Screening for suicide risk in penal institutions in the Netherlands
Published as:
Blaauw, E., Kerkhof, A.J.F.M., Winkel, F.W., & Sheridan, L. (2001). Identifying suicide risk in penal institutions in the Netherlands. British Journal of Forensic Practice, 3(4), 22-28.
Taking up almost half of all deaths in penal institutions suicide is the main cause of death among prisoners. The phenomenon of suicide occurs several times more often among those confined in penal institutions than among a similar age group in the general (male) population (cf. Backett, 1987; Davis & Muscat, 1993; Hayes, 1989; Liebling, 1995). In the period 1987-1998, the prisoners suicide rate in the Dutch prison system was approximately 102 per average daily population of 100.000 prisoners and the suicide rate in the Dutch community was approximately 13 per 100.000. In this period the number of prison suicides increased, which was principally due to the increasing number of prisoners held in the Dutch prison system (Blaauw & Kerkhof, 1999). Although a higher detection rate in prisons as well as different definitions of suicide and a high turnover in prisons may account for a part of the difference, there is sufficient ground to conclude that penal institutions have a relatively high suicide rate.
Prisoner suicides pose a problem, among other things because of the many consequences of such suicides. Suicides in penal institutions seem to indicate that the authorities fail in their responsibilities regarding the health and safety of their prisoners. The gravity of the issue is also illustrated by the many people affected by such an incident, namely prison officers, the psycho-medical staff, fellow prisoners, relatives and partners. For those who discover the deceased, this can be a traumatising experience. Prison officers can develop feelings of guilt for not having interpreted correctly signs that indicated a suicide risk. A suicide confronts fellow prisoners with the proven viability of applying a drastic change to their lives. Suicides may also cause unrest among prisoners, when they have observed signs of suicidal risk that went unnoticed by officers and other prison staff, or when they consider the regime, the work atmosphere, the social climate to be major causes of the suicide. For relatives and partners, coming to terms with a suicide is difficult in itself, but a suicide in a penal institution may be even more painful. The more so, because in general little information is available to the relatives about the situation surrounding a suicide. A suicide can cause much disturbance in the institution and be the cause of negative publicity. Furthermore, the continuous threat of a possible suicide may put much pressure on the institution's staff. In view of the above, i.e. the high number of prisoner suicides and their consequences, both the early identification of prisoners having a high suicide risk and the prevention of suicide are of great importance.
It is not easy to distinguish suicidal prisoners from non-suicidal prisoners. Especially not, when limited information is available on risk factors within a population of prisoners. For many prisoners are characterised by aspects that in a normal population would be indicative of an increased suicide risk, such as being addicted, having a psychiatric history and broken relations in the past (Blaauw, Winkel & Kerkhof, 2001; Blaauw et al., in press). Therefore, it is usually necessary to examine the characteristics that distinguish prisoners with a high suicide risk from 'normal' prisoners. In the Netherlands, this was done in a research project that was carried out by Blaauw and Kerkhof at the request of the Dutch Ministry of Justice (see also Blaauw, Winkel & Kerkhof, 2001; Blaauw et al., in press).
The research project consisted of a records study focusing on the characteristics, conditions of death and possibly identifiable signs prior to the suicides that had been completed in detention centres, prisons and TBS-institutions[1] in the period 1987-1997. To this end files were examined from all agencies and institutions that might have information about the persons who had completed suicide. Also, records were examined at the penal institutions and TBS-institutions where the suicides had occurred. All agencies, bodies and institutions were willing to co-operate. All in all, 95 suicides that had been completed over the period from 1987 to 1998 were examined, i.e. 95 per cent of all suicides having occurred in penal institutions during this period of time.
The research project also consisted of the interviewing of randomly selected non-suicidal prisoners from the regular population of prisoners in the institutions. In the survey, 251 prisoners of 10 detention centres were interviewed. A total of 26 prisoners were excluded from the sample because they had high suicidal ideation or because they had a history of earlier suicide attempts with a high lethality risk. Four prisoners were excluded from the sample because of many missing data. As a result, the final sample consisted of 221 randomly selected prisoners with low suicide risk. On numerous points, these prisoners were representative of the average prisoner population.
The information gathered about the characteristics of the suicide cases was compared with information on the characteristics of the non-suicidal prisoners.
Contrary to some English-speaking countries, the Netherlands did not have an instrument with which to determine the risk of suicide among prisoners. During their confinement procedure, prisoners in Great Britain and in New South Wales, Australia, are screened for suicide risk with the help of the "Form F2169" and "Suicide and Self Harm Risk Assessment" respectively; in penal institutions in the Canadian province of Ontario the "Suicide Checklist" is used (see Arboleda-Florez & Holley, 1988, 1989) and in many states of the USA prisoners are screened for suicide risk on their arrival, using the “Suicide Prevention Screening Guidelines” (see Cox & Morschauser, 1997; Sherman & Morschauser, 1989). An examination of these screening instruments shows that three clusters of issues seem to be important when screening for suicide risk:
1. Present state of suicidal ideation. Examples in the existing instruments are: the presence of suicidal thoughts, hallucinations or death illusions and the presence of a depressive mood.
