Predicting dynamic risk factors for suicide ideation in prisoners: perceived entrapment and goal management in the context of the IMV Model Rachael Miller DClinPsy Thesis (Volume 1), 2019 University College London 1 UCL Doctorate in Clinical Psychology Thesis declaration form I confirm that the work presented in this thesis is my own. Where information has been derived from other sources, I confirm that this has been indicated in the thesis. Signature: Name: Rachael Miller Date: 21/06/19 2 Overview This thesis focuses on management of suicide and self-harm in prisoners. The literature review (Part 1) is a narrative systematic review of the impact of psychological interventions on suicide and self-harm outcomes applied with offenders in secure correctional facilities. The review highlights the lack of high quality studies in this area and the vast range of different outcome measures used to assess risk of self-harm and suicide. Evaluation of study quality lends itself to a comprehensive discussion of recommendations for future research. The empirical research paper (Part 2) is part of a joint research project (Schombs, unpublished thesis). The research describes a cross-sectional questionnaire based study aiming to further investigate the pathway between feelings of entrapment (internal and external) and suicide ideation suggested by the Integrated Motivational-Volitional model (IMV; O’Connor, 2011), within a prison population. It also aims to further our understanding of mechanisms that may contribute to an individual’s perception of entrapment, specifically goal adjustment and goal perception (e.g. how important a goal is or how ambivalent someone is about setting and achieving goals). Results of this study offer further insight into the relationship between entrapment and suicide, and more specifically, adds to previous findings of differential effects of internal and external entrapment. Discussion expands on the concept of entrapment and the meaning of this for prisoners. Part 3, the Critical Appraisal, discusses the challenges and barriers faced in carrying out research with prison populations and the important factors and considerations highlighted during data collection. Finally, clinical implications of the empirical study are discussed within the context of current UK practices in the management of suicide and self-harm in prisons. 3 Impact Statement Improvement in the area of prisoner safety in terms of suicide and self-harm has wide implications and the impact of this research can be discussed as spanning three different areas. Research This study highlights gaps that future research can address, particularly in improving the quality of psychological intervention studies for self-harm and suicide in prisons, and the need for use of standardised outcome measures. The prison setting introduces challenges that can affect the scientific rigour of studies and suggestions are made for how this can be addressed, for example, through multi-site research, and standardised treatment for control groups. This research also highlights the importance of considering how entrapment is conceptualised and thus measured within a prison setting, given the restrictive context of the setting. Future research may develop a prison-specific measure of entrapment or use qualitative methods to gain a richer understanding of the meaning of entrapment for prison populations. Results support that there is an important role for entrapment and poor social support in relation to suicide ideation in prisoners and therefore this study adds to a growing literature base for this population. Very little research has investigated prisoner goals and goal adjustment, and this study has highlighted the need for greater attention in this area. Clinical This research has shown that psychological interventions in prisons can give some positive results in improving suicide and self-harm outcomes, as well as related psychological factors including depression, anxiety, problem solving deficits and hopelessness. Prison clinicians and/or staff should consider the routine application of 4 Cognitive Behaviour Therapy (CBT) informed interventions, and other therapies, for at-risk prisoners. Further, feelings of entrapment and poor social support are modifiable factors and therefore can be targeted, where indicated, for those at risk of suicide. Measures of entrapment could be administered by reception staff to new arrivals as part of prevention strategies. Support is offered for the current management practices in prisons i.e. the nationally used Assessment, Care in Custody and Teamwork framework (ACCT). There is also some preliminary evidence to support prisoners to identify and engage with new goals and explore their perceptions of their goals. As an