The Prevention of Suicide in Prison

Cognitive behavioural approaches

Daniel Pratt

• Publisher: Routledge
• Year: 2015
• ISBN:
  9781317932710
• Edition: 1
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Suicide is considered to be the leading cause of preventable death in prisons. While there is increasingly expansive literature examining the various risk factors associated with a likelihood of eventual prison suicide, so far this has struggled to lead to successful prevention programmes. An alternative approach is needed that seeks to understand, at the individual level, what leads a prisoner to contemplate ending their own life. This book describes how the authors developed and delivered evidence-based psychological interventions for suicide prevention in prison.The authors present a compelling argument for a psychological approach to the prevention of prison suicide, drawing upon a cognitive behavioural perspective, with chapters investigating two novel psychological therapies: Cognitive Behavioural Suicide Prevention and Problem Solving Training. The methodology behind each study is presented alongside preliminary findings emerging from the evaluations, and detailed case studies are included as exemplars of the process and content of the therapies, as well as the individual and contextual challenges to be overcome. The book provides timely research into the development of a better understanding of why prisoners engage in suicide behaviour, and the preventive interventions showing the most promise for future investigation. The Prevention of Suicide in Prison will be critical reading for clinical and forensic psychologists, psychological therapists, psychiatrists and other mental health staff working within a prison context, as well as postgraduates in training and researchers studying suicide in forensic settings.

1 Suicide in prisons

Introducing the problems

Daniel Pratt

DOI: 10.4324/9781315857107-1

Background

More than 10 million people are currently held in custody across the world, and the numbers of prisoners are increasing in more than 70% of countries (Walmsley, 2013). Around half of the prisoners are contained in the United States (2.24M), China (1.64M) or Russia (0.68M). The proportion of a country’s general population held in prison can be referred to as its prison population rate and is calculated per 100,000 of the nation’s population. Whilst not regarded as precise, such rates do allow for comparisons across various countries and regions of the world. The United States has the highest prison population rate in the world with 716 prisoners per 100,000 persons, whilst the prison population rate for England and Wales (148 per 100,000) is at the mid-point in the World List and one of the highest rates in the European Union (Walmsley, 2013).

Sykes’s (1958) seminal work on prison society brought attention to the ‘pains of imprisonment’ as deprivations of liberty, autonomy, goods and services, security and heterosexual relationships. The impact of these stressors upon the individual and how effectively the prisoner can manage this impact varies substantially (Toch, 1992). Prisoner suicide can be seen as the most extreme expression of a failure to cope and adapt to the demands, restraints and frustrations of imprisonment. It remains the responsibility of the prison authorities to protect the health, safety and well-being of prisoners, and failure to meet this responsibility can be open to legal challenge (World Health Organization, 2007).

What is suicide?

One of the first problems encountered when researching suicide, in any population, is how best to define what this term actually means. There are a great number of definitions of ‘suicide’, and the working definition adopted by a study can have a large impact on the findings of the investigation. According to the Oxford English Dictionary, ‘suicide’ is defined as “the, or an, act of taking one’s own life; self-murder”. Perhaps one of the most frequently quoted definitions of suicide used in medical research is by Durkheim (1897, p. 42):

The termination of an individual’s life resulting directly or indirectly from a positive or negative act of the victim himself which he knows will produce the fatal result.

However, this definition has been heavily criticised and even described as unworkable (Baechler, 1980). For example most people would be aware that regularly drinking vast amounts of alcohol, injecting heroin and smoking crack cocaine is likely to inflict serious injury, and even death, upon a person. If a death does result from such behaviour, should this be considered to be a suicide?

Farmer (1988) suggested that a death should be declared as ‘suicide’ only if three sufficient conditions are met:

1. The death must be recognised as unnatural
2. The initiator of the course of action that led to the death has to be recognised as the deceased himself
3. The motive of self-destruction has to be established.

In England and Wales, deaths are declared as ‘suicide’ according to the verdicts returned at inquest by coroners or their juries, where the coroner or jury is convinced ‘beyond reasonable doubt’ that the victim’s death was self-inflicted and that the deceased intended to end his or her own life. This high standard of proof leads to some deaths not to be declared as ‘suicide’. A death may be commonly considered to have been a deliberate and intended attempt to end life, but the absence of sufficient evidence of intent prevents a verdict of suicide. In such circumstances, the self-inflicted death tends to be recorded as an ‘open’ verdict.

