Psychiatric Annals

CORRECTIONAL PSYCHIATRY: EFFECTIVE AND SAFE LINKASE OF MENTALLY ILL OFFENDERS 

Prevention of Suicide in a Large Urban Jail

Anderson Freeman, PhD; Carl Alaimo, PsyD

Abstract

We describe a successful suicide prevention program in a large urban jail. By doing so, we hope to offer clinicians, correctional administrators, and correctional health care advocates an opportunity to examine the specific efforts that have been made by a large urban correctional facility to reduce suicides. First, however, we review salient statistics on inmate suicide and briefly review the literature on jail suicide.

STATISTICS

The incidence of suicide, both attempted and completed, has always been high in jails and prisons. According to Bureau of Justice Statistics, during 1993 and 1994 more than 400 detainees took their lives annually.1 In a national study of jail suicides published in 1989, it was calculated that there were 107 suicides per 100,000 detainees.2 This rate was 9 times greater than the rate in the general nonincarcerated population during the same period. The New York State Commission of Corrections reported that suicide rates within jails in New York State averaged 42.2 per 100,000 admissions for 1988 through 1997.3 This figure is considered improved; the rate in New York State was as high as 177 deaths per 100,000 detainees in 1984. Similar rates were noted for Texas county jails, which averaged 58 suicides per 100,000 detainees from 1986 through 1995.4 Their rates had peaked at 151 per 100,000 detainees in 1984.

LITERATURE REVIEW

Most of the literature on jail suicide implicates combinations of situational factors, detainee adjustment and coping factors, and conditions of confinement in suicidal behavior. These factors clearly differentiate the dynamics of suicidal behavior in jails from those of suicidal behavior in other settings. Although most authors indicate the presence of multiple precipitating factors, it is clear that they all agree that incarceration can be a uniquely overwhelming experience that has strong implications for suicidal behavior.2,5-9

Hayes2 states that the precipitating factors for suicidal behavior in jails are well established. He cites the two primary causes of inmate suicide as the jail environment and the crisis situation that the inmate is facing. Environmental factors include fear of the unknown, distrust of an authoritarian environment, lack of control over the future, isolation from family and significant others, shame of incarceration, and dehumanizing aspects of incarceration. Factors in the crisis situation that predispose an inmate to suicide include recent excessive drinking, use of drugs, or both; recent loss of stabilizing resources; severe guilt or shame over the alleged offense; current mental illness; history of suicidal behavior; and approaching court date.

In a later publication, Hayes5 distinguished characteristics of suicide situations in jails in large urban centers and jails in general. Detainees who complete suicide in large urban jails are more apt to be charged with violent crimes; recent intoxication is not a factor, and the suicide does not always occur immediately after incarceration. Hayes contrasts these factors with those associated with suicide in smaller jails and lockups, where a typical suicide profile would include a nonviolent offense, recent intoxication, isolation from others, youthfulness, white ethnicity, and a completed suicide within 24 hours of incarceration.

Table

Vignette 2. Mr. M, a 26-year-old African American man charged with first-degree murder, had been jailed three times previously on drug charges. During intake, he was interviewed by a mental health specialist with a bachelor's degree who administered a primary mental health screening instrument (Table 2). This questionnaire addresses various aspects of psychiatric history, drug and alcohol use, suicide history, and current risk of suicidal behavior, homicidal behavior, or both.

Mr. M reported no history of psychiatric treatment, but admitted to smoking upward of $150 of crack cocaine per day for the past 2 years. He also denied any history…

We describe a successful suicide prevention program in a large urban jail. By doing so, we hope to offer clinicians, correctional administrators, and correctional health care advocates an opportunity to examine the specific efforts that have been made by a large urban correctional facility to reduce suicides. First, however, we review salient statistics on inmate suicide and briefly review the literature on jail suicide.

STATISTICS

The incidence of suicide, both attempted and completed, has always been high in jails and prisons. According to Bureau of Justice Statistics, during 1993 and 1994 more than 400 detainees took their lives annually.1 In a national study of jail suicides published in 1989, it was calculated that there were 107 suicides per 100,000 detainees.2 This rate was 9 times greater than the rate in the general nonincarcerated population during the same period. The New York State Commission of Corrections reported that suicide rates within jails in New York State averaged 42.2 per 100,000 admissions for 1988 through 1997.3 This figure is considered improved; the rate in New York State was as high as 177 deaths per 100,000 detainees in 1984. Similar rates were noted for Texas county jails, which averaged 58 suicides per 100,000 detainees from 1986 through 1995.4 Their rates had peaked at 151 per 100,000 detainees in 1984.