2. Previous suicide attempts or self-destructive behaviours.
3. Risk factors that may be more or less unrelated to current suicidal risk and previous attempts. Examples are the death of a loved one, previous psychiatric treatments, alcohol and drug abuse and a severe term of imprisonment.
The similarities between the screening instruments suggested that the above three clusters also needed to be represented in the Dutch screening instrument that was to be developed. The Dutch instrument, though, was not designed on the basis of content analysis, but based on the analysis of statistical data. This means that characteristics were included in the screening instrument if they could distinguish suicides from non-suicidal prisoners. In the construction of the screening instrument, a number of content related considerations were taken into account also. The instrument had to be easy to apply, the questions and their scores had to be clear to everyone, and the screening procedure not too time-consuming. Also, the instrument had to be highly sensitive, in order to identify many prisoners with a high suicide risk, and the instrument needed to have a high degree of specificity, to prevent prisoners without an increased suicide risk from being regarded as suicidal.
Not all characteristics that were found to distinguish suicides from non-suicidal prisoners appear in the screening instrument. When selecting the characteristics to be used in the instrument, those characteristics were opted for that made the best distinctions between suicides and non-suicidal prisoners. By making use of logistic regression techniques, each characteristic was considered for its influence on suicidal risk, taking into account the influence of the other characteristics. Each characteristic in the screening instrument was then assigned the logistic regression beta weight, multiplied by 100.
The screening instrument consists of eight questions, each with its corresponding weight. Weighing 27 points, a history of (intramural or outpatient) mental health care has the highest predictive value for suicide risk. It concerns the question whether the prisoner ever received treatment for psychiatric problems (addictions excluded) at the psychiatric department of a general hospital, in a psychiatric hospital, any institute for outpatient mental welfare, or from an independent psychologist or psychiatrist. The lack of a fixed residence in the months prior to confinement (of which the week immediately preceding confinement is the most decisive), weighing 23 points, ranks as the next strongest indicator of an increased suicide risk. Thirdly, belonging to the age group of 40 years and over is a strong indicator of an increased suicide risk: this characteristic weighs 17 points. As the fourth characteristic, weighing 14 points, a past with one previous period of confinement distinguishes clearly between the suicides and the non-suicidal prisoners. A multiple addiction to hard drugs and a history of suicide attempts or self-destructive behaviours[2] appear to be equally important to make a clear distinction; both characteristics weigh 13 points. Addiction as a characteristic applies when during some weeks in his lifetime the prisoner used hard drugs (at least once a week) in combination with soft drugs, large amounts of alcohol or non-therapeutic quantities of medication. Examples of previous suicide attempts or self-destructive behaviours are: taking an overdose of drugs or medication, cutting one's wrists, trying to hang oneself, and trying to come to grief in other ways.
To two important characteristics no statistically determined weight could be assigned. It may be expected, certainly on the basis of the study, that psychiatric disorders, particularly psychotic disorders, are of a highly predictive value as regards the risk of suicide. Therefore, it was decided to give attention in the instrument to prisoners who in the previous five years had contact with a psychologist or a psychiatrist who made such a diagnosis[3]. Recent suicidal expressions, too, or self-destructive behaviours have their predictive value. In this regard, attention was given in the instrument to the prisoner who expressed himself in this manner or showed such behaviour during his stay at the police station, at the courthouse, or during his transportation to the penal institution[4] .
The screening instrument is accurate in indicating prisoners with an increased suicide risk. Between 1987 and 1997, 44 per cent of the suicides had been identified by staff as being suicidal prior to their act. If in the past the instrument had been available, and prisoners scoring 24 points and over had been considered as potentially suicidal, as many as 95 per cent of the suicides would have been identified in advance. Using the instrument, therefore, results in more than twice the number of cases identified[5]. All cases that were identified as suicidal beforehand, would also have been indicated with the help of the instrument. Of much more importance is the fact that 82 per cent of the cases not identified then, would in fact now have been identified with the use of the instrument.
