Elements of State and Federal Prison Suicide Prevention and Response Policies

Abstract

There are no mandatory national standards for custodial suicide prevention and response programs in the United States. While some professional organizations do offer accreditation, those programs are optional. Recent research on jails found that most facilities have formal suicide prevention policies, but they differ in their comprehensiveness. Little is known about the elements of state and federal prison suicide prevention policies. This study involves an analysis of state- and federal-level department of corrections suicide prevention and response policies. Elements of each jurisdiction’s policies were compared against a list of best practices, developed by professional organizations and correctional suicide scholars, for suicide prevention and response. Results revealed that, on average, department policies contain about half of the recommended elements, and that some policies, including those that could improve the culture of each institution, are not included in most departmental policy documents.

Keywords

prison suicide mental health policies

Prisons must contend with managing people who are mentally ill or experiencing a mental health crisis, and the number of incarcerated individuals who experience mental health problems has increased over the past 50 years (Johnson, 2011; Kolodziejczak & Sinclair, 2018; Looman & Carl, 2015). The United States conducted a mass incarceration boom, beginning in the 1980s, that resulted in a 500% increase of the prison population (The Sentencing Project, 2022). This coincided with decades of reductions in available psychiatric beds throughout the country, from 559,000 in 1955 to just 35,000 by 2012 (Torrey, 2016). These two factors, combined with the lack of funding for community mental health programs, dearth of affordable housing, income inequality (Frederick et al., 2018), and a get-tough-on-crime mentality, have contributed to the United States leading the world in incarceration and using correctional facilities as de facto mental health institutions. The United States currently houses 1.2 million adults in prison (Carson, 2022), 37% of whom have been diagnosed with a mental health disorder (Bronson & Berzofsky, 2017).

Prisons also house a disproportionate percentage of people who struggle with substance misuse or addiction (National Center on Addiction and Substance Abuse, 2010; National Institute on Drug Abuse, 2020). Just as prisons were never intended to serve as psychiatric facilities, they are also ill-equipped to provide the necessary levels of substance abuse treatment and medical attention to people suffering from substance misuse. Both people with mental illness and individuals struggling with substance misuse are at high risk for suicide and are overrepresented by those who die by suicide while in custody (Favril et al., 2018; Hayes, 2010; Patterson & Hughes, 2008; J. Shaw et al., 2003).

While the “imported vulnerability” (Liebling & Ludlow, 2016) factors of mental illness and substance misuse are important predictors of suicide in custody, it is important to remember that people who are not mentally ill can also be at risk for suicide (Liebling, 1992, 1993). The deprivations associated with incarceration, including but not limited to separation from family and friends, security threats stemming from being housed with other offenders, and lack of freedom and autonomy (Sykes, 1958), weigh on people in prison, and individuals vary in their ability to cope with these challenges (Liebling, 1999). Even in the absence of mental illness or struggles with addiction, people may find the stress and sadness produced by incarceration to be too much to bear and consider suicide as their only form of relief from the pain they are experiencing.

In 2019, 8.1% of people housed in state prisons in the United States, who died, did so by suicide, and this was the highest percentage of self-inflicted deaths since the Bureau of Justice Statistics began collecting mortality data in 2001 (Carson, 2020). From 2001 to 2019, suicides increased in the U.S. Federal Bureau of Prisons (BOP) and state prisons by 61% and 85%, respectively (Carson, 2021). The suicide rate in state prisons was 27 per 100,000 and 20 per 100,000 in the federal system in 2019 (Carson, 2020).¹ Outside of incarceration settings in the United States, the suicide rate was 13.9 per 100,000 adults and 22.4 per 100,000 adult males (Hedegaard et al., 2021). Suicide risk may also extend past the expiration of one’s time in prison or jail. Researchers from multiple countries have found that people recently released from incarceration tend to die by suicide at a higher rate than people permanently residing in the free community (Binswanger et al., 2007; Daigle & Naud, 2012; Haglund et al., 2015; Pratt et al., 2006; Spittal et al., 2014). Since custodial facilities often serve as a suicidogenic environment for people forcibly kept inside, suicide prevention programs have become key elements of efforts to maintain safe facilities.

