Suicide Prevention Level I

1. Suicide PreventionLevel I Oklahoma Department of Corrections 2014

2. 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.

3. 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

4. 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

5. 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

6. 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.

8. 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.

9. 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.

10. 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.

11. Speaking with Suicidal Offenders • 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.

12. Speaking with Suicidal Offenders • 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?

13. Speaking with Suicidal Offenders • 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.

14. Speaking with Suicidal Offenders • 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.

15. Speaking with Suicidal Persons Positive contact with a suicidal person may prevent suicide from happening.

16. Speaking with Suicidal Persons DO’s 1. Speak calmly and respectfully 2. 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 Objective 7. Be Professional Don’ts 1. Don’t use a threatening tone or manner 2. Don’t create conflict 3. Don’t invade their personal space 4. Don’t take offensive language personally 5. Don’t be judgmental 6. Don’t make dismissive statements such as, “This is stupid” “What are people going to say”

17. Talking with Suicidal Persons Positive contact with a suicidal person may prevent suicide from happening.

18. How hard can communication be?

19. 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.

20. 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?

21. 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:

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. Suicide Prevention Screening • LARC Mental Health Screening • Facility Mental Health Screening

34. 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.

35. 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

36. 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.

37. 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.

38. 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.

39. 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.

40. 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)

41. Suicide Watch • Level II • 15 minute observation and documentation (at staggered intervals) • Safe cell • QMHP will determine clothing, meals, and allowable property

42. 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

43. 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.

44. 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.

45. 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.

46. Suicide Attempt Response 3. 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.

47. 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.

48. 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.

49. Responding to Persons with Suicidal Threats or Concerns 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

50. Responding to Persons with Suicidal Threats or Concerns 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.”