On completing suicide reviews… - FMHAC

On completing suicide reviews… - FMHAC

Reasons Inmates Attempt Suicide or Die by Suicide Implications for Assessment, Treatment, and Institutional Prevention Programs Robert Horon, Ph.D. California Department of Corrections and Rehabilitation/Division of Health Care Services March 14, 2019 Disclosures I am an employee of the California Department of Corrections and Rehabilitation (CDCR)s California Correctional Health Care Service (CCHCS). Other than employment, I have no financial

or commercial interest in presenting this material. 03/14/2019 2 Outline 1. Review of the complexity of suicide phenomena in correctional and forensic settings 2. Obtaining accuracy in suicide risk assessment and risk formulation in these settings 3. Studies of suicide survivors in prisonrelevant findings 4. Motivations found in suicide death reviews 5. Summary of findings and implications 6. Applying findings to suicide risk assessment interviews and practices via group discussion

7. Reports from groups, discussion, Q&A 03/14/2019 3 I. The complexity of suicide phenomena in correctional and forensic settings 03/14/2019 4 Complex phenomena Clinicians in correctional settings are particularly vulnerable to underestimation or overestimation errors, as

(1) there has been little empirical study of correctional suicide risk assessment procedures; (2) prisons predominantly house individuals with externalizing psychopathology that differs significantly from the internalizing psychopathology commonly related to suicidality (Verona, Patrick, & Joiner, 2001; Young, Justice, & Erdberg, 2006); and (3) attributions of manipulative motivation associated with suicidal behavior may underestimate actual risk (Dear, Thomson, & Hills, 2000). Horon, McManus, Schmollinger, Jimenez, & Barr, SLTB, 2013 03/14/2019 5 Was this a

suicide attempt? Likelihood of rescue? Intention? Ambivalence? 03/14/2019 6 Complex phenomena To evaluate a behavior such as this, consider: 1.) The inmates impression management: Does he want us to see him as ill and in crisis? Did he panic within an attempt and now tells us he made an error and is fine (now)? 2.) How does the inmate want to be seen by other inmates? 3.) External factors: Was he told to end his life? Pressured to leave

the building or yard? About to be transferred to/from a medical/psychiatric setting? 4.) Internal factors: Did he believe he would instantly die? What are his beliefs about and relationship with dying? Is this part of an ambivalence about living or dying? 5.) Was this an impulsive act or an act long considered? 03/14/2019 7 Complex phenomena Clinician 1: This was not an attempt, it was manipulation. Clinician 2: This was an attempt, not manipulation. The reality: 03/14/2019

8 Complex phenomena Or, the reality looks something along this line 03/14/2019 9 Complex Phenomena The paradigm of suicide is not the simplistic one of wanting to or not wanting to. The prototypical psychological picture of a person on the brink of suicide is one who wants to and does not want to. He makes

plans for self-destruction and at the same time entertains fantasies of rescue and intervention. It is possible indeed probably prototypical for a suicidal individual to cut his throat and to cry for help at the same time. 2/12/2019 10 Complex phenomena Lets look briefly at a few specific issues to illustrate the complexity of the suicidal phenomena in the context of correctional and forensic settings. 03/14/2019

11 Would you have known the risk? One day away from a parole hearing 03/14/2019 12 Would you have known the risk? One day after a court

hearing 03/14/2019 13 Complex phenomena 35-50% of jail suicides occur with 7 days of adjudication, either before or after a hearing.* *Hayes, L. (2010) National Study of Jail Suicide: 20 years later. US DOJ/National Institute of Corrections 03/14/2019 14

