Managing suicidal behaviour in prison

Prisoner suicide is an area where medical and correctional cultures share the same objectives of prevention. It is unfortunately also where the differences of approach are often conducive of conflict rather than co-operation. Suicidal and self-damaging behaviour in prison cannot be usefully conceptualized merely as the produce of depressive or other psychiatric disorder. Though mental disorder plays a role (previously overstated, currently often almost totally discounted) equally important is the impact of the prison environment on vulnerable and impulsive young people with limited coping capacities. Suicidal and self-damaging behaviours often run through prisons like epidemics when the aggravating factors in the institutional milieu reduce the threshold for the emergence of such behaviour and imitation does the rest. (5.ยง>

To understand the fluctuating level of suicide risk in an individual prisoner it is necessary to integrate the interaction of immediate stresses on a vulnerable individual in a potentially highly stressful environment.(60) The following factors are of relevance in the individuals current level of suicidal or self-damaging potential.

!. Personality vulnerabilities which include impulsivity, and a tendency to hopelessness and suspiciousness with a lack of trust which isolates them from sources of social support.

2. Past self-damaging behaviours.

3. Substance abuse particularly in withdrawal phase or when there is continuing intoxication (prisons aspire to be drug-free environments but this is rarely achieved).

4. The nature of the prisoner's offending history and their likely consequences. Risk is particularly high in those who face, or have recently received, long sentences and in those whose crimes have induced intense guilt and self-blame.

5. The prisoner's physical health. In prison as in the community, chronic painful illness and fatal diseases predispose to suicidal behaviour.

6. The factors in the prison environment which place stress on the prisoner include:

a. fear produced by victimization and intimidation from fellow prisoners or even from prison staff;

b. social isolation;

c. loss of all the usual supports of status and even identity;

d. powerlessness to control what happens and to a large extent what is done to the prisoner;

e. physically spartan conditions;

f. lack of meaningful activities productive of boredom;

g. humiliations which all too often form part of the daily lot of many prisoners.

Against these potential prison stressors can be balanced elements in the prison environment which may be supportive and protective including:

a. prison practices which acknowledge the prisoner's individuality and provide meaningful support;

b. effective anti-bullying policies (currently many prisons have vulnerable prisoner units where victims are sent and by which they are stigmatized; it would be preferable to establish bully units which deal with the problem by isolating bullies and exposing them to remedial programmes);

c. occupation and activities which include education and training which give realistic hopes for the future;

d. encouragement of social contact;

e. buddy schemes;

f. opportunities to maintain, through visits in decent surroundings, contact with relatives and friends outside of the prison.

7. Mental disorders which are not confined to primarily depressive states but also include anxiety states and schizophrenic and paranoid disorders. Psychologically it is perhaps a pervasive sense of hopelessness, from whatever cause, which is of greatest importance.(6!)

8. The interaction of pre-existing vulnerabilities, current mental disorder, and prison environment produce a fluctuating level of vulnerability which is tipped towards suicidal behaviours by situational triggers including:

a. loss of a significant relationship with someone outside or inside the prison;

b. change and disruption of social networks produced, for example by moves between prisons or between units;

c. bullying and victimization;

d. isolation (sometimes imposed as punishment occasionally as 'suicide prevention');

e. the example of suicidal and self-damaging behaviour by fellow prisoners;

f. disappointments of expectations (e.g. of parole, appeal, transfer).

Factors involved in suicide prevention include the following.

!. Institutional change to minimize prison-induced stress and maximize protective factors.

2. The early recognition and treatment of mental disorder.

3. The recognition of potential stressors.

4. A rapid response to any intensifying of distress and associated suicidal inclination.

Recognizing distress is not always easy in a prison population even if there is the inclination to look for the cues. Distress in this population can manifest in increased surliness, non-compliance with regulations, social withdrawal, and increased anger. Any change in behaviour and emotional state here, as so often, is a cause for concern.

Unfortunately, responding to a perceived suicide risk can lead to a conflict between correctional attitudes and health-care approaches. Correctional cultures tend to emphasize prevention strategies centring on removing the physical means of suicide. This can encourage the placement of suicidal prisoners in isolation cells bereft not only of hanging points but of character and company. In similar vein a series of suicides in a correctional facility is likely to be followed by a flurry of removing hanging points and restructuring cells. Attention to those elements in prison practice which might effectively reduce suicide risk take a back seat. Mental health service responses can be equally lacking in variety, relying on managing the perceived depression as the central, if not sole, intervention. Prison suicides usually occur because of a fatal concatenation of a wide range of risk factors. Reducing suicide has to involve an equally diverse response to those risk factors.

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