Suicide is a global public health problem: In 2012, there were an estimated 800,000 deaths worldwide, and by 2020, this figure is expected to rise to 1.53 million. This represents an annual, global, age-standardized suicide rate of 11.4 per 100,000 population. The figures suggest that death by suicide causes a significant public health problem which is likely to be underrepresented due to differences in reporting systems, the sensitive nature of the topic, and the legality of suicide in some countries. Whatever the shortcomings of current underreporting, it is a fact that rates of self-harm and suicide are far higher among offender populations than the general population. That means that assessing who is at risk and determining how best to intervene are important topics. This entry addresses self-harm and suicide in prisons, offender suicide and self-harm risks factors, and management of suicide and self-harm in prisons, including psychological interventions and problem-solving skills.
Self-Harm and Suicide in Prisons
Rates of self-harm and eventual suicide in prisons far exceed the rate within the general population. Estimates of self-harm differ within different offender populations and by country. Part of the reason for these differences surrounds how selfharm is defined. That being said, research has estimated that between 30% and 49.4% of prisoners worldwide engage in some self-harming behavior, with the rate reportedly higher in females. A case-control prison study estimated that the annual incidence of self-harm of people in custody was between 5% and 6% for men and teenage boys and between 20% and 24% for women and adolescent girls. The measurement of, and thus the exacerbated risk of, self-harm behavior in prison is particularly difficult because individuals often repeatedly harm themselves and such repetition has been shown to increase the risk of ultimate suicide. Eventual suicides are 5 times higher in male prisoners and 20 times higher in females than in general population controls. As many as 1.8% of people who harm themselves die by suicide in the year following the incident, and in the offender community, as many as 8.5% die by suicide over a 22-year period.
Risk Factors
Two systematic reviews have examined the risk factors associated with self-harm in prisons. Evidence from these reviews and other studies suggests that White ethnic origin, a history of self-harm, mental disorders, substance misuse, violent offending, and suicidal ideas are risk factors for self-harm and attempted suicides. Additionally, the risk of death is highest in the immediate period after prison reception. In male prisoners, deaths occur most typically in local adult prisons in the United Kingdom or in jails in the United States. These prisoners are particularly vulnerable while on remand and awaiting a sentencing decision. What is difficult to ascertain is that such risk factors are already exacerbated in the prisoner population, making it challenging to identify those most at risk and to determine how to intervene.
Management and Interventions
Management of self-harm and attempted suicide in prisons often represents a logistically complex challenge, not least because of where the individual is accommodated and its associated environment. Most prisons (80%) in the United States and all in the United Kingdom adhere to a Suicide Prevention Policy. However, a review of U.S. prisons suggested that only 15% of prisons meet clinical recommendations for the scope of these policies. In the United Kingdom, a scheme referred to as Assessment of Care and Custody Teamwork is used as a mechanism for developing a care plan and monitoring someone who is deemed to be at risk. This management tool facilitates communication between staff and prisoner, linking risk factors to level of risk in order to ascertain the best possible approach. The Assessment of Care and Custody Teamwork system provides multidisciplinary support to prisoners at risk of harming themselves. The plan encourages staff to work together to provide individual care to prisoners in distress, to help defuse a potentially suicidal crisis, or to help individuals with long-term needs (e.g., those with a pattern of repetitive self-injury). Prisoners are fully involved in the Assessment of Care and Custody Teamwork process and their individual care plan with the aim of reducing distress.
Psychological Interventions to Reduce and Prevent Suicide
Evidence surrounding how best to treat people who self-harm in prison is limited. Treatment in the United Kingdom has focused on monitoring and safety (as opposed to treatment per se) to ensure that staff are vigilant in their approach. Two systematic reviews have evaluated the impact of psychological interventions in reducing self-harm behavior in the general population within the community; however, possible treatment options for offender populations in the United Kingdom have only been tested in two pilot randomized controlled trials (RCTs) of cognitive behavioral therapy and interpersonal psychotherapy and a feasibility study of problem-solving skills.