Complex phenomena Several studies have noted high-risk periods: The first hours and days of a stay and court outcomes (James & Glaze, 2006) Release from prison: 156 suicides per 100,000 in 1st year; 21% occur in the 1st month after release (Pratt et al., 2006) Many prison suicides occur shortly after incarceration or in transition periods (e.g. placement in Administrative Segregation; Patterson & Hughes, 2008) 19% of males who were sexually assaulted in prison attempted suicide following the incident (StruckmanJohnson, 2006). Complex phenomena Several studies have noted high-risk periods: -Transitions out of psychiatric inpatient settings confers risk

for correctional patients (Hayes et al., 2008; Sirdifield et al., 2009). -The community rate for suicide post-inpatient psychiatric hospitalization are markedly high in the first week and first 90 days after discharge, estimated at 178 per 100,000 in the 90 days after discharge. Heightened risk exists post-release for longer time-frames (Chung et al., 2017). Complex phenomena Who Commits Suicide in Jails? -By offense type: Rate for Violent Offenders= 92 per 100,000 Rate for Nonviolent Offenders=31 per 100,000 By offense category: Kidnapping = 275 per 100,000

Rape offenses = 252 per 100,000 Murder offenses = 182 per 100,000 Drug offenses =18 per 100,000 Source: Mumola, C. U.S. Dept. of Justice, Bureau of Justice Statistics Special Report, Suicide and homicide in state prisons and local jails, August 2005). Complex phenomena Its not just prisons and jails 03/14/2019 18 Complex Phenomena -A study of prisons and forensic hospital patients in Germany (Voulgaris, et al., 2018) found no statistically significant

difference in the rate of suicide per setting (both were very high; 123 per 100,000 vs. 130 per 100,000) [yes, this is a real prison cell in Germany] 03/14/2019 19 II. Obtaining accuracy in suicide risk assessment and risk formulation in these settings 03/14/2019 20

Obtaining accuracy in risk assessment and formulation Accuracy requires, or may require: 1. An understanding of the patients historic risk of self-harm, including the triggers, purposes, response to survival, degree of lethality and preparation, etc. during prior events. 2. A thorough interview with consideration of risk factors, a formulation of risk status, an understanding of protective factors, etc. 3. Use of structured interview guides that help clinicians consider all key factors. 4. Use of instruments developed or normed to the inmates/patients seen (to aide precision). 03/14/2019

21 Obtaining accuracy in risk assessment and formulation Accuracy requires, or may require (cont.): 5. Careful methods for assessing acute and imminent risk. 6. An understanding of the patients baseline vulnerability to suicide (chronic risk). 7. A good understanding of the phenomenology of suicide. 8. An effective approach to framing suicidal inquiries and potential suicide interventions. 9. An understanding of suicide inquiry that can be used in the service of safety planning, crisis intervention, and treatment planning. 03/14/2019

22 Obtaining accuracy in risk assessment and formulation Obtaining competency and proficiency in suicide risk assessment and risk formulation takes time, mentorship, an understanding of the suicidology literature, and more. Rudd, Cukrowicz, & Bryant (2008). Core Competencies in Suicide Risk Assessment and Management: Implications for Supervision. .Training and Education in Professional Psychology, 4 219-228 03/14/2019 23 Obtaining accuracy in risk assessment and formulation

One competency discussed by Rudd, Bryant and Cukrowicz is an understanding of the phenomenology of suicide as a method to inform our risk assessment and frame our risk formulation. Lets listen in on some aspects of suicide phenomena with suicidologist David Jobes, Ph.D. 03/14/2019 24 Video 1 David Jobes, Ph.D. 03/14/2019

25 Shneidmans Cubic Model of Suicide Low to High Press (Stress) (1987) Completed Suicide 1 5 5 High to Low Perturbation/ Agitation

4 3 2 1 1 2 3 4 5 Low to High Psychache

(Pain) Obtaining accuracy in risk assessment and formulation How do these concepts inform risk assessment, risk formulation, and help frame treatment? In essence, we cant discuss the reasons inmates or forensic patients attempt or die by suicide without understanding what drives such behavior in general, just as we cant understand suicidal behavior for inmates and patients outside the context of their environment. 03/14/2019 27

Obtaining accuracy in risk assessment and formulation What we discuss below is meant to be understood in the context of competency in suicide risk assessment, formulation, and risk management/treatment. That is, the information is meant to be additive or complementary to adequate practice in assessing and treating suicidal patients. 03/14/2019 28 Video 2

