information. These procedures include From Standards for Health Services in jails and prisons, National Commission on Correctional communication between transferring authorities (e.g., county facility, Health Care, 2018 medical/psychiatric facility) and facility correctional personnel.

Suicide Prevention Resource Guide 39 Acknowledgments and Thanks

American Foundation for Suicide Prevention Suicide Prevention Summit Task Force

Jill Harkavy-Friedman, PhD, Vice President, Research Karen Abram, PhD, Professor of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine/Associate Director, Health Disparities and Public Alex Karydi, PhD, Program Manager, Project 2025 Policy Program Christine Moutier, MD, Chief Medical Officer Jeffrey Alvarez, MD, CCHP-P, CCHP-A, Chief Medical Officer, Western States, NaphCare Michael Rosanoff, MPH, Senior Director, Project 2025 Sharen Barboza, PhD, CCHP-MH, Vice President, Mental Health, Centurion Steven Bonner, MD, CCHP-MH, Mississippi Statewide Director of Psychiatry, Centurion National Commission on Correctional Health Care Jerry Boyle, Founder, Correct Care Solutions/Board Member, Wellpath Danielle Bradshaw, DO, Regional Psychiatric Director, Corizon Health Brent Gibson, MD, MPH, CAE, CCHP-P, Chief Health Officer Mariann Burnetti-Atwell, PsyD, CCHP, Chief Executive Officer, Association of State and Edward Harrison, former President Provincial Psychology Boards Loretta Reed, Project Manager Daniel L. Conn, MBA, CCHP, President and Chief Executive Officer, Wexford Health Sources Debbie Savaiano, Customer Service Specialist Kristen Dauss, MD, Chief Medical Officer, Indiana Department of Correction Tracey Titus, RN, CCHP-RN, CCHP-A, Vice President, Accreditation Charlene Donovan, PhD, MSN, RN, PMHNP-BC, Vice President, Behavioral Health Services, Wellpath Jim Donovan, Vice President, Business Development, Wellcare Health Plans William Elliott, PhD, Licensed Clinical Psychologist, National Presenter (Treating Cluster B Personality Disorders), PESI Health Care Seminars and Continuing Education Authors Elizabeth Ford, MD, Chief of Psychiatry, NYC Health and Hospitals Corporation Correctional Health Services Sharen Barboza, PhD, CCHP-MH, Vice President, Mental Health, Centurion Brent Gibson, MD, MPH, CAE, CCHP-P, Chief Health Officer, National Commission on Russell Blair, DNP, MSN, RN, CCHP, Assistant Professor and Associate Chair of Nursing for Correctional Health Care Administration, Maria College Uduakobong Ikpe, PhD, JD, Vice President, Behavioral Health, Wellpath Gregory Cook, AIA, CCHP, Justice Principal, HDR Architecture, Inc. Nneka Jones Tapia, PsyD, Clinical Psychologist, Leader in Residence, Chicago Beyond William Elliott, PhD, Licensed Clinical Psychologist, National Presenter (Treating Cluster B Personality Disorders), PESI Health Care Seminars and Continuing Education Carl Keldie, MD, CCHP, Chief Clinical Officer, Wellpath Edward Kern, MD, Director of Psychiatry, Alabama Department of Corrections Edward Kern, MD, Director of Psychiatry, Alabama Department of Corrections William Kissel, MS, CCHP-MH, Regional Vice President, Jail Operations, Wellpath John May, MD, CCHP, Chief Medical Officer, Centurion

40 NCCHC – AFSP Jim McLane, Chief Executive Officer, NaphCare Editors Barbara Granner, CCHP, Marketing and Communications Manager, National Commission on Dana Neitlich, MSW, Regional Vice President, Operations, Centurion Correctional Health Care Cassandra Newkirk, MD, MBA, CCHP, Chief Psychiatric Officer, Wellpath Jaime Shimkus, CCHP, Vice President, Communications, National Commission on Correctional Joseph Pastor, MD, MHM, CCHP, Chief Psychiatry Officer, Corizon Health Health Care Joseph V. Penn, MD, CCHP-MH, Director, Mental Health Services, University of Texas Medical Branch (UTMB) Correctional Managed Care/Clinical Professor, UTMB Department of Psychiatry Graphic Design Kevin Meyers, Meyers Design Inc. Peter Perroncello, MS, CJM, CCT, CCHP, Jail Management Consultants LLC Ashley Phelps, PhD, Regional Mental Health Director, Corizon Health Donna N. Sewell, PhD, LCSW, Corporate Mental Health Director, NaphCare Ronald Smith, PsyD, CCHP-P, Corporate Vice President, Behavioral Health Clinical Services, Wexford Health Sources Dana Tatum, PhD, MS, CCHP, Chief Behavioral Health Officer, Armor Correctional Health Services Abdi Tinwalla, MD, CCM, CCHP, Forensic Psychiatric Consultant, Wexford Health

Senior Reviewer

Lindsay Hayes, MA, Project Director, National Center on Institutions and Alternatives

Case Studies

Sheriff Peter Koutoujian, Middlesex House of Correction, Massachusetts Special Sheriff Shawn Jenkins, Middlesex House of Correction, Massachusetts Superintendent Osvaldo Vidal, Middlesex House of Correction, Massachusetts Ronald Edwards, MAS, Director of Corrections, Hudson County (NJ) Correctional Center in Kearney Dennis Sandrock, PhD, CCHP, Regional Mental Health Director, Wellpath