LITERATURE REVIEW

Most of the literature on jail suicide implicates combinations of situational factors, detainee adjustment and coping factors, and conditions of confinement in suicidal behavior. These factors clearly differentiate the dynamics of suicidal behavior in jails from those of suicidal behavior in other settings. Although most authors indicate the presence of multiple precipitating factors, it is clear that they all agree that incarceration can be a uniquely overwhelming experience that has strong implications for suicidal behavior.2,5-9

Hayes2 states that the precipitating factors for suicidal behavior in jails are well established. He cites the two primary causes of inmate suicide as the jail environment and the crisis situation that the inmate is facing. Environmental factors include fear of the unknown, distrust of an authoritarian environment, lack of control over the future, isolation from family and significant others, shame of incarceration, and dehumanizing aspects of incarceration. Factors in the crisis situation that predispose an inmate to suicide include recent excessive drinking, use of drugs, or both; recent loss of stabilizing resources; severe guilt or shame over the alleged offense; current mental illness; history of suicidal behavior; and approaching court date.

In a later publication, Hayes5 distinguished characteristics of suicide situations in jails in large urban centers and jails in general. Detainees who complete suicide in large urban jails are more apt to be charged with violent crimes; recent intoxication is not a factor, and the suicide does not always occur immediately after incarceration. Hayes contrasts these factors with those associated with suicide in smaller jails and lockups, where a typical suicide profile would include a nonviolent offense, recent intoxication, isolation from others, youthfulness, white ethnicity, and a completed suicide within 24 hours of incarceration.

Table

TABLE 1Components of the Cermak Mental Health Services-Cook County Department of Corrections Suicide Prevention Program

TABLE 1

Components of the Cermak Mental Health Services-Cook County Department of Corrections Suicide Prevention Program

Bonner6 explained inmate suicide using a stress vulnerability model. His theory views suicide as a process by which an inmate is (or becomes) ill equipped to handle the common stresses of confinement. As the inmate reaches a breaking point, the result can be suicidal ideation, attempt, or completion. During initial confinement in a jail, these stressors can be limited to fear of the unknown or isolation from family, but over time may become exacerbated and include the loss of outside relationships, conflicts within the institution, victimization, further legal frustrations, physical and emotional breakdown, and problems coping within the jail environment.

Haycock7 examined factors that are related to detainees' emotional functioning and family relationships. He differentiated non-life-threatening and life-threatening suicide attempts and discussed factors associated with life-threatening suicide attempts in jails and prisons. Inmate factors included the use of opiates, intoxication or withdrawal at the time of the attempt, recent family turmoil, and high scores on hostility, depression, and hopelessness measures.

Finally, Felthous8 reviewed the literature on jail suicide and outlined factors that contribute to the risk of it. He implicated the state of mind of the suicidal detainee prior to incarceration and existing mental illness. Felthous stated, "(1) Jails can be extremely stressful places to be, and, combined with the inmate's dreadful legal situation, ominous possibilities of disruption of employment and family ties and other ensuing, destabilizing stressors can precipitate a situational crisis with a hopeless outlook; (2) Before apprehension and jailing, the individual may already have been experiencing an overwhelming crisis, which led to criminal acts and arrest; and (3) Mental illness alone can predispose inmates to take their lives, more or less independent of situational stressors." He supported his third assertion by pointing out that up to 11% of incarcerated individuals have serious mental illness.

PROGRAM DESCRIPTION

In the 10-year period from 1988 to 1998, the jail's receiving unit at Cook County Department of Corrections (CCDOC) averaged 80,000 new detainees annually. The intake at Cook County Jail surpassed 100,000 for the year in December 1998. Given the high volume of new detainees, the stressful conditions of arrest and confinement and the multiproblem profile of the population entering the system at CCDOC, suicide rates could be expected to be high and certainly reflective of the rates historically seen in jails. However, the suicide rates at Cook County Jail have been reduced to a level of fewer than 2 suicides for every 100,000 admissions since 1990.

The comparatively low rate of completed suicides at Cook County Jail, the third largest jail jurisdiction in the United States based on total inmate population, can be directly attributed to a multifaceted program focused on suicide prevention and care of detainees who are at high risk because of their psychiatric status. Specifically, this low rate can be attributed to the set of program components outlined in Table 1.

Mental Health Screening of All New Detainees on Intake

The identification of detainees who are potentially suicidal begins at the CCDOCs "front door." Spread over 100 acres with 14 different divisions classified as minimum, medium, or maximum security that each house up to 1,500 detainees, CCDOC is a "correctional city" with an average daily census of 10,000 detainees. As buses arrive from local lockups across the county, as many as 300 new detainees daily are screened at the Receiving Classification and Diagnostic Center.