Jail hanging 03/14/2019 29 Studies of suicide survivors in prison relevant findings As youve just heard, the individual discussed in this story did not survive. Video surveillance shows the inmate: Tying a noose on the upper bunk (at noon) Practicing trying on the noose and tightening it Receiving a meal from an officer while the noose is clearly visible tied to the upper bunk (at 1715 hours) Hanging himself (at 2030 hours), discovered roughly 15 minutes later

Jail policy was officer checks every 20 minutes Well return to reviews of deaths by suicide later, but for now, think of ways the death could have been prevented. 03/14/2019 30 Studies of suicide survivors in prison relevant findings 03/14/2019 31 Studies of suicide survivors in prison

relevant findings Greg Dear and colleagues worked with the Australian prison system, evaluating all inmates who had survived suicide attempts. They conducted a series of studies on these inmates, with interviews within 3 days of attempt survival. 71% of attempters reported the reason for attempting to be within prison stresses, categorized as stressful events that occurred within the prison. *Dear, Thomson, Hall, and Howells (2001). Non-fatal self-harm in Western Australian prisons: Who, where, when and why. Australian and New Zealand Journal of Criminology, 34, 4766. Studies of suicide survivors in prison relevant findings Key finding: The potential lethality of suicide attempts did not differ between

inmates who reported their attempt was motivated by new charges, safety concerns, or conflict with other inmates versus those who reported mental health reasonse.g., depression, anxiety, bereavement, etc. Studies of suicide survivors in prison relevant findings In a summary article,* Dr. Dear wrote, Importantly, prisoners who reported manipulative or attention-seeking motives for selfharming were just as likely as other prisoners to show a high degree of suicidal intent (Dear, Thomson, and Hills, 2000). The desire of someto separate the manipulative gestures from the genuine suicide attempts seems to be a risky strategy as one cannot assume that manipulators and suicide attempters are mutually exclusive groups. Failing to treat seriously an apparently

or reportedly manipulative act can result in a subsequent suicide, particularly if the response is to punish or ignore the prisoner in order to avoid reinforcing or rewarding the manipulation. *Dear, G.E., (2008). Ten Years of Research into Self-Harm in the Western Australian Prisons. Psychiatry, Psychology and Law, 15, (3), 469481. Studies of suicide survivors in prison relevant findings In the same article,* Dr. Dear wrote, We proposed that the critical determinant of selfharm is the severity of distress that results from the interaction of psychological vulnerability and the intensity or nature of the stressful events the prisoner faces. *Dear, G.E., (2008). Ten Years of Research into Self-Harm in the Western Australian Prisons. Psychiatry, Psychology and Law, 15, (3), 469481.

Studies of suicide survivors in prison relevant findings 03/14/2019 Dear, 2008 36 Studies of suicide survivors in prison relevant findings Studies of suicide survivors in prison relevant findings Our suicide risk assessment study took place at an inpatient psychiatric facility located within a prison (CMF). The goals of the

study were: Explore reliability, validity, and clinical utility of commonly used suicide risk measures in a correctional setting Generate a normative comparison group to help clinicians interpret assessment results Evaluate current forms and procedures processing suicide risk Assess other variables related to risk within the population, such as violence history, etc. Determine which variables and test findings most relate to high risk within the study population. Studies of suicide survivors in prison relevant findings Studies of suicide survivors in prison relevant findings

The study sample consisted of 617 male inmates admitted to the Department of State Hospitals-Vacaville between May, 2007 and February, 2015 All inmates were referred for inpatient psychiatric care, with nearly equal numbers admitted for acute psychiatric services (average stay of 75 days) as those admitted for intermediate care services (average stay of 180 days) The Department of State Hospitals-Vacaville (now a CDCR Psychiatric Inpatient Program) is a large inpatient psychiatric facility that admits 1,200-1,400 patients per year Approximately 84% of admissions for the Acute Psychiatric Program (APP) are for suicidality (ideation/attempt/reported intent), distilled mostly from MHCB settings (where >90% of admissions relate to suicidality). 03/14/2019

