Suicide Prevention and Intervention in Texas: Latest Updates and Standards

SUICIDE PREVENTION AND INTERVENTION Updated August 2023 ACA/NCCHC Credit: 1HR

OBJECTIVES Recall agency policy on suicide prevention plans and handling potentially suicidal inmates. Identifying warning signs of impending suicidal behavior. Recognize certain suicide risk factors and victim s profiles.

DEMOGRAPHICS Since the year 2000, Texas has seen an overall increase in suicide mortality with the death rate by suicide rising 36.7 percent; According to the American Foundation for Suicide Prevention, a person dies by suicide approximately every two hours in Texas. Suicide has become the eleventh leading cause of death across all age groups in Texas. More men than women complete suicide, more women attempt suicide; Males are three to four times as likely to die by suicide as females in the state of Texas; however, rates among females increased slightly more than males between 2000 and 2020. Similar to suicide rates in general, since 2000 the number of suicides within TDCJ has increase dramatically, averaging 32 annually since 2000.

SUICIDE PREVENTION STANDARDS This Photo by Unknown Author is licensed under CC BY

DEFINITIONS Suicide attempt is an effort to commit suicide involving definite risk. The outcome frequently depends on circumstances alone and is not under the person s control. Suicidal ideation, also known as suicidal thoughts, is thinking about or an unusual preoccupation with suicide. The range of suicidal ideation varies greatly from fleeting thoughts, to extensive thoughts, to detailed planning, role-playing (e.g., standing on a chair with a noose), and incomplete attempts. Suicide Precautions are continuous interventions aimed at providing a safe environment for patients identified as exhibiting suicidal behavior and/or ideations. (UTMB IHOP Policy 09.13.38 2022)

DEFINITIONS (CONT.) Suicide risk assessment is a method to separate patients who are at risk for suicide from those who have moderate, low or no risk of suicide. Suicidal threat is a statement of intent to commit suicide that is accompanied by behavior changes indicative of suicidal thoughts. (UTMB IHOP Policy 09.13.38 2022)

DEFINITIONS (CONT.) Crisis Management A status ordered by a QMHP for an inmate at imminent risk of significant self-injury, suicide, or their mental health needs cannot be managed at their assigned unit. The inmate is to be placed in a specially prepared and approved cell and are observed for psychiatric symptoms at least every fifteen minutes by medical/mental health staff or a correctional officer with special training at a Behavioral Health Facility (BHF). Constant and Direct Observation (CDO) A status in which an inmate who is determined to require movement to Crisis Management is pending transport. In CDO the inmate is constantly observed by an officer who is close enough and has the means to intervene to prevent self-injury.. (CMHC Policy G53.1 Suicide Prevention Plan 2022)

DEFINITIONS (CONT.) Mental Health Observation (MH Obs) A status authorized by a Qualified Mental Health Professional (QMHP) for an inmate who is determined to be at risk of self-injury but is not actually suicidal or an imminent risk to do significant medical harm. The inmate is to be placed in a specially prepared and approved cell. Inmates in MH Obs are observed for psychiatric symptoms at least every thirty minutes by medical/mental health staff. Safety Garment When standard issued clothing presents a security or medical risk (for example, suicide observation), provisions are made to supply the inmate with a safety garment that will promote inmate safety in a way that is designed to prevent humiliation and degradation. Safety garments include smocks and/or suicide blankets. (CMHC Policy G53.1 Suicide Prevention Plan 2022)

UTMB and TDCJ developed a suicide prevention plan to identify and respond to suicidal inmates. The plan consists of several components and is consistent with the recommendations by the American Correctional Association and the National Commission on Correctional Health Care. SUICIDE PREVENTION PLAN CMHC Policy G53.1 Suicide Prevention Plan (2022) UTMB CMC MHS Policy B-3 Suicide Prevention (2022)

COMPONENTS Identification Training Assessment Monitoring Housing Referral Communication Intervention Notification Reporting Review / Critical Incident Debriefing This Photo by Unknown Author is licensed under CC BY-SA

Identification The identification of potentially suicidal inmates generally takes place during the intake process. inmates are screened for suicide indicators and documentation of this assessment is placed in their medical record for review by clinical staff. TrainingAll staff, including medical, security, classification, and others receive training during pre-service and/or new employee orientation and at least annually thereafter. Assessment All trained staff will provide an ongoing assessment, always being alert for the verbal and behavioral clues that may indicate a potentially suicidal inmate. We will discuss these clues later in this program

Monitoring Potentially suicidal inmates will remain under constant supervision until proper medical disposition is determined. This is a joint responsibility between medical and security. Housing Any inmate assessed to be potentially suicidal will be housed in a safe, secure setting that is in accordance with the current Mental Health Services Policies and Procedures. Referral At risk inmates will be immediately referred to the facility mental health department. If mental health personnel are not available, the inmate will be immediately referred to the on-call mental health clinician.