Table

TABLE 2Brief Primary Psychological Screening Tool Suicide Assessment Items of the Department of Psychiatry, Cermak Mental Health Services

TABLE 2

Brief Primary Psychological Screening Tool Suicide Assessment Items of the Department of Psychiatry, Cermak Mental Health Services

Detainees enter jail experiencing suicidepotentiating dysphoric states that include anxiety, guilt, shame, depression, hopelessness, sadness, anger, and psychomotor agitation. These mental and emotional states may be reactions to arrest and confinement, and may also reflect preexisting and chronic psychological conditions. In addition, these detainees may be predisposed to suicide when examinations of their backgrounds reveal histories of suicidal behavior, limited coping and social skills, dysfunctional families, educational and employment failures, substance abuse and addiction, and social alienation. These factors, along with high rates of major psychiatric disorders, make the proper screening of detainees before they join the general population of the jail a critical first step in suicide prevention.

It is the job of the mental health staff assigned to the receiving room to screen each new detainee as he or she enters the jail system and identify those who are in critical need of psychiatric assistance and potentially suicidal. During an afternoon and late-evening shift, 7 days a week, an average of 5 to 7 receiving room staff members use a combination of structured questionnaires, clinical observation, and experience from conducting thousands of screenings to accomplish their task. A licensed clinical psychologist supervises and trains them and coordinates their activities. The following vignette is an example of a typical screening that culminates in an admission to the acute care psychiatric unit.

Table

TABLE 3Secondary Psychological Screening Tool Items of the Department of Psychiatry, Cermak Mental Health Services

TABLE 3

Secondary Psychological Screening Tool Items of the Department of Psychiatry, Cermak Mental Health Services

Vignette 2. Mr. M, a 26-year-old African American man charged with first-degree murder, had been jailed three times previously on drug charges. During intake, he was interviewed by a mental health specialist with a bachelor's degree who administered a primary mental health screening instrument (Table 2). This questionnaire addresses various aspects of psychiatric history, drug and alcohol use, suicide history, and current risk of suicidal behavior, homicidal behavior, or both.

Mr. M reported no history of psychiatric treatment, but admitted to smoking upward of $150 of crack cocaine per day for the past 2 years. He also denied any history of suicide attempts and suicidal or homicidal ideation at intake. On closer questioning, the mental health specialist elicited that Mr. M was charged with murdering his mother. He spoke sofìly, appeared disheveled, and tears welled up in his eyes several times during the brief interview. Later he became mute and refused to answer further questions.

The mental health specialist conducted a secondary interview immediately (Table 3). The secondary interview determined whether Mr. M. should be referred for admission to the acute care psychiatric unit. A more in-depth assessment, the secondary interview includes questions about mental status and background information designed to both elicit risk factors for suicide and detect mental instability.

Although Mr. M was unresponsive to secondary interview questions, he was referred for admission to the acute care psychiatric unit based on his despondent behavior and the fact that he was charged with murdering his mother. He also was considered high risk because of possible depression related to cocaine withdrawal. His disheveled appearance suggested possible underlying mental illness, an unstable living situation, and possible cognitive impairments related to substance withdrawal. These factors increase concerns about suicidal behavior.

The entire evaluation process takes less than 20 minutes. Brevity that does not undermine accuracy is important in screening when 300 other individuals are waiting for primary screenings. An irony of screening in a correctional setting is that often detainees who are most at risk do not readily or willingly reveal symptoms that indicate their need for assistance. Conversely, detainees who are malingering to avoid placement in the general population of the jail may quickly verbalize suicidal ideations, a plan, and a method of killing themselves. At CCDOC, the receiving room staff are taught to err on the side of caution whenever suicidal preoccupations are verbalized or indicated by a detainee's profile. The questionnaire items most relevant to detecting proneness to suicide and the presence of mental instability are listed in Tables 2 and 3.

Inpatient Care of Detainees Who Aie Acutely IU and Suicidal

The post-screening care of suicidal detainees initially takes place on a 58-bed inpatient psychiatric unit for men and a 24-bed unit for women located on the jail grounds that is part of Cermak Mental Health Services. After a medical assessment in the health services emergency department, any detainee who is considered to be at risk for suicide is immediately transported by correctional officers to the inpatient unit. Immediately on entering the acute care unit, suicidal detainees are assessed by a nurse and a mental health specialist. A psychiatrist evaluates the suicidal detainee during the first 8 hours that he or she is on the unit and continues to monitor the detainee while he or she remains in acute care treatment.