The first national studies of suicides in American corrections were published in the 1980s (Hayes, 1983; Hayes & Rowan, 1988). This work, plus correctional facilities’ exposure to litigation stemming from suicides in custody, focused attention on the problem and promoted the development of suicide prevention programs in prisons and jails. Suicides are generally preventable (Forbus, 2023; Klein & Klein, 2022; Patterson & Hughes, 2008; J. Shaw et al., 2003; Tartaro, 2019). Strong, comprehensive, and well-implemented suicide prevention programs can help correctional staff create a safer, less stressful environment, detect potential crises, and intervene before someone is injured or killed. Hayes (2010) collected data on jails and police detention centers in 2005 and 2006 and found that 85% had written suicide prevention policies, an increase from 58% in the 1980s (Hayes & Rowan, 1988). Hayes (2010) did observe, however, that the policies varied a great deal in the extent to which they were comprehensive and multifaceted. The aforementioned studies focused on jails and lockup areas in police stations, but little is known about the content of prison suicide prevention policies in the United States. The goal of this study was to review suicide prevention policies for the BOP and all state prison systems in the United States and assess the extent to which they are in line with best practices recommended by professional organizations and correctional suicide scholars. Best practices for this study were derived from the correctional suicide prevention literature as well as standards published by professional medical and correctional associations.²

Components of Suicide Prevention and Response Programs

Professional associations, such as the American Psychiatric Association (APA, 2016), the National Commission on Correctional Health Care (NCCHC, 2015), and the American Correctional Association (ACA, 2010, 2016, 2021), have written standards for care and treatment of incarcerated individuals. These organizations recommend comprehensive, multifaceted suicide prevention and response programs. The NCCHC and ACA both offer accreditation, but unless mandated by law in a particular jurisdiction, becoming accredited is optional for prisons. The result is that the nation’s 51 departments of corrections (DOCs; 50 states plus the BOP) lack a uniform mandate for required components of suicide prevention and response policies.

Comprehensive, multifactored suicide prevention and response programs are thought to be necessary to maximize the safety of the entire correctional population. After studying suicide for decades, Hayes (2013) warned correctional personnel against developing a narrow outlook and thinking of suicide prevention simply as ensuring the safety of people while they are on suicide precautions. People who have been identified as being at risk for prison-based suicide attempts clearly need to be kept safe, but it is also important to continuously check on all incarcerated individuals throughout the entire term of confinement to detect when someone is in crisis. Suicidal ideation tends to come and go (Coppersmith et al., 2023; Drum et al., 2009; Felthous, 1994), so it is important that correctional staff communicate with each other, be mindful of any changes that they notice in individuals, and be aware of common high-risk periods within a prison term. The NCCHC (2015) has identified the following moments during incarceration as high-risk times for suicide attempts: initial admission or transfer to a facility, before and after court hearings, upon receipt of bad news from home, and after suffering humiliation or rejection. Multifactored suicide prevention policies, if implemented properly, are expected to enhance safety, because they establish a culture that views suicide prevention as relevant to the entire correctional population, and the work surrounding suicide prevention occurs throughout incarceration, not just during admissions.

Barker et al. (2014) conducted a systematic literature review of research on custodial suicide prevention and found that multifaceted prevention programs were the most promising. Specifically, the most effective programs were those that viewed the work of suicide prevention as beginning upon an individual’s incarceration and continuing until they finish serving their time. In addition, successful programs were characterized as having strong intake screening procedures, enhanced staff training, mental health treatment for suicidal individuals, social support for individuals, and safe housing assignments with an emphasis on using the least restrictive settings necessary.

An example of a multifactored suicide prevention program can be found in England and Wales. The Ministry of Justice for England and Wales developed the Assessment, Care in Custody and Teamwork (ACCT) program with the goal of providing corrections staff with clear guidance for how to safeguard individuals in crisis. ACCT can be initiated by any staff member who is concerned about the well-being of someone in custody by completing a form to employ an assessment (Newcomen, 2014; Pike & George, 2019; J. Shaw & Turnbull, 2009). Following the assessment, mental health professionals create an individualized management plan, called a “CAREMAP.” The CAREMAP is “the ongoing action plan documenting how the care and support, to address the relevant issues, is to be delivered” (Pike & George, 2019, p. 6). This document is supposed to be updated daily, read by all staff who interact with the individual, and frequently monitored by case managers to ensure that the care plan is completed. The plan is expected to be multidisciplinary and involve communication with law enforcement and court staff who interact with the clients³ (Newcomen, 2014; J. Shaw & Turnbull, 2009).