institution, a prison can consider environmental factors that promote social support and limit feelings of entrapment. On a wider scale, these ideas could also be incorporated into policies and training. Societal This current research provides insight into the lack of psychological interventions available to prisoners experiencing thoughts of suicide and/or self- harm. Mental health, substance misuse, trauma and other psychological problems have been linked to offence behaviour. Improved knowledge about identifying and treating these issues not only has positive implications for offenders and their families, but also improves the safety of the public. Reductions in suicide and self- harm in prisons would in-turn impact on demands on prison resources and levels of staff burnout, which also has implications for public spending. 5 Contents Overview……………………………………………………………………………..3 Impact statement……………………………………………………………………4 List of Tables………………...………………………………………………………8 List of Figures………………………………………...……………………………..8 Acknowledgements………………………………………………………………….9 Part 1: Literature review ………………………………………………… ………10 Abstract……………………………………………………………………………...11 Introduction……………………………………………………………………......12 Suicide and self-harm……………………………………………………………….12 Secure correctional facilities………………………………………………………..13 Interventions for suicide and self-harm……………………………………………..14 Focus of current review……………………………………………………………..17 Method……………………………………………………………………………...18 Design……………………………………………………………………………….18 Population…………………………………………………………………………...18 Interventions………………………………………………………………………...18 Comparators………………………………………………………………………...18 Study design……………………………………………………………………...…19 Outcomes……………………………………………………………………………19 Additional parameters………………………………………………...…………….19 Search strategy………………………………………………………………………20 Quality assessment…………………………………………………………….........21 Results………………………………………………………………………………21 Database search results……………………………………………………………...21 Data extraction………………………………………………………………………22 Study design…………………………………………………………………...……23 Settings…………………………………………………………………………...…23 Participant characteristics…………………………………………………………...23 Primary outcomes…………………………………………………………………...24 Quality of studies……………………………………………………………………33 Interventions………………………………………………………………………...36 Intervention characteristics………………………………………………………….36 Control groups………………………………………………………………………36 Cognitive Behavioural Therapy…………………………………………………….37 Problem Solving…………………………………………………………………….42 Dialectical Behaviour Therapy……………………………………………………...43 Interpersonal therapies………………………………………………………………45 Combined approaches……………………………………………………………....49 Suicide and self-harm outcomes…………………………………………………….50 Behavioural outcomes……………………………………………………………....51 Psychological outcomes…………………………………………………………….56 Discussion………………………………………………………………………......57 Limitations…………………………………………………………………………..61 Clinical implications………………………………………………………………...62 Future research……………………………………………………………………...64 Conclusion…………………………………………………………………………..67 References………………………………………………………………………….68 6 Part 2: Empirical paper ………………………………………………………......85 Abstract……………………………………………………………………………...86 Introduction………………………………………………………………………..88 Risk factors for suicide in prisons………………………………………………......89 Entrapment and suicide…………………………………………………………......91 Goal adjustment, goal perceptions and suicide…………………………………......93 Study aims and hypotheses………………………………………………………….96 Method……………………………………………………………………………...97 Joint research project………………………………………………………………..97 Participants………………………………………………………………………….97 Procedure…………………………………………………………………………..100 Missing data………………………………………………………………………..101 Ethics………..……………………………………………………………………..102 Design……………………………………………………………………………...102 Measures…………………………………………………………………………...102 File information…………………………………………………………………....103 Predictor measures………………………………………………............................106 Outcome measures…………………………………………………………………106 Data analysis……………………………………………………………………….107 Results……………………………………………………………………………..109 Participant demographics………………………………………………………….109 Predicting suicide ideation…………………………………………………………112 Moderation…………………………………………………………………………117 Discussion…………………………………………………………………………118 Entrapment…………………………………………………………………………11 9 Goals……………………………………………………………………………….123 Suicide ideation findings………………………………………………………......124 Strengths and limitations…………………………………………...……………...125 Clinical implication…………………………………………………...…………...127 Future recommendations for research…………………………...………………...128 Conclusions………………………………………………………...……………...130 References…………………………………………………………………………131 Part 3: Critical Appraisal …………………………...…………………………..145 Overview………………………………………………...………………………...146 Personal motivations.………………………………...…………………………....146 Challenges