Suicide Prevention Level I

Suicide PreventionLevel I

Oklahoma Department of Corrections2014

Objectives

Understand essential elements and principles of a successful suicide prevention program

Identify warning signs and symptoms of impending suicidal behavior Know rates, personal characteristics, and factors affecting suicidal

behavior in the correctional setting Realize importance of accurate and complete documentation Know required response to suicidal and depressed offenders as

outlined in this procedure, including: Identification and placement of offenders on suicide watch; Communication and referral procedures between security, unit and other

facility staff and mental health staff Housing observation and suicide watch level procedures Follow-up monitoring of offenders who make a suicide attempt.

Warning Signs of Suicide Threats of self harm Actual self-injury Sudden change in behavior and/or mood Bizarre speech or behavior Personal crisis-misconduct, parole denial,

personal loss, threat from others Giving things away

Suicides in Prison:National Statistics

Suicide remains a leading cause of death for prison offenders, ranking 5th among all deaths that occur in prison Other leading causes include cancer, heart disease, liver

disease, and respiratory diseases. The number of suicides for male offenders is significantly

higher than the number of suicides for females Suicides in prison occur at the rate of 16 per 100,000

offenders per year versus 11.3 per 100,000 people in the general population per year

Suicides in Prison:National Statistics

Hanging is the most prevalent method of suicide for those who are incarcerated followed by cutting oneself and overdosing on prescribed and/or illegal medications

Maximum and medium security prisons have higher rates of suicide than minimum security prisons

A higher rate of suicide is evident in offenders convicted of crimes against another person than offenders convicted of property crimes

Suicides in Prison:Oklahoma Statistics

Offender suicides are more likely to include offenders who are white, male, and currently serving time for a violent offense

The age distribution of offender suicides in DOC (since 1997) is 21 to 60, and the average age is 37.

FY1998 FY1999 FY2000 FY2001 FY2002 FY2003 FY2004 FY2005 FY2006 FY2007 FY2008 FY2009 FY2010 FY2011 FY2012 FY20130

10

20

30

40

50

60

25

31

30

42

74

8

42 3

12

5

9

24

13

4

1316

8

27

15

30

15

7

12

48

19

Oklahoma Department of Corrections Inmate Suicides -- FY 1998 - FY 2013

Number of Suicides Suicide Rate per 100,000

Essential Elements and Principles

A comprehensive Suicide Prevention program includes specific procedures for handling intake, screening, identifying, and supervising a suicide-prone offender. The program has clear protocols, which are written in policies and procedures.

Communication Skills Instead of working on offenders by trying to

force them into correct ways of being, when we instead begin talking and working with them, we find our jobs start to become easier and more effective.

With practice, we are not fighting for control; rather we are communicating that we have a professional response to offender’s wants and needs.

We maintain control by utilizing these skills.

Speaking with Suicidal Offenders

Speak to the offender in a calm, matter-of-fact manner.

Listen closely and be sensitive to the thoughts and feelings expressed.

Never demean or respond jokingly to suicidal expressions.

Directly question the offender about suicidal thinking.


Determine if the offender has made prior suicide attempts.

Past behavior is the best predictor of future behavior. If there have been prior suicide attempts, there is increased risk. Inquire if the offender has a history of suicide in his or her family or friends since it often represents an increased risk.


Determine if the offender has a specific plan to accomplish suicide.

If the offender has a suicide plan and the means to affect the plan, you can discover this by asking questions such as: Have you ever thought about taking your own life? If so, how would you do it? When would you do it? Where would you attempt suicide?


When talking to a suicidal offender, it is important to develop as much empathy as possible for the situation.

Try to understand the offender’s point of view as much as possible.

Try to determine what the person wants to escape by suicide.


Use a non-threatening manner; Do not be judgmental; Be as natural as possible; Accept the possibility that the person is suicidal;

and Keep calm.