Communication Medical and security staff will maintain open communication regarding the status of a potentially suicidal inmate. This communication will be both verbally reported, and documented in the health record. Intervention The facility management team and supervising psychologist will develop a policy outlining the steps to be taken when managing a suicidal inmate. This includes proper first-aid measures. Notification The procedures for notifying prison administrators, any outside authorities and family members is outlined in Health Services Policy A-10.1. This policy is available for your reference on the facilities.

Reporting The Suicide Prevention Plan details requirements for documenting the identification and monitoring of inmates who have attempted suicide, been identified as at risk of self-harm, as well as detailing procedures for reporting a completed suicide. Review / Critical Incident Debriefing In addition to procedures for medical and administrative staff review of critical incidents such as suicide or self-harm, health care and correctional staff involved in the critical incident are provided with an opportunity to debrief in order to understand and process the symptoms of stress that can be associated with such incidents. The documentation of the critical debriefing(s) is the responsibility of the Mental Health Manager. This documentation is privileged and confidential. Appropriate mental health staff will receive a copy of the documentation.

NOTIFICATION / OBSERVATION If someone states he/she is having suicidal thoughts, attempts suicide, or is at risk for suicide, they will need to be constantly monitored until the proper mental health staff evaluates, refer to crisis management, or release the patient. DO NOT LEAVE THE PATIENT ALONE!!!! Monitoring will be completed by medical/security staff. Documents observation every 15 minutes. The patient will be placed in single housing for monitoring. The designated staff member will maintain an unobstructed view of the patient at all times and must be able to intervene without delay. Specific items will be issued to the patient to ensure the patient can t self-harm If a patient must be transported off the unit, he/she will be accompanied at all times by two persons. One person is qualified staff to observe the patient and one other person(two-person transport is required at a minimum).

RISK Recognizing the warning signs and risk factors is vitally important in preventing suicidal inmates from acting on their thoughts. FACTORS AND It is important that all staff are familiar with agency policy regarding suicide prevention. WARNING SIGNS

RISK FACTORS Recent loss such as loss of a family member, friend, or personal identity. Sexual assault-inmates who are victims of recent or repeated sexual assault are at a higher risk for suicide. They are alone, hurt and embarrassed. Physical assault- inmates who have been physically assaulted may think suicide is the only escape from repeated abuse. This Photo by Unknown Author is licensed under CC BY-SA

RISK FACTORS (CONT.) Fear for one s Safety An inmate worried about being labeled by other inmates as a possible snitch may attempt suicide in order to be placed in a safe place. Unit or Cell Reassignment An inmate may feel suicidal after a change in environment, such a facility or cell re-location, including release from transient or Pre-hearing detention status. Mental Illness An inmate with a history of mental illness is automatically in a higher risk group for suicide. They are mentally unstable and the stress of a prison environment could push them towards suicide.

RISK FACTORS (CONT.) Substance Abuse An inmate with a history of substance abuse, placed in a prison environment, has to deal with being cut-off from their addictive behavior. The need for drugs may be more than they can stand. Suicide, to them, may be a way out. Previous Suicide Attempts An inmate with previous suicide attempts may be asking for help in the only way they know how. They may feel it is an escape from the reality of their present situation. Family History of Suicide An inmate who has lost family members to suicide may consider suicide as a easy way out of a difficult situation.

RISK FACTORS Impulsive or Aggressive Tendencies inmates who display impulsive or aggressive tendencies are more prone to handle situations irrationally. They may make extreme decisions, and attempt suicide under extreme emotional distress.

WARNING SIGNS It is crucial to take any warning signs or threats of suicide seriously.