40 Studies of suicide survivors in prison relevant findings We looked at differences between three groups of CDCR patients referred to an inpatient psychiatric hospital : 1. Patients with no history of suicide attempts 2. Patients with a history of one suicide attempt 3. Patients with a history of multiple suicide attempts We found stark differences between groups based on attempt status. *Horon, McManus, Schmollinger, Barr, & Jimenez (2013). A Study of the Use and Interpretation of Standardized Suicide Risk Assessment Measures within a Psychiatrically Hospitalized Correctional Population, Suicide and LifeThreatening Behavior, 43, (1): 17-38. Studies of suicide survivors in prison

relevant findings Differences between groups: Demographic: Multiple attempters were more likely to have endured a host of childhood traumas, particularly witnessing domestic violence. They were more likely to have been in special education during school years and to have experienced significant head trauma with loss of consciousness and/or the development of seizures. Endorsement Patterns: Multiple attempters endorse more concerning answers for both direct (face valid) and indirect measures of suicide risk Studies of suicide survivors in prison relevant findings Compared to non-attempters and single attempters, multiple attempters endorsed:

More desire to die and more frequent preparation or planning for suicide (BSS) More frequent contemplation of suicide across a broader range of thoughts related to suicidality (ASIQ) Fewer or less protective degrees of emotional, spiritual, behavioral, or interpersonal barriers to suicide (CRQ, CAPSSIP, CAI-Id.) More painful emotional experiences, such as worthlessness, agitation, and psychache (CAI-Acute, RASQ-Internal) More problematic clinician ratings, suggesting a likelihood of the patient resisting suicide prevention/risk management efforts (CAI Idiosyncratic) 03/14/2019 43 Studies of suicide survivors in prison

relevant findings Compared to non-attempters and single attempters, multiple attempters endorsed: A greater sense of being a burden to others, such as family and loved ones (INQ-Perceived Burdensomeness) A more frequent belief that suicide would not negatively affect the afterlife or that no afterlife exists (CAPSSIP interview) More likely to report loopholes to familial, cultural, or religious prohibitions to suicide (CAPSSIP interview) 03/14/2019 44

Studies of suicide survivors in prison relevant findings Factors that were found not to distinguish groups: Endorsement of extrapunitive or manipulative reasons for suicide attempts (RASQ-Ext) Fearlessness about death (ACSS) Only slightly increased feelings of lack of belonging in multiple attempters (INQ Belonging) 03/14/2019 45 Studies of suicide survivors in prison relevant findings Lets take a closer look at one study measure, the Culture and

Protective Suicide Scale for Incarcerated Persons (CAPSSIP). The tool was designed to assess protective factors and cultural barriers to suicide for inmates. Analyses of protective factors on a suicide risk assessment checklist (SRAC) found no difference in attempt groupsprotective factors are not yes/no variables. CAPSSIP sought to quantify degree of protection present and to evaluate if the patient had maintained or moved away from familial, cultural, and/or religious/spiritual prohibitions to suicide. Horon, R., Williams, S. N., McManus, T., & Roberts, J. (2018). The Culture and Protective Suicide Scale for Incarcerated Persons (CAPSSIP): A measure for evaluating suicide risk and protection within correctional populations. Psychological Services, 15, 45-55. doi:10.1037/ser0000197 CAPSSIP Recognizing the need to assess suicide protective factors with items that are relevant to incarcerated individuals, and

recognizing a need to incorporate cultural assessment within suicide risk evaluations of inmates, the authors of the present study developed a measure called the CAPSSIP. The CAPSSIP was designed to reflect the unique environment within prisons. The individuals cultural, religious, and familial beliefs that prohibited suicide may be challenged in the setting. The context of incarceration is also very relevant to how protective factors function within this population... The socioeconomic, racial, and cultural make-up of individuals inhabiting prison systems clearly impacts suicide risk formulation. 03/14/2019 47 Studies of suicide survivors in prisonrelevant findings

No Attempts 1 Attempt 2 or More Attempts Feeling of support from family and loved ones 15.6 13.8 10.4

Sense of purpose, meaning, and ability to contribute 18.8 16.8 12.5 Acceptance of community and religious prohibitions to suicide