Speaking with Suicidal Persons

Positive contact with a suicidal personmay prevent suicide from happening.

Speaking with Suicidal Persons

DO’s1. Speak calmly and respectfully2. Avoid Conflict 3. Be Patient and listen carefully

without interrupting. 4. Be Direct in questioning about

suicidal thoughts 5. Be Honest and admit you don’t

have all of the answers, but offer hope

6. Be Objective7. Be Professional

Don’ts1. Don’t use a threatening tone or

manner2. Don’t create conflict3. Don’t invade their personal

space4. Don’t take offensive language

personally5. Don’t be judgmental6. Don’t make dismissive

statements such as, “This is stupid” “What are people going to say”

Talking with Suicidal Persons

Positive contact with a suicidal personmay prevent suicide from happening.

How hard can communication be?

How Hard Can Communication Be?OBJECTIVE: To demonstrate the complexity of

communication. Get in pairs and sit back to back so you can’t see each other. Choose who will be the talker and who will be the listener. I will give the talker a copy of a design. I will give the listener a blank sheet of paper and a pencil. The one with the design begins to give directions on what to

draw. The goal is to have the design and the drawing turn out as similar as possible. The participant who is drawing cannot ask questions or talk at all. I will give you 3 minutes to complete the task.

How Hard Can Communication Be?

DISCUSSION QUESTIONS: What was it like to be the person giving

directions? What was it like to be the person drawing? How does this exercise relate to the work

environment? How does this exercise relate to working with

people diagnosed with a mental illness?

Suicide Risk Factors

The following Risk Factors and Signs and Symptoms of suicide are a collaboration of lists from six of the survey states policies and/or training materials:

Suicide Risk Factors Has a history of suicide attempts History of suicide in the family Pending disciplinary time, placed in segregation

or protective custody Increased hours of isolation Institutional problems (e.g. classification,

unwanted transfer) Recent death or serious illness of a family

member

Suicide Risk Factors Loss of family support due to divorce or family

relocation Denied parole; convicted of a new crime; facing

detention time Has a long sentence Will be leaving soon after serving a lengthy

sentence Recently sexually assaulted, or threats of such

in the future

Suicide Risk Factors Other offender conflicts, assaults, victimization Has been having problems with his peer

group/friends Has a serious mental illness such as depression

or schizophrenia Self-injury of self-destructive behavior

Suicide Risk Factors Has a language barrier or disability resulting in

him being isolated Progressive health problems – chronic or

terminal illness Has a significant anniversary date approaching

Signs and Symptoms Seems extremely sad or is crying Loses interest in or almost all people and

activities Stopped attending groups, work assignments,

mental health sessions, medical appointments, refusing visitors

Withdrawn and non-communicative Sudden drastic changes in eating or sleeping

habits

Signs and Symptoms Loss of appetite, weight loss Sleeping difficulties, irregular sleeping hours,

insomnia, sleeping all the time Neglect of personal hygiene Seems to be in slow motion; no energy Is tense, agitated, and cannot seem to relax.

Emotional outbursts and sudden anger Expresses pessimism, hopelessness, and

helplessness

Signs and Symptoms Offender talks about suicide or verbalizes

thoughts of wanting to be dead Asking questions about death; talking about

death or afterlife Offender packs up and/or gives his possessions

to others, paying off debts Offender appears calm, elated or carefree after

a period of agitation or depression

Oklahoma DOC Suicide Events Informed of impending

transfer month prior Gastroenteritis Transfer to OSP 2 days

prior Received LARC

12/8/1999, date of death 12/17/1999

Threatened suicide upon reception

Letters from wife saying she would take everything he owned;