Psychological assessments conducted by psychologists are often used to rule out malingering and help develop treatment plans. Emergency procedures, including close observation, medical restraints, and therapeutic seclusion, may be initiated by clinical staff and followed with orders from physicians and psychiatrists for detainees who are highly agitated and suicidal. On-call psychiatrists are available for emergency medication orders during evening and midnight shifts.

Suicidal detainees who are treated on the inpatient unit of Cermak Mental Health Services present a variety of clinical challenges for psychiatrists. Adding to the complexity of patient care are factors such as the extremely high incidence of comorbid disorders, diagnostic uncertainty created by the absence or unreliability of background information provided by detainees, and endemic jail conditions (eg, overcrowding, dehumanization, and deprivation). Approaches to psychiatric treatment vary according to each suicidal detainee's clinical presentation. The appropriate and humane use of medical restraints is an important factor in the low suicide rate at CCDOC. The following case vignette illustrates the complexity of situational and clinical factors associated with the acute care treatment of a detainee who was extremely suicidal.

Vignette 2. Mr. J was a 30-year-old white man who itad been incarcerated for 4 days after being charged with the stabbing death of his wife. Due to his unstable psychological state on admission, Mr. J was housed on the acute care psychiatric unit with the added emergency precaution of medical restraints. He was anxious, agitated, and depressed, and reported mood-related psychotic symptoms. He told clinical staff that he constantly heard the voice of his dead wife telling him to "join her."

Mr. J was experiencing withdrawal symptoms from 3 months of daily cocaine use. Cocaine withdrawal increased the acuity of his depressive symptoms. As his mind cleared, Mr. J became more despondent about the reality of his legal and personal situation. His personal background included physical abuse during childhood, abuse of multiple substances, several prior suicide attempts, numerous head traumas from violent encounters, and recent treatment with methylphenidate that suggested a history of impulsive behavior.

Several hours later, Mr. J was released from restraints after appearing less agitated, assuring mental health staff that he was feeling better, and stating that his mood-related command hallucinations had decreased. He continued to have difficulty sleeping because of intrusive thoughts about the death of his wife. Psychotropic medication was prescribed to help control his ruminations and impulsiveness.

On day 4 of his acute care stay, without warning Mr. J attempted suicide by hanging himself with a sheet. An alert correctional officer rescued him after other detainees called out when they witnessed the hanging attempt. After Mr. J received medical treatment for his injured neck, he continued to report intense suicidal ideations and uncertainty about his ability to control his suicidal impulses. Emergency procedures, including restraints, emergency medication, and close observation, continued for several days until he was stable enough to be discharged to a lower acuity psychiatric unit in the jail.

The strength of the inpatient care system of Cermak Mental Health Services of Cook County is that detainees are continually evaluated and monitored in a therapeutic environment. Psychiatrists, with input from several disciplines, make decisions regarding the detainee's stability for transfer to the jail's general population or whether care should be continued on a low acuity psychiatric care unit. This process also serves to screen out detainees who may be feigning symptoms of suicide and occupying limited space in the inpatient unit. Detainees often use unsophisticated and overly dramatic attempts to feign visual and auditory command hallucinations and deliberately self-inflict superficial injuries to appear suicidal.9

Foliow-Up Services foi Detainees Who Are Suicidal

Follow-up treatment of detainees who are at high risk and have been stabilized is accomplished by referring male detainees to a 286-bed residential treatment unit for intermediate and subacute care and female detainees to a comparable 60-bed unit. Symptoms are monitored daily in a low acuity therapeutic environment within the jail complex. Suicidal detainees whose active symptoms reemerge can be returned immediately to the acute care inpatient unit. In the residential treatment unit's dormitory-style settings for men and mental health tier for women, observations made by correctional officers, nurses, mental health specialists, psychologists, and psychology interns determine whether changes in a detainee's mental status necessitate a return to the inpatient unit for restabilization of suicidal symptoms.

Referral and Crisis Intervention Services for Detainees Housed in the General Population of the jail

After stabilization and the remission of suicidal symptoms, some detainees may be appropriately housed in the general population of the jail. In this population, suicide prevention efforts are accomplished through 24-hour availability of a 2-person crisis team to respond to psychiatric emergencies. Flexible procedures have been established for medical, civilian, and correctional staff to refer to the crisis team detainees who appear to be in need of psychiatric evaluation.

The mental health crisis team stationed in the receiving area of the jail evaluates as many as 8 to 10 "backdoors" (ie, detainees who are referred from general population living units for mental health evaluations) daily. These detainees typically do not come to the attention of psychiatric services at the time of their primary screening on admission. This group may also include detainees who are receiving psychotropic medication in the jail's general population. If they have a psychiatric crisis, cannot adjust to the general population, or have serious problems with their medication before scheduled psychiatry clinic visits, they can be readmitted to an acute care unit. All emergency requests and referrals are responded to immediately.