27.8 20.6 15.0 Total CAPSSIP Score 59.0 52.5 38.6 All group comparisons differed at a .01 level of

significance Table 7. Divergent validity: CAPSSIP scale scores and the ASIQ, ACSS, BSS and INQ scores *Significant at p <.05; **Significant at p < .01 ASIQ ACSS BSS INQ INQBUR

INQBEL RASQINT RASQEXT CAPSSIP Total Factor 1 -.433** -.253** -.585**

-.283** -.308** -.202** -.272** .162* -.343** -.145* -.504**

-.266** -.283** -.196** -.153* .110 Factor 2 -.411** -.221**

-.547** -.252** -.278** -.178* -.248** .072 Factor 3 -.337**

-.269** -.509** -.255* -.273** -.185* -.304** .226** Table 10.

Beliefs about the Effect of Suicide on an Afterlife No effect Effect Single/non 15 25 Multiple 61 40

*Chi square = 6.045, a =.014 03/14/2019 49 Studies of suicide survivors in prison relevant findings So what? The impact of distress in correctional and forensic institutions is moderated by vulnerability to suicidal contemplation and attempts. That is, of 2 patients or inmates facing the same stress: Suicide or suicide attempts are more likely in individuals who have already previously crossed the line and engaged in

suicidal behavior. The prior behavior(s) point out a lack of protections or barriers to suicide, a willingness to engage in self-harm, and a recklessness about living. Chronic or frequent contemplation of suicide leaves patients and inmates less likely to benefit from activities connected to living. 03/14/2019 50 Studies of suicide survivors in prison relevant findings Summary: 1. Suicide attempts in prison settings often occur in vulnerable individuals who are distressed by events occurring within incarceration.

2. Suicide attempt lethality did not differ between individuals who attempted as a reaction to within prison events and those who made attempts due to primarily mental health reasons. 3. Individuals with a history of multiple past, potentially lethal attempts as a group endorse multiple markers of elevated risk across suicide risk measures, and should be seen as at a high chronic risk for suicide. 4. Contextual issues, such as distress related to receiving new charges or upon inpatient release, can be anticipated. 03/14/2019 51 IV. Motivations found in suicide death reviews

03/14/2019 52 Video 3 A Hernandez 03/14/2019 53 Motivations found in suicide death reviews Aaron Hernandez was an ex-NFL player sentenced to Life for murder in Massachusetts. When discovered at his death: -His cell door was stuffed with cardboard (to slow officers

entry) and large amounts of shampoo and/or lotion covered the floor (making the floor slick) -He was found hanging and was unclothed -He was acquitted of two murders five days prior -No illicit substances were found in his possession or on autopsy 03/14/2019 54 Motivations found in suicide death reviews -He had written a Bible verse in ink on his forehead (John 3:16); the verse states: For God so loved the world that he gave his one and only son, that whoever believes in him

shall not perish but have eternal life. -He had cut several fingers and drew on his cell wall in blood and had underlined John 3:16 in blood. -3 notes were found next to a Bible at his desk; the content was not revealed but at least one was a suicide note to an ex-girlfriend. 03/14/2019 55 Motivations found in suicide death reviews Reviews of cases of suicide can reveal: 1.) Idiosyncratic suicide risk factors and motivations (e.g., as in the process of Psychological Autopsy).

2.) Adherence to policy or procedure breaches, the quality of care received, and so forth (e.g., as in suicide review processes by licensing and regulatory agencies). 3.) Issues or factors identified as potentially contributing to the suicide that can be applied to institutions or policies in such a way as to help prevent future suicides. 03/14/2019 56 Motivations found in suicide death reviews What would you guess are the major motivations identified in prison suicide reviews? -While there is some support for depression, psychosis, and

hopelessness as major motives, once more contextual motivations appear to predominate 03/14/2019 57 Suspected Motives/Precipitants to Suicides Precipitant Category, n=24 Frequency Percent of Total Receipt of new charges, convictions, disciplinary actions, or

added time in prison 9 20 Safety concerns, drug debts, fears of victimization 7 15 Mental health symptoms, e.g. anxiety, psychosis 7