Wrote suicide letter to wife

Health problems Could not bear to serve

24 year sentence “Dear John” letter

Thursday before death on Saturday

Oklahoma DOC Suicide Events Wife did not visit as usual To Segregated Housing

Unit (SHU) Assaulted within 2 weeks

prior Depressed about

incarceration Decreasing staff attention Decreasing family

attention

Family refused phone calls

Spoke with dad evening before death

Altercation day before D/C imminent fears INS

detainer return to Mexico Estranged from family Homeless prior to

incarceration

Oklahoma DOC Suicide Events Friday previous court

denied custody of daughter to parents

2 days prior to SHU for cigarettes

3 days prior “accidental” human bite on elbow

Holiday stress Guilty about separation

from children

No English – Spanish only

Parents died Debt Fear of assault Request/refusal of money Marriage of mom day

after

Oklahoma DOC Suicide Events Assaulted within 6 weeks

prior Suicide attempt 6 weeks

prior Gang persecution Letters

from wife saying she would take everything he owned

Wrote suicide letter to wife

Health problems Could not bear to serve

24 year sentence

Suicide Prevention Screening LARC Mental Health Screening Facility Mental Health Screening

Initiation of Suicide Watch In acute, emergency situations, with possible

imminent danger of self-harm, a designated shift supervisor or health care professional trained in suicide-risk assessment may order a Level I suicide watch, continuous watch.

The facility head/duty officer will be notified as appropriate.

Initiation of Suicide Watch

Suicide watch procedures will be initiated for the following reasons: An offender engages in behavior that is likely to cause

physical harm to him/herself An offender makes suicidal gestures or threats; A suicide attempt is made Results of the “Risk Management Interview Worksheet,”

(DOC 140129B) indicate a need All less restrictive measures have failed or are judged not

to be effective

Initiation of Suicide Watch Designated staff member should stay in visual

contact person until a decision has been made about the plan of intervention. The staff member MUST NOT leave the offender unattended.

In the above situations of imminent risk, the offender will be placed under Level I Suicide Watch status which is constant supervision.

Initiation of Suicide Watch

During normal working hours, the on-site QMHP will be contacted immediately after the watch has been initiated and the offender and the situation will be evaluated as soon as possible after the watch is initiated. After normal working hours, the on-call QMHP will be contacted immediately after the watch is initiated so that the QMHP can determine whether to come in immediately or if the first available scheduled QMHP can do an in-person evaluation of the need for continuation of the suicide prevention procedures.

Initiation of Suicide Watch Only the QMHP can evaluate the actual Risk

and assess the individual.

Only the QMHP can make changes to the watch order and further recommendations for intervention if needed. Additionally, only the QMHP can discontinue a watch.

Initiation of Suicide Watch The following will be specified by the QMHP

Clothing Property Meals

Unless medically contraindicated, water will be available in the cell or offered at least every 2 hours

The QMHP will schedule in-person interviews at least twice each normal work shift or more often as necessary.

Suicide Watch Level I

Constant observation (documentation at least every 15 minutes at staggered intervals)

Safe-cell Safety smock (normally) Safety blanket (if QMHP approved)

Suicide Watch Level II

15 minute observation and documentation (at staggered intervals)

Safe cell QMHP will determine clothing, meals, and allowable

property

Suicide Watch Level III

30 minute observation/documentation (staggered intervals)

Safe cell or regular SHU cell as indicated by the QMHP

QMHP will determine clothing, meals, and allowable property

Suicide Watch Every placement of an offender on suicide watch

will be recorded on the Suicide Watch List. Following discharge from suicide watch,

offenders will have an individualized treatment plan developed by the responsible QMHP that addresses continued follow-up and treatment goals.

Suicide Attempt Response Despite legitimate prevention efforts, there may

be occasions when an attempt or actual suicide occurs.

Principle #1-When such an incident occurs is that the preservation of an offender’s life takes precedence over the preservation of a crime scene.

Principle #2-In all correctional facilities, professional judgment must consider safety risk factors for staff. Any delay in response for security reasons must be reported in detail in the incident report.