Cramer and colleagues (2017) reviewed the suicide prevention and response practices recommended in the scholarly literature, professional commentaries, and standards of several professional organizations, including the ACA, APA, and NCCHC. Based on their review, Cramer et al. (2017) identified four categories of best practices for suicide prevention and response for prisons and jails. While the list is not exhaustive, it is a good starting point for guiding the development of multifactored suicide prevention programs. The best practices consist of oversight of policies, training, assessment and management, and responding to suicide (Cramer et al., 2017). These four categories will be discussed in greater detail in the following paragraphs.

Oversight of Policies

Correctional administrators, frequently centralized staff rather than frontline employees, need to draft policies that prioritize custody concerns, including prevention of escapes, movement of contraband, and assaults against staff. Requiring medical or mental health staff to review and approve of suicide prevention policies may help DOCs achieve balance between custody and care priorities (ACA, 2021; NCCHC, 2015). Due to their training and education, medical and mental health staff are likely to be more attuned to the therapeutic needs of people dealing with mental health challenges and histories of substance misuse. Medical and/or mental health staff review of the suicide prevention policy presents an opportunity to advocate for making medical and mental health personnel key decision-makers in care and custody decisions for people in crisis.

Staff Training

Best practices call for comprehensive and ongoing suicide prevention training (ACA, 2021; APA, 2016; Cramer et al., 2017; NCCHC, 2015). Cramer and colleagues (2017) stated that institutions should mandate at least 8 hr of initial training, followed by a minimum of 2 hr of in-service training each year. Training should include several topics, including assessment and screening of individuals; facility monitoring policies; housing options and rules for appropriate use; mental health referral processes; communication of medical, mental health, and security information; interventions for suicide attempts; notifications of suicide attempts and deaths; attitudes toward suicide; factors that predispose correctional populations to suicide; warning signs of suicide; and review of the institution’s suicide policy (ACA, 2021; Cramer et al., 2017; NCCHC, 2015). Cramer et al. also recommended that all staff in contact with incarcerated persons should receive training in suicide prevention and response (Cramer et al., 2017). Given the prevalence of self-harm and suicide in segregation (Patterson & Hughes, 2008; Reeves & Tamburello, 2014; Roma et al., 2013), officers assigned to those units should receive additional suicide prevention training (“Boston Congress of Correction Policies and Resolutions,” 2016; Cramer et al., 2017).

Assessment and Management of Suicidal Individuals

As noted earlier, suicidal crises can be triggered by a number of different events. While departments often mandate screening at initial facility intake or transfer to another institution, conducting screening at additional stages of incarceration might help staff learn how incarcerated individuals are coping with stressful events (Cramer et al., 2017; Hayes, 2013; Tartaro, 2019). It is not uncommon for someone to become suicidal after receiving bad news from home, learning of a negative court ruling, or experiencing an interpersonal crisis within the institution (APA, 2016; NCCHC, 2015). All these are likely to occur after the individual has undergone admission screening. Hayes (2013) likened screening to taking someone’s temperature to check for a fever, and doing that just once at the time of admission is likely to leave staff with insufficient information about the wellness of incarcerated people throughout their sentence.

Screening forms should allow staff to collect information on common risk factors for suicide, such as current suicidal ideation⁴ (APA, 2016; Daeid & Lynch, 2000; Encrenaz et al., 2014; NCCHC, 2015; Sanchez et al., 2018; Suto & Arnaut, 2010), history of suicide attempts and/or self-harm (APA, 2016; Austin et al., 2014; Hawton et al., 2014; Klonsky, 2007; Klonsky et al., 2013; NCCHC, 2015; Patterson & Hughes, 2008), mental illness diagnosis or symptoms (APA, 2016; Baillargeon et al., 2009; Kovasznay et al., 2004; NCCHC, 2015; Patterson & Hughes, 2008; Rivlin et al., 2013; Suto & Arnaut, 2010), and drug use/intoxication (Hayes, 2010; NCCHC, 2015; Newcomen, 2014; Rivlin et al., 2013). These tend to be recommended or required elements of correctional facility screening forms (ACA, 2021; NCCHC, 2015).