15 Medical illness and/or pain issues; medical disability 5 11 Holidays or anniversaries of losses, crimes, etc. 5 11 Disruption in prison program; e.g., transfer between facilities, cellmate change, loss of single cell housing

4 9 Conflict or loss of external supports 4 9 Conflict or loss of within prison supports 3 6

Receipt of or anticipation of negative outcomes with the Board of Prison Hearings 1 2 Loss of parole to the community (e.g., due to added sentence, finding of MDO or SVP) 1 2 4/18/2018

Totals: 46 58 100 Motivations found in suicide death reviews What surprises you about this list? 03/14/2019 59

What Suicide Case Reviews Illustrate 1. Environmental problemsligature points, etc. 2. Means restriction issuesready availability of razors, meds 3. Errors related to a lack of understanding of suicidology 4. Errors related to risk formulationunderestimating risk, missing imminent risk signs 5. Lack of cultural risk formulationnot incorporating, for example, afterlife beliefs of specific cultures 6. Errors related to assumptions of secondary gain/motivation 7. Emergency response errors 8. Failure to follow policy 03/14/2019 60

What Reviews Illustrate-- Errors related to a lack of understanding of Suicidology Common errors: -Assumptions that any ambivalence suggests low acute/imminent risk. -Assumptions that any future orientation rules out risk. -Assuming participation in mental health treatment rules out risk for suicide. 03/14/2019 61 V. Summary of findings and

implications 03/14/2019 62 Summary of findings and implications Which of the following are true? 1.) Suicide attempts occur in correctional and forensic settings for many reasons, reflecting a very complex phenomena and challenges for clinicians in risk formulation. 2.) Deaths by suicide in prison are motivated by contextual factors, such as receiving disciplinary actions, having conflicts with other inmates, etc. 3.) Certain time points are crucial in developing suicide prevention strategies.

4.) Most suicidal behavior with moderate to high degree of likelihood of rescue can be assumed to be a cry for help or manipulative behavior. 03/14/2019 63 Summary of findings and implications Match the term with its description: 1. Psychache a. Feeling of having to do something; agitation 2. Internal Perturbation b. A desire for a break from suffering 3. Escape c. Misery of the mind

03/14/2019 64 Summary of findings and implications Which of the following cases confer some risk? 1.) A patient has had three prior suicide attempts, but denies current suicidal ideation. She was found, however, with a braided noose. 2.) An inmate is facing an additional term of 7 years after an assault on a peer. He has no mental health history. 3.) A patient is refusing medications and confidential visits with mental health. He denies suicidal ideation, shaking his head no. He has complained in the past of hallucinations urging him to take his life. 4.) A patient reports suicidal intent. However, he recants this

statement the following morning, stating I just needed to get off my yard. I owe some guys. 03/14/2019 65 Summary of findings and implications Reviews of deaths by suicide can (more than one may be correct): 1.) Suggest new or revised policies or procedures. 2.) Review adequacy of clinical risk formulation. 3.) Develop strategies to reduce access to means. 4.) Illustrate misunderstandings of suicidal phenomena.

5.) Provide support for tailored training. 03/14/2019 66 Summary of findings and implications Which of the following may be incorrect: 1. Suicide attempts in prison settings often occur in vulnerable individuals who are distressed by events occurring within incarceration. 2. Suicide attempt lethality differs between individuals who attempted based on within prison events and those who made attempts due to primarily mental health reasons. 3. Individuals with a history of multiple attempts should be seen as at a high chronic risk for suicide.

4. Contextual issues, such as distress related to receiving new charges or upon inpatient release, can often be anticipated. 03/14/2019 67 VI. Applying findings to suicide risk assessment interviews and practices 03/14/2019 68 Applications

Group discussions: Group 1: Develop 5 interview prompts to add to a clinical evaluation of suicide risk (based on the information presented today) Group 2: List 4 efforts that can be undertaken at your institution to prevent suicide based on the information provided today. Group 3: Summarize 4 implications for correctional and forensic systems (e.g., DSH should) 03/14/2019 69 VII. Group Discussion, Group Reports, Q&A

03/14/2019 70 Thank you! [email protected] 916-691-9926 03/14/2019 71

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