At a demarcation value of 24 points, around 18 per cent of all prisoners are placed in the high-risk of suicide group. Although the majority of these prisoners are not suicidal, probably most of them suffer from serious mental and emotional problems. For, when the separate predictors of suicide risk are considered, it becomes obvious that each of these characteristics points at some degree of special circumstances. During their confinement, prisoners with a history of mental health care will quite often suffer from the problems that required earlier treatment. Of course, prisoners with a psychotic or other psychiatric disorder require extra care, whereas those with no fixed address in many cases experience social or psychological problems. Relatively older prisoners in the institution may feel isolated compared to other, usually much younger, fellow prisoners (being of older age is a risk factor in the community as well). Prisoners who were imprisoned once before, quite often do not feel comfortable during their confinement and prisoners with a history of multiple hard drug abuse still tend to struggle with their addiction problems and withdrawal symptoms. Prisoners with a history of suicide attempts and those who recently expressed themselves as such or showed self-destructive behaviours, also are a cause of concern. In short, the majority of those prisoners who meet one or more characteristics from the screening instrument, probably belong to the group that are usually referred for a further interview[6].
The outcomes of a trial phase also show that prisoners identified with the help of the screening instrument suffer from mental and emotional problems. In three penal institutions the screening instrument was tested on 30 prisoners. The prisoners who in this trial phase were considered as potentially suicidal, appeared to have numerous mental and emotional problems. Usually, after the admission interview most of them would have been referred for a further interview.
It is recommendable to have the screening for suicide risk performed by a prison nurse, because the questions of the screening instrument are likely to have a major overlap with the questions that are usually asked during admission interviews in order to assess mental or addiction problems. In addition, it is recommendable to apply the screening instrument immediately on arrival, because of the fact that relatively many suicides occur during the first hours and nights of confinement (see also Crighton & Towl, 1997).
A prisoner scoring 24 points or more on the instrument and as such belonging tot the high risk group should be referred immediately to a psychologist, psychiatrist or psychiatry-trained nurse for a further diagnostic interview. Almost all prisoners in the high risk group have mental problems, but it is unknown which prisoners from this group (under an unchanging policy) will finally attempt suicide. In order to prevent suicides this entire group should (immediately) receive extra attention, in the shape of a further diagnostic interview to be carried out by trained staff. As in this interview the suicide risk has to be assessed, it is prerequisite that the member of staff conducting the interview has a certain level of training in the identification of mental problems.
In the further diagnostic interview insight must be acquired into the prisoner's suicide risk. Of course, the degree to which the prisoner thinks of attempting suicide must be examined, as well as the content of these thoughts and the preparations he has made. Also, it is important to explore the thoughts, intentions and preparations in connection with possible previous suicide attempts. Motives, provoking factors and mental problems and emotions relating to a possible suicide, too, must be looked into during the further diagnostic interview.
The degree of suicide ideation may differ in the course of time and can be influenced by certain events. Therefore, regular further interviews seem advisable to assess the suicide risk at a later moment in time. It is important to record all findings (the score on the screening instrument, findings during a possible further diagnostic interview as well as possible findings during confinement) on a registration form which can be included in the prisoner's medical file. Inclusion in the medical file promotes the transfer of information between the various members of the medical and mental health staff, and will contribute to the continuity of care in case of relocation to other penal institutions. The next institution will know immediately on arrival which prisoners require extra attention. Also, after relocation it will not be necessary to screen prisoners again.
Early identification of suicidal prisoners is an important first step to reduce the number of suicides in penal institutions. Screening for suicide risk, however, is no more than a first step toward the prevention of suicides. Often numerous preventive measures are required to avert a suicide. For those prisoners who completed suicide and had been previously identified by the institution's staff as being suicidal, often the numerous preventive measures that had been taken to ward off suicide, were to no avail. Further examination of preventive measures against suicide and their effectiveness seems therefore essential to reduce the number of suicides.
The research project resulted in an instrument that may be of great value for penal practice. An identification of 95 per cent of the suicides is over twice as much as the number of those that were identified in the field as being suicidal (before the deed), which is actually more than could have been expected beforehand. Moreover, applying the screening instrument has proved to be easy and require little time and effort. Also, a group of 18 per cent of high risk prisoners should not pose a special problem to penal practice. However, the screening instrument has its value only if all prisoners are subjected to a careful screening with the instrument and if afterwards appropriate measures are taken. The future will tell if the instrument does in fact contribute to the effective prevention of suicide in penal institutions.
Arboleda-Florez, J., & Holley, H.L. (1988). Development of a suicide screening instrument for use in a remand centre setting. Canadian Journal of Psychiatry, 33, 595-598.
Arboleda-Florez, J., & Holley, H.L. (1989). Predicting suicide behaviors in incarcerated settings. Canadian Journal of Psychiatry, 34(7), 668-674.
Backett, S.A. (1987). Suicide in Scottish prisons. British Journal of Psychiatry, 151, 218-221.
Blaauw, E., & Kerkhof, A.J.F.M. (1999). Suďcides in detentie [suicides in prison]. The Hague: Elsevier.