WARNING SIGNS Threat of Suicide or Self-Injury Any inmate making verbal or written threats of suicide or self-injury is a cry for help and must be taken seriously. inmates May Stop Eating Recreating Showering Engaging in normal activities

WARNING SIGNS (CONT.) Eating An inmate who has a normal appetite and is always in line for meals may suddenly stop eating or going to the dining room altogether. Recreating An inmate who recreates and has a normal level of activity may now linger in their cell. Showering An inmate who is suicidal may lose interest in personal hygiene. They may stop showering because they do not care and feel no one else cares either. Engaging in Normal Activities Any inmate who stops participating in or loses interest in normal activity may be potentially suicidal. This is a warning sign and should not be ignored.

VICTIM PROFILES Certain characteristics about an inmate profiles them and puts them at a higher risk for suicide. These characteristics are as follows. Younger first time inmates Intoxicated at time of arrest Placed in isolated housing such as Solitary Older inmates with long term sentences History of suicide attempts History of mental illness This Photo by Unknown Author is licensed under CC BY-SA-NC

MOST Hanging Self-Poisoning Drug Overdose Self-Mutilation COMMON METHODS OF SUICIDE

HANGING The most common method of suicide for an inmate. They may use homemade ropes made from clothing, linens or belts, all of which are easily accessible to them. It is important to note that in many, if not most, of the suicides by hanging / strangulation the individual is not suspended. In many cases the inmate may be sitting on the floor with the ligature tight enough to prevent circulation of blood to the brain. This Photo by Unknown Author is licensed under CC BY-NC-ND

SELF POISONING Depending on their job assignments, inmates may have access to cleaning chemicals, insecticides, gasoline, paints and other hazardous chemicals that they may inhale or ingest in a suicide attempt. This Photo by Unknown Author is licensed under CC BY-SA

DRUG OVERDOSE Inmates may stockpile prescription or over-the-counter medications to use in a suicide attempt. Tylenol, for example, is frequently used in these overdose attempts ( This Photo by Unknown Author is licensed under CC BY-SA-NC

SELF-MUTILATION The inmate may cut themselves or put themselves in dangerous situations in order to cause self harm. They have a don t care attitude, and feel that no one else cares either. This Photo by Unknown Author is licensed under CC BY-SA

BE EFFECTIVE! In order for the Suicide Prevention and Intervention Program to be effective, everyone must be involved. Here are some tips that will help make this program a success! Be sure you are familiar with basic CPR/AED and First Aid procedures.

Staff Must Enter the cell or Dormitory as Soon as Possible. BUT Remember SCENE SAFETY! ALWAYS make sure the area is secure and security officers are present. Allow the security officer to enter the cell first. Never presume the victim is dead. Should they lack a pulse, respirations, or other signs of circulation, life-saving measures should be initiated immediately!

BE PREPARED TO RESPOND Schedule practice suicide response drills at least once a year. Know where the nearest first aid kits are located in your area. If You discover an inmate attempting or contemplating suicide. YOU MUST respond immediately. NEVER LEAVE a potentially suicidal person ALONE!

EFFECTS OF SUICIDE Suicide Is very emotional for medical staff, correctional staff, and inmates. POST TRAUMA TEAMS are available -in each region -on every facility For any personnel requiring counseling or guidance. ALL information is kept confidential. This Photo by Unknown Author is licensed under CC BY-SA

IN SUMMARY. Suicide prevention is the goal of TDCJ/UTMB. Preventing inmates from harming themselves should be the focus of all trained medical and mental health staff in addition to correctional staff. It is vitally important that all staff members be familiar with the risk factors, warning signs, and victim profiles in order to identify and treat potentially suicidal inmates.

REFERENCES UTMB CMC Health Impact Newsletter (2017). Know the signs: Suicide warning signs and precaution tips. Retrieved from https://www.utmb.edu/impact/home/2017/08/18/know-the- signs-suicide-warning-signs-and-prevention-tips UTMB CMC Institutional Handbook of Operating Procedures.(2020).Continuous Observation of a patient with suicide precautions or Behavioral Restraints. Retrieved from https://intranet.utmb.edu/policies_and_procedures/Non- IHOP/Nursing_Service/Administration/3.56%20Continuous%20Observation%20of%20a%20Patie nt.pdf UTMB CMC Mental Health Services Departmental Policy (2020). Suicide Prevention. Retrieved fromhttps://www.utmb.edu/policies_and_procedures/IHOP/Clinical/General_Clinical_Proce dures_and_Care/IHOP%20-%2009.13.38%20- %20Suicide%20Risk%20Screening%20and%20Suicide%20Precautions%20for%20Patients.pdf

HOTLINE This Photo by Unknown Author is licensed under CC BY-ND