Suicide Attempt Response With those two principles in mind, the following actions

will be taken under normal conditions when an offender has attempted suicide or has sustained deliberate self-inflicted injury:

1. The first responder will call for help and initiate first aid and/or cardiopulmonary resuscitation (CPR) as needed. If the offender is found hanging, the responder will immediately cut him/her down and start appropriate medical care. 2. The facility’s health services unit will be contacted when a second responder arrives on the scene. The facility's local emergency medical procedures will be initiated.

Suicide Attempt Response3. The facility mental health authority (QMHP) will be notified as soon as reasonably possible.

4. Both medical and mental health evaluations will be conducted after the offender’s condition is stabilized. The mental health evaluation will include a recommendation for placement into an appropriate housing unit, along with recommendations for the appropriate level of suicide watch.

Responding to Persons with Suicidal Threats or Concerns Take precautions when dealing with a suicidal

offender. Some suicidal offenders may be unpredictable and become violent.

Responding to Persons with Suicidal Threats or Concerns

1. You should protect yourself and others:

a. Call for assistance

b. Survey the scene for safety

c. If the area is safe, enter the scene.

d. Remember to use communication DO’s and Don’ts.


2. Contain the situation:

a. Lock the area down, if possible

b. Move other offenders from the area

c. Limit the suicidal offender’s movement to within a manageable area


3. Remove the Source of Danger.

As soon as it is possible and only when safe to do so:

Contact Security Control or have others alert Security Control identifying the location, the situation and your name

Notify, or have others notify, your supervisor If force is necessary, follow the guidelines set forth in

OP-050108 entitled “Use of Force Standards and Reportable Incidents.”


4. The offender’s area must be shaken down and items that could be used as a weapon removed. Care should be taken regarding clothing, belts, shoe strings, sheets, etc.

5. If mental health staff members are present at the facility, an immediate referral should be made for an assessment. (4-4373M b#5)

6. If determined to be necessary by the QMHP, the offender will be transported to an observation or safe cell and placed on suicide watch.

Documentation In a correctional setting, as in any organizational

system, documentation of critical events is essential for effective communication, maintaining medical and legal record, and for allowing others to review the event.

With respect to suicidal offenders, proper

documentation is important. Adequate documentation may protect the department against legal action and assist in the revision of policy for managing suicidal offenders

Documentation The warden, duty officer or designee will be notified as appropriate.

Both medical and mental health evaluations will be conducted after the offender’s condition is stabilized. The mental health evaluation will include a recommendation for placement into an appropriate housing unit, along with recommendations for the appropriate level of suicide watch. (4-4373M b#6) These evaluations must be made a part of the medical record via progress note or by a written summary in accordance with OP-140106 entitled “Medical Record System.” A copy of these evaluations and any other pertinent information required of OP-050108 will be forwarded to the warden and chief mental health officer within five working days after the incident.

Suicide The Chief Mental Health Officer will be notified

verbally by the responsible QMHP of any suspected suicide.

Debriefing A critical incident debriefing will be conducted as

required by OP-050108 entitled “Use of Force Standards and Reportable Incidents”

Offenders will be included in critical incident debriefings as determined necessary by the facility mental health authority.

All staff involved in the critical incident will be included in the debriefing (i.e., correctional officers responsible for watching the suicidal offenders)

Suicide Administrative Review

The warden will establish a clinical review team to conduct a systematic analysis of any offender suicides in order to study the context in which death occurred.

The warden will ensure that the team’s first meeting is within five working days following any suicide.

Team members must not include either facility administrators or facility staff whose performance or responsibilities may be directly involved in the suicide incident. (4-4373M)

Summary As correctional professionals, it is our duty to

treat each suicidal offender with concern and be responsive to their needs.

Correctional personnel are obligated by standards set forth by the Oklahoma Department of Corrections to identify those offenders at risk, protect them from themselves, and assist them in getting proper care and treatment.

Documents

Suicide Prevention Level I