Community Linkage of Detainees Who Are Suicidal

The court determines when a detainee is released from CCDOC. Detainees cannot be held beyond the point that their court cases are adjudicated unless the judge sentences them to serve time in the jail. When a detainee is determined to be suicidal at the point of release from the jail, special efforts have to be made to certify the individual and petition the court for civil commitment to a state hospital.

Training Procedures for Correctional Officers

A key component of suicide prevention in CCDOC is the training of correctional officers to increase their sensitivity to the mental health needs within a jail population. Officers are trained in identifying potentially suicidal detainees when they enter the Sheriff's 11-week training academy to become correctional officers, and those who are assigned to psychiatric units receive an additional 80 hours of mental health training. Within this additional 2-week training program, 8 hours are dedicated to suicide prevention. The training of officers is essential. Officers' attitudes or insensitivity can affect whether a detainee who is suicidal seeks assistance. Officers' observations can facilitate access to emergency services for a detainee who is potentially suicidal. Officers also assist with the medical restraint process for detainees who are highly agitated and suicidal.

CONCLUSION

The treatment of detainees who are suicidal and the prevention of suicide in jails have improved substantially during the past 20 years. Decreasing national suicide rates attest to this improvement. Generally, increased attention to the plight of incarcerated individuals with mental illness has created an atmosphere of positive change. Specifically, legal actions related to completed suicides,10 greater sensitivity on the part of jail administrators to controlling factors that affect facility management, and greater attention to safety and security in physical plant designs have improved suicide rates.

Health care professionals who have published articles to increase understanding of jail suicide also have helped reduce suicide rates. It is an optimistic sign that although jail populations have increased, suicides in jail have decreased. Organizations such as the National Commission for Correctional Health Care, which sets standards for health care in jails, and the American Correctional Association, which sets standards for conditions of confinement in jails, have greatly contributed to national reductions in jail suicide rates.11'12 It is hoped that the trend will continue with greater attention to quality mental health care and the creation of continuity of care among jail-based programs, state mental health facilities, and community programs.

REFERENCES

1. U.S. Department of Justice. Jails and Jail Inmates 1993-1994. Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics; 1995. Publication NCJ-151651.

2. Hayes LM. National study of jail suicides: seven years later. Psychiatr Q. 1989;60:7-29.

3. New York State Commission of Corrections. Medical Review Boards Statistical Breakdown of Inmate Mortalities by Type of Facilities and Manner of Death (1977-1995). Albany, NY: New York State Commission of Corrections; 3996.

4. Texas Commission on Jail Standards. State standards and suicide prevention: Lone Star. Jail Suicide/Mental Health Update. 1996;6:9-11.

5. Hayes LM. Suicide prevention in correctional facilities: an overview. In: Puisis M, ed. Clinical Practice in Correctional Mediane. St. Louis, MO: Mosby; 1998:245-256.

6. Bonner RL. Isolation, seclusion, and psychological vulnerability as risk factors for suicide behind bars. In: Berman AL, Maris RW, Maltsberger JT, Yufit RL eds. Assessment and Prediction of Suicide. New York: Guilford; 1992:389-419.

7. Haycock J. Manipulation and suicide attempts in jails and prisons. Psychiatr Q. 1989;60:85-98.

8. Felthous AR. Preventing jailhouse suicides. Bulletin of the American Academy of Psychiatry and the Law. 1994;22:477-488.

9. Resrdck PJ. The detection of malingered mental illness. Behav Sei Law. 1984;2:21-38.

10. Harrington v DeVito. U.S. District Court for the Northern District of Illinois Eastern Division, Consent Decree No. 74 C 3290, June 24, 1980:3-7.

11. National Commission on Correctional Health Care. Standards for Health Services in Jails, 3rd ed, Chicago: National Commission on Correctional Health Care; 1996:65-67.

12. American Correctional Association. Standards for Adult Local Detention Facilities, 3rd ed. Laurel, MD: American Correctional Association; 1991:91-92.

TABLE 1

Components of the Cermak Mental Health Services-Cook County Department of Corrections Suicide Prevention Program

TABLE 2

Brief Primary Psychological Screening Tool Suicide Assessment Items of the Department of Psychiatry, Cermak Mental Health Services

TABLE 3

Secondary Psychological Screening Tool Items of the Department of Psychiatry, Cermak Mental Health Services

10.3928/0048-5713-20010701-09

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