Cognitive Behavioral Interventions
Evidence for the effectiveness of cognitive behavioral therapies comes from a host of studies in the general population, including those focusing on suicidal behaviors. The evidence suggests such interventions are most effective when specifically targeted and designed to focus on suicidality. In addition, in 2011, cognitive behavioral therapy was recommended by the National Institute for Health and Clinical Excellence as one of the recognized treatments for reducing suicidal ideation.
Although this evidence is limited to community populations, one study evaluated the impact of cognitive behavioral treatment for offenders in prison. This study used a pilot RCT to compare a cognitive behavioral therapy in addition to treatment as usual in a group of 62 participants. The trial specified the primary outcome of self-harm behavior within 6 months. A number of secondary outcomes were also measured including suicidal ideation, psychiatric symptomology, personality dysfunction, and psychological determinants of suicide including depression and hopelessness. The authors found that participants receiving the therapy (in addition to usual care) showed a significantly greater reduction in suicidal behavior in comparison to participants receiving usual care only. A number of other significant improvements were reported, including a reduction in psychiatric symptomology and personality dysfunction. The study showed that the delivery of a cognitive behavioral therapy was feasible within the prison environment and showed significant promise for evaluating the therapy in a larger RCT.
Interpersonal Psychotherapy Interventions
The second trial employed the use of interpersonal psychotherapy with women in prison. The findings of the study showed general improvements in both groups across depression, hopelessness, and suicidal intent. This suggested that for women to improve they might not necessarily require intensive interpersonal psychotherapy treatment. In this trial, the intervention employed varied between four and eight sessions of therapy lasting 50 min per session.
Problem-Solving Interventions
Two systematic reviews provide tentative support for the use of problem-solving techniques in the repetition of self-harm behavior, and an updated review shows inconsistent findings for evidence to support improvement in subsequent problem-solving skills. The first of these reviews combined 2 of 6 RCTs for the treatment of deliberate self-harm behavior (containing a total of 71 and 55 individuals assigned to the intervention and control groups, respectively). The results overall showed that patients who were offered the therapy had significantly greater improvement in scores for depression and hopelessness and also, importantly, reported a greater level of improvement in their problems in comparison to those in the control group. However, because the trials were relatively small, concerns were raised about the lack of statistical power, poor description of standard care, and the inconsistent age ranges across the studies.
The second review formed part of a larger Cochrane systematic review focusing on psychological therapies for self-harm and included trials comparing problem-solving interventions alongside standard treatment. The problem-solving meta-analysis showed a trend toward reduced repetition of self-harm with problem-solving therapy compared with standard aftercare. Since these original reviews, a subsequent meta-analysis including the addition of two new trials shows modest effects in favor of problem-solving therapy for the treatment of repetition of self-harm in the community.
The last review presented an update of the original Cochrane review. This review identified greater inconsistencies which stem from a number of fundamental differences between the presentation of the results and the other reviews. Only four of the known seven problem-solving studies used to assess intervention impact on improved individual problem-solving skills (and not repetition of self-harm) were presented in one model. The authors found the model of analyses were changed by one study which applied a Zelen design, altering the significance of the studies overall impact.
Nevertheless, problem-solving therapy is an obvious choice because so many people who harm themselves report the main immediate cause as being problems in their lives. It is also known that poor problem-solving skills are associated with impulsive responses. Such actions often result in not thinking through all possible solutions to a problem and relying upon the actions of others, or waiting for a problem to resolve itself before taking an action.
The theory behind social problem-solving stems from a concept originally outlined by psychologists Burrhus Skinner and James Davis in the 1950s and 1960s. These influential psychologists were among the first to identify problem-solving as a self-directed cognitive behavioral process. The process involves an individual attempting to identify or discover effective or adaptive ways of coping with problematic situations. They argued that the role of coping within problem-solving was recognized through the use of two different information processing systems. These are referred to as the automatic or experiential system and the nonautomatic or rational system which includes rational problem-solving. Automatic responses often result in rapid decision-making and are instinctively validated as the right decision. In contrast, the rational system is a somewhat slower process whereby the person takes his or her time to deliberate and as a consequence makes a logical decision based on all the available evidence.