So far, the answer to the question of “What is suicide?” may be seen as apparently straightforward. However, this would be misleading because there has been considerable definitional obfuscation around suicide and suicide-related behaviours for several decades (De Leo, Burgis, Bertolote, Kerkhof, & Bille-Brahe, 2006; Linehan, 2000). The academic literature is “replete with confusing terms, definitions and classifications” (Silverman, Berman, Sanddal, O'Carroll, & Joiner, 2007a, p. 249), such as suicidal ideation, intent, threat, gesture, attempt, parasuicide and completed suicide. Confusion is particularly common when considering the terms ‘self-harm’ and ‘suicide’, because both refer to acts of deliberate self-injury. If we look to the definitions presented earlier in this chapter, for behaviour to be described as related to suicide, there would be an intent or motive for this behaviour to lead to the end of one’s own life. Self-harm comprises behaviours with a broader range of motives or reasons which, in addition to suicidal, may also include non-suicidal intentions. For instance, a person’s motivation for self-harm may be to show desperation to others, to seek help, to change the behaviours of others or to gain relief from tension (Hawton & James, 2005). There is further potential for confusion when the consequences of self-harm behaviours are considered, because some deaths may result from self-harm even though this outcome was not intended by the individual.

To be clear, within this book, we consider suicide to lie on a cognitive behavioural continuum from thoughts about death and a reluctance to go on living, through suicide ideation, planning, action in the form of attempts, through to a suicidal death. The suicidal individual is not considered to progress along this continuum in a linear fashion but more likely to oscillate across various stages according to his or her changing circumstances and daily experiences. Certain aspects of this continuum may overlap with features of self-harm; however, rather than becoming entangled into a definitional argument, we have taken a more pragmatic view that all aspects of suicide behaviour are in themselves distressing, disruptive and undesirable and, as such, are important targets of preventive intervention (Tarrier et al., 2013).

Rates of suicide in the general population

According to World Health Organization (WHO) estimates, each year approximately one million people die from suicide and 10 or 20 times more people attempt suicide worldwide. This represents one death every 40 seconds and one attempt every 3 seconds. More people are dying from suicide than in all of the several armed conflicts around the world.

In the UK, suicide is the third largest cause of death, accounting for almost 6,000 deaths per year (Office for National Statistics [ONS], 2014). Over the past 60 years, the total number of suicides in the UK has changed little. In 1950, there were 4,660 self-inflicted deaths, and in 2012, this figure was 5,981, an increase of less than 30% in 62 years. Despite slight variation each year, the suicide rate over this time period has steadily remained between 7 and 11 persons per 100,000 persons (ONS, 2014).

The rate of suicide varies widely across and within the different continents of the world. Within some regions of the world, all countries seem to maintain similar rates. For example in the Western Pacific region, which includes Australia, New Zealand, China and Hong Kong, all countries maintain average suicide rates of between 12 and 15 persons per 100,000 per year. In the Americas region, Argentina and Brazil have a similar suicide rate of between 3 and 7 persons per 100,000 per year, and yet Cuba has a rate of over 20 persons per 100,000 per year (http://www.who.int/healthinfo/mortality_data/en/). In Europe, variation across countries is also quite marked. For instance, Denmark has an average rate of over 18 persons per year, much in line with its Scandinavian neighbours. Even higher rates have been observed since 2000 for Russia and many of the former Soviet Republics with rates of more than 40 persons per 100,000 per year. Conversely, the southern European countries of Italy and Greece, have observed much lower suicide rates of less than 7 per 100,000 persons per year.

Diekstra and Garnefski (1995) analysed suicide rates from 1881 to 1988 for 16 European nations by rank ordering according to their national rate of suicide. Whilst each country’s suicide rate varied over the 100 year time period, the rank ordering remained relatively constant. One conclusion made from these findings was that suicide rates are determined by persisting cross-national differences including traditions, customs, religions, social attitudes and climate. Durkheim (1897) suggested that suicide rates may be influenced by, amongst other factors, the extent to which individuals are integrated within society. These theories have been extensively researched for more than a century, such that a body of evidence now exists that stresses the importance of social factors such as unemployment, divorce and religion, in explaining national differences and trends in suicide (Gunnell et al., 1999; Lester, 1997).

Investiga...

Table of contents

• Cover Page
• Half-Title Page
• Title Page
• Copyright Page
• Table of Contents
• List of tables and figures
• Notes on contributors
• 1 Suicide in prisons: introducing the problems
• 2 The epidemiology of prison suicide
• 3 Psychological models of suicidal ideation and behaviour
• 4 Cognitive behaviour therapy for suicidal prisoners
• 5 Problem-solving training for suicidal prisoners
• 6 Forensic patient and public involvement: the development and maintenance of an ex-offender service user reference group
• 7 Overcoming the challenges of implementing psychological interventions for the prevention of suicide in a prison setting
• 8 Improving the delivery of psychological therapy within a male high-security prison: a qualitative enquiry
• 9 Concluding reflections
• Index