Blaauw, E., Kerkhof, A.J.F.M., & Hayes, L.M. (2000). Identification of suicide risk on the basis of demographic, psychiatric and offence-related characteristics. Manuscript submitted for publication.
Blaauw, E., Kraaij, V., Arensman, E., Winkel, F.W., & Bout, R. (in press). Life-events and suicidal behavior among prisoners. Journal of Traumatic Stress.
Blaauw, E., Winkel, F.W., & Kerkhof, A.J.F.M. (2001). Bullying and suicidal behavior in jails. Criminal Justice and Behavior, 28, 279-299.
Cox, J.F., & Morschauser, P.C. (1997). A solution to the problem of jail suicide. Crisis, 18, 178-184.
Crighton, D., & Towl, G. (1997). Self-inflicted deaths in prison in England and Wales: an analysis of the data for 1988-90 and 1994-95. Issues in Criminological and Legal Psychology, 28, 12-20.
Davis, M.S., & Muscat, J.E. (1993). An epidemiologic study of alcohol and suicide risk in Ohio jails and lockups, 1975-1984. Journal of Criminal Justice, 21, 277-283.
Hayes, L.M. (1989). National study of jail suicides: seven years later. Psychiatric Quarterly, 60, 7-29.
Liebling, A. (1995). Vulnerability and prison suicide. The British Journal of Criminology, 35, 173-187.
Sherman, L.G., & Morschauser, P.M. (1989). Screening for suicide risk in prisoners. Psychiatric Quarterly, 60, 119-138.
[1] TBS is a special hospital order that the judge imposes on people who have been sentenced for a grave crime and who are more or less insane.
[2] For this analysis, the original sample of 251 prisoners was used.
[3] This can be an Axis-1 diagnosis according to the Diagnostic and Statistic Manual of Mental Disorders (DSM) as well as a diagnosis according to the International Classification of Diseases (ICD).
[4] For further information on the risk factors and characteristics of suicides and of the regular (non-suicidal) population of prisoners see Blaauw, Kerkhof & Hayes (2000).
[5] This does not mean that all of these persons would have been prevented from completing suicide.
[6] In the Netherlands, the weekly consultation between the members of the Psycho-Medical Consultation Team, which is attended by the institution's psychologist, the district psychiatrist, the physician, nurse, penal probation officer and a member of the Social Welfare Agency, is at the basis of special care provided to prisoners.
Screening instrument for suicide risk
|
Name of prisoner: Date of birth: Cell number: Interview date: Interview time: Name of nurse: Institution: |
|||||
|
Characteristic |
Description |
No |
Yes |
||
|
1 |
Aged 40+ |
Prisoner is aged 40 years or older |
0 |
17 |
|
|
2 |
No fixed address or residence |
In the time shortly before confinement the prisoner has not had a fixed address or residence |
0 |
23 |
|
|
3 |
One prior confinement |
In the past the prisoner was held once previously in a detention centre or a prison. The current confinement is the second time. |
0 |
14 |
|
|
4 |
History of multiple hard drug abuse |
In the past the prisoner has taken hard drugs (at least once a week) in combination with: (at least one of the following) a. soft drugs (at least 3 times a week) b. large quantities of alcohol (at least 3 times a week) c. non-therapeutic amounts of medication (at least once a week) |
0 |
13 |
|
|
5 |
Treatment history for psychiatric symptoms |
The prisoner has at any time been treated for psychiatric symptoms in a psychiatric (ward of a general) hospital, at an outpatient mental welfare centre or by an independent psychologist or psychiatrist. |
0 |
27 |
|
|
6 |
Psychotic disorder or other DSM-IV As-1 disorder * |
In the past five years the prisoner has been diagnosed as schizophrenic (or another psychotic disorder), or suffering from anxiety, mood, somatoform or dissociative disorder. |
0 |
24 |
|
|
7 |
Previous suicide attempts or self-destructive behaviours |
In the past the prisoner has intentionally cut, poisoned or wounded himself, or has tried to hang himself, drown or come to grief in other ways. |
0 |
13 |
|
|
8 |
Suicidal utterances or suicide attempts during current (court) procedure |
During the admission interview the prisoner has made remarks that may point at suicidality or has done so during confinement at the police station, in the court house or during transport or has attempted suicide in one of these situations. |
0 |
24 |
|
Total score |
If 24 points or over, alert mental health staff member |
Total points |
|
||
* This question is to be answered in the affirmative only if a definitive diagnosis was made. A mental health care history is no sufficient indication for the existence of a diagnosable disorder.
If the prisoner gives the impression of being suicidal without it showing from the screening instrument, a mental health staff member must be informed of this suspicion.
Referred to……………(mental health staff member) on ……….(date) at …………hrs (time).