More times than not, we do an admirable job of safely managing inmates identified as suicidal and placed on suicide precautions. After all, few inmates successfully commit suicide while on suicide watch. When they do, you can surely expect to incur liability. What we continue to struggle with is the ability to prevent the suicide of an inmate who is not easily identifiable as being at risk for self-harm. Kay Redfield Jamison, a prominent psychologist and author, has best articulated the point by stating that if “suicidal patients were able or willing to articulate the severity of their suicidal thoughts and plans, little risk would exist” [Jamison, K. R. (1999), Night Falls Fast: Understanding Suicide, New York, Knopf, at page 150]. With this in mind, the following guiding principles to suicide prevention are offered.

1) The assessment of suicide risk should not be viewed as a single event, but as an on-going process. Because an inmate may become suicidal at any point during confinement, suicide prevention should begin at the point of arrest and continue until the inmate is released from the facility. In addition, once an inmate has been successfully managed on, and discharged from, suicide precautions, they should remain on a mental health caseload and assessed periodically until released from the facility.

2) Screening for suicide during the initial booking and intake process should be viewed as something similar to taking one’s temperature – it can identify a current fever, but not a future cold. The shelf life of behavior that is observed and/or self-reported during intake screening is time-limited, and we often place far too much weight upon this initial data collection stage. Following an inmate suicide, it is not unusual for the mortality review process to focus exclusively upon whether the victim threatened suicide during the booking and intake stage, a time period that could be far removed from the date of suicide. If the victim had answered in the negative to suicide risk during the booking stage, there is often a sense of relief expressed by participants of the mortality review process, as well as a misguided conclusion that the death was not preventable. Although the intake screening form remains a valuable prevention tool, the more important determination of suicide risk is the current behavior expressed and/or displayed by the inmate.

3) Prior risk of suicide is strongly related to future risk. At a minimum, if an inmate had been placed on suicide precautions during a previous confinement in the facility or agency, such information should be accessible to both correctional and health care personnel when determining whether the inmate might be at risk during their current confinement.

4) We should not rely exclusively on the direct statements of an inmate who denies that they are suicidal and/or have a prior history of suicidal behavior, particularly when their behavior, actions and/or history suggest otherwise. Often, despite an inmate’s denial of suicidal ideation, their behavior, actions, and/or history speak louder then their words. For example:

In Washington State, an inmate was booked into a county jail and informed the intake officer that she had a history of mental illness, had attempted suicide two weeks earlier, but “will not hurt herself in jail.” Jail records indicated that the inmate threatened suicide during a recent prior confinement in the facility. The inmate attended a court hearing two days later and the escort officer noticed that she appeared despondent, was crying, and appeared worried about her children. She was not referred to mental health staff, nor placed on suicide precautions. The inmate committed suicide the following day.

In Michigan, police were called to the home of a man who accidentally shot and killed a friend during a domestic dispute with his estranged wife. Upon arrival of the police, the suspect placed a handgun to his head and clicked the trigger several times. He also encouraged the officers to shoot him. Following five hours of negotiations, the suspect surrendered without incident. He was transported to the county jail and denied being suicidal during the intake screening process. The inmate was not referred to mental health staff, nor placed on suicide precautions. He committed suicide the following day.

It is not all that surprising that these preventable deaths often escape our detection. Take, for example, the booking area of a jail facility. It is traditionally both chaotic and noisy; an environment where staff feel pressure to process a high number of arrestees in a short period of time. Two key ingredients for identifying suicidal behavior – time and privacy – are at a minimum. The ability to carefully assess the potential for suicide by asking the inmate a series of questions, interpreting their responses (including gauging the truthfulness of their denial of suicide risk), and observing their behavior is greatly compromised by an impersonal environment that lends itself to something quite the opposite. As a result, the clearly suicidal behavior of many arrestees, as well as circumstances that may lend themselves to potential self-injury, are lost.

In yet another example, a suicidal inmate may appear to be stable in front of a mental health clinician, even deny suicide risk, only to be discharged from suicide precautions and returned to the correctional facility from a hospital where they again revert to the same self-injurious behavior that prompted the initial referral. Given such a scenario, correctional staff should not assume that the clinician was cognizant or even appreciative of this cyclical behavior. On the contrary, regardless of what the clinician might have observed and/or recommended, as well as the inmate’s denial of risk, whenever correctional staff hear an inmate verbalize a desire or intent to commit suicide, observe an inmate engaging in suicidal behavior or otherwise believe an inmate is at risk for suicide, they should take immediate steps to ensure that the inmate’s safety.

5) Facility officials must provide both pre-service and annual suicide prevention training to all staff. While implementing suicide precautions for an inmate that verbally threatens suicide requires little training, identifying suicidal behavior of inmates unwilling and/or unable to articulate their feelings, or who deny any ideation, requires both pre-service and annual training. Simply stated, correctional staff, as well as medical and mental health personnel, cannot detect, make an assessment, nor prevent a suicide for which they have little, if any, training.
All suicide prevention training must be meaningful, i.e., timely, long-lasting information that is reflective of our current knowledge base of the problem. Training should not be scheduled to simply comply with an accreditation standard. A workshop that is limited to an antiquated videotape, or recitation of the current policies and procedures, might demonstrate compliance (albeit wrongly) with an accreditation standard, but is not meaningful, nor helpful, to the goal of reducing inmate suicides. Without regular suicide prevention training, staff often make wrong and/or ill-informed decisions, demonstrate inaction, or react contrary to standard correctional practice, thereby incurring unnecessary liability.