The link between suicide and self-harm behavior and problem-solving skills has been demonstrated by a number of researchers. In particular, research by Thomas D’Zurilla noted that individuals who are suicide prone have negative thoughts and feelings about problems. Such individuals often perceive problems as some sort of a threat to their well-being. As a result, they tend to blame themselves for problems when they occur and doubt their own ability to solve problems effectively. These suicide prone individuals are more likely to view problems as unsolvable and to feel distressed and upset when faced with a problem.
Other characteristics of suicide prone individuals include a host of other negative behaviors. These are often associated with an avoidance of problems. For example, instead of facing problems as they arise, and being persistent in their problem-solving efforts, suicide prone individuals are likely to either avoid problems or respond impulsively. This leads to individuals putting off their problems for as long as possible, waiting for problems to resolve themselves, or trying to shift the responsibility for solving problems on to others. When responding impulsively, the person does attempt to solve problems, but these attempts are not well thought out. Avoidant and impulsive responses are not likely to result in effective problem-solving and thus risk reinforcing the negative beliefs and feelings.
A New Model
A study funded by the National Institute of Health Research in the United Kingdom evaluated the feasibility of implementing a problem-solving training model for prison staff and prisoners at risk of repeat self-harm. This study was conducted in four prisons in the North of England and considered whether it is possible to train prison staff (i.e., chaplaincy, management, prison officers, education, and health-care staff) and for those staff to cascade the skills to prisoners at risk of suicide and self-harm behavior. The study is using an adaptation of a community problem-solving model which was originally devised in New Zealand for patients at risk of self-harm in the community. The adaptation process was thought to be important to ensure that both staff and patients felt that the training and intervention delivery was applicable and relevant to the prison setting. The study resulted in training 280 staff, and 48 prisoners at risk received the intervention. The training used a series of case studies and featured the seven-step problem-solving model:
Step 1: Getting the right attitude—The first step involves identifying whether the client has a negative attitude toward problem-solving (i.e., avoiding problems, being frustrated by problems and taking impulsive actions) versus someone who has a positive attitude (i.e., facing the problem, taking steps to solve it, and using a rationale problem-solving approach).
Step 2: Reflecting and recognizing triggers—The training introduces the idea of recognizing problems and trigger factors; the process of problem-solving involves getting the client to identify thoughts, behaviors, feelings, and physical symptoms associated with his or her particular problem.
Step 3: Defining a problem clearly—Selecting and defining a problem is helpful in turning ill-defined problems such as “My life is a mess” into a well-defined problem which the client has control over. Picking suitable problems will use criteria including ease of solution (quick wins boost confidence), urgency, or salience to the prisoner.
Step 4: Brainstorming solutions—Facilitators are asked to work with a client to discuss what possible options are available to resolve or improve the situation. Brainstorming is a method of generating as many possibilities and alternative solutions to the problem without evaluating the potential usefulness. It is useful to split solutions into the practical (i.e., steps to reduce or resolve problems) and the emotional (i.e., steps to deal with the consequences of problems that can’t be immediately resolved).
Step 5: Decision-making—Once the client has identified a number of potential solutions, the next step is decision-making. In this stage, a more in-depth examination of the solutions allows the individual to weigh the advantages and disadvantages of potential solutions. The next step is for the individual to identify which of the potential solutions he or she would like to work and develop a plan for how to tackle the problem.
Step 6: Making a plan—The final stages of problem-solving involve the client implementing or carrying out an action plan. This should be a step-by-step process that is used to transform the chosen solutions into concrete actions. A specific, measurable, achievable, relevant, time-bound plan which is focused around when, where, whom, and how is key to a successful plan. Potential barriers need to be identified and addressed when the plan is not successfully carried out or the problem is not solved. The important elements of the process also involve the facilitator reviewing progress with the client to evaluate whether the plan is underway, whether it is having the desired impact, whether any more needs to be done in relation to the problem, and to understand the key areas which may need to be fine-tuned.
Step 7: Reviewing the process—The reviewing process plays an important role in the reflection and ongoing management of an individual who is attempting to problem solve. At this stage in the process, the reflection offers an opportunity to identify how effective the solution to the problem was and to identify whether the action plan worked, whether he or she would have done anything differently if he or she were to try again, and if any obstacles prevented the plan from happening. In essence, the problem-solving approach is a skill which helps an individual to gain confidence in dealing with a range of complex issues.
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