6) Many preventable suicides result from poor communication amongst correctional, medical and mental health staff. Communication problems are often caused by lack of respect, personality conflicts, and other boundary issues. Simply stated, facilities that maintain a multidisciplinary approach avoid preventable suicides. As aptly stated by one clinician:

The key to an effective team approach in suicide prevention and crisis intervention is found in throwing off the cloaks of territoriality and embracing a mutual respect for the detention officer’s and mental health clinician’s professional abilities, responsibilities and limitations. All of us, regardless of professional affiliation, need to make a dedicated commitment to come forward and acknowledge that suicide prevention and related mental health services are only effective when delivered by professionals acting in unison with each other. Just as the security officer alone can not ensure the safety and security of the jail facility, neither can the mental health clinician alone ensure the safety and emotional well-being of the individual inmate [Severson, M. (2005), “Security and Mental Health Professionals Revisited: Still a (too) Silent Partnership? Jail Suicide/Mental Health Update, 14 (3):1-7, at page 4].

7) On size does not fit all and basic decisions regarding the management of a suicidal inmate should be based upon their individual clinical needs, not simply on the resources that are said to be available. For example, if an acutely suicidal inmate requires continuous, uninterrupted observation from staff, they should not be monitored via CCTV simply because that is the only option the system chooses to offer. A clinician should never feel pressured, however subtle that pressure may be, to downgrade and/or discharge an inmate from suicide precautions because additional staff resources (e.g., overtime, post transfer, etc.) are required to maintain the desired level of observation. Although they would never admit it, clinicians have prematurely downgraded, discharged, and/or changed the management plan for a suicidal inmate based upon pressure from correctional officials.

8) We must avoid creating barriers that discourage an inmate from accessing mental health services. Often, certain management conditions of a facility’s policy on suicide precautions appear punitive to an inmate (e.g., automatic clothing removal/issuance of safety garment, lockdown, limited visiting, telephone, and shower access, etc), as well as excessive and unrelated to their level of suicide risk. As a result, an inmate who becomes suicidal and/or despondent during confinement may be reluctant to seek out mental health services, and even deny there is a problem, if they know that loss of these and other basic amenities are an automatic outcome. As such, these barriers should be avoided whenever possible and decisions regarding the management of a suicidal inmate should be based solely upon the individual’s level of risk.

9) Few issues challenge us more than that of inmates we perceive to be manipulative. It is not unusual for inmates to call attention to themselves by threatening suicide or even feigning an attempt in order to avoid a court appearance, or bolster an insanity defense; gain cell relocation, transfer to the local hospital or simply receive preferential staff treatment; or seek compassion from a previously unsympathetic spouse or other family member. Some inmates simply use manipulation as survival technique.

Although the prevailing theory is that any inmate who would go to the extreme of threatening suicide or even engaging in self-injurious behavior is suffering from at least an emotional imbalance that requires special attention; too often we conclude that the inmate is simply attempting to manipulative their environment and, therefore, such behavior should be ignored and not reinforced through intervention. Too often, however, a feigned suicide attempt goes further than anticipated and results in death. Recent research has warned us that we should not assume that inmates who appear manipulative are not also suicidal, i.e., they are not necessarily members of mutually exclusive groups.

Although there are no perfect solutions to the management of manipulative inmate who threat suicide or engage in self-injurious behavior for a perceived secondary gain, the critical issue is not how we label the behavior, but how we react to it. The reaction must include a multidisciplinary treatment plan.

10) As previously noted, few suicides take place when inmates are managed on suicide precautions. Rather, most deaths suicides take place in “special housing units” (intake/booking, classification, disciplinary/administrative segregation, mental health, etc.) of the facility. One effective prevention strategy is to create more interaction between inmates and correctional, medical and mental health personnel in these housing areas by: increasing rounds of medical and/or mental health staff, requiring regular follow-up of all inmates released from suicide precautions, increasing rounds of correctional staff, providing additional mental health screening to inmates admitted to disciplinary/administrative segregation, an avoiding lockdown due to staff shortages (and the resulting limited access of medical and mental health personnel to the units).

11) A lack of inmates on suicide precautions should not be interpreted as meaning that there are no currently suicidal inmates in the facility, nor a barometer of sound suicide prevention practices. We cannot make the argument that our correctional systems are increasingly housing more mentally ill and/or other high risk individuals and then state there are not suicidal inmates in our facility today. Correctional facilities contain suicidal inmates every day; the challenge is to find them. The goal should not be “zero” number of inmates on suicide precautions; rather the goal should be to identify, manage and stabilize suicidal inmates in our custody.

12) We must avoid the obstacles to prevention. Experience has shown that negative attitudes often impede meaningful suicide prevention efforts. These obstacles to prevention often embody a state of mind that unconditionally implies that inmate suicides cannot be prevented (e.g., “If someone really wants to kill themselves there’s generally nothing you can do about it” and/or “We did everything we could to prevent this death, but he showed no signs of suicidal behavior,” etc.) There are numerous ways to overcome these obstacles, the most powerful of which is to demonstrate prevention programs that have effectively reduced the incidence of suicide and suicidal behavior within correctional facilities. As one administrator has offered: “When you begin to use excuses to justify a bad outcome, whether it be low staffing levels, inadequate funding, physical plant concerns, etc., issues we struggle with each day, you lack the philosophy that even one death is not acceptable. If you are going to tolerate a few deaths in your jail system, then you’ve already lost the battle” [Hayes, L. (2005), “Model Suicide Prevention Programs: Part II,” Jail Suicide/Mental Health Update, 14 (2): 1-6, at page 6].

13) We must create and maintain a comprehensive suicide prevention program that includes the following essential components: staff training, intake screening/assessment, communication, housing, levels of supervision, intervention, reporting, follow-up/morbidity-mortality review.