Lack of communication between offices, daily staff shifts, and corrections personnel and outside parties can prevent correctional and mental health staff from taking much-needed precautions with people at risk for suicide. Communication breakdowns have contributed to suicides in custody on multiple occasions (see Cavalieri v. Shepard, 2003; Conn v. City of Reno, 2010; Turney v. Waterbury, 2004). The NCCHC accreditation requires written policies to ensure both intrasystem and intersystem communication about possible suicide risk, including who to inform and when. Intersystem communication involves intake staff collecting information from all transferring officers and agencies about suicidal comments or behaviors at the previous institution or during the transfer (Cramer et al., 2017; Hayes, 2010; NCCHC, 2015; Newcomen, 2016; Tartaro, 2019).

Staff interpretation of suicidal ideation or self-harming behavior can be counterproductive, particularly when those judgments are coming from those who lack proper medical or mental health credentials. Correctional personnel can become preoccupied with classifying behavior as either “mad,” meaning it was a result of mental illness, or “bad,” indicating that the intent was to manipulate staff (Fagan et al., 2010), even though these categories are not mutually exclusive. This black-and-white approach can sometimes result in staff discounting the seriousness of statements and self-harming behaviors and labeling self-harm or talk of suicide as “manipulative.” Montross (2020) referred to this type of correctional staff reaction as a “misalignment” between symptoms of people with mental illness and the expectations of behavior in prisons and jail. The NCCHC (2015) standards require that decisions about someone’s clinical status and the care they need reside with qualified mental health staff.

The predominant method of suicide in correctional facilities is hanging/asphyxiation (Austin et al., 2014; Boren et al., 2018; Carson, 2021; Favril et al., 2018; Hayes, 2010; Willis et al., 2016). This can occur very quickly, as it only takes minutes to fashion a ligature. Best practices for correctional suicide prevention call for constant, face-to-face monitoring of people who are acutely suicidal to prevent them from being able to engage in self-harming behaviors (Cramer et al., 2017; NCCHC, 2015; Tartaro, 2019). In addition, placement in safe cells, also known as suicide-resistant cells, that lack tie-off points and materials that can be used for a ligature is recommended for the acutely suicidal (Hayes, 2005; NCCHC, 2015; Pompili et al., 2009), as is using housing in areas fully visible to supervising staff members (Cramer et al., 2017). Suicide-resistant cells and housing areas can be depressing, stigmatizing, and isolating, which is why experts recommend transitioning individuals to less restrictive settings as soon as safely possible (Barker et al., 2014; Cramer et al., 2017; Hayes, 2005; Tartaro, 2019). Cramer et al. (2017) recommended assigning a corrections officer to serve as a source of support for the suicidal individual. Another best practice is to seek approval from qualified mental health personnel any time a person is going to be either taken off suicide watch or provided less frequent monitoring (Hayes, 2013; NCCHC, 2015; Tartaro, 2019).

Response to a Suicide Attempt

There are several best practices for correctional staff response to suicide in progress. Policies should mandate that corrections officers be trained in first aid and cardiopulmonary resuscitation (CPR) because it will take time for emergency medical technicians (EMTs) to travel to and enter the prisons (ACA, 2021). Policies should also include instructions for officers to enter the area as soon as it is safe and to immediately begin lifesaving measures, as preserving life must take priority over preserving the scene (Hayes, 1997, 2010). Cut-down tools should be available for officers, given the frequency of hangings for suicide (ACA, 2010). In the event of a death, accreditation standards require written policies outlining who contacts outside authorities (ACA, 2021; NCCHC, 2015) and next of kin (NCCHC, 2015) as well as critical incident debriefing and psychological autopsies (ACA, 2021; APA, 2016; NCCHC, 2015).

Little is currently known about the comprehensiveness of prison suicide prevention policies. This study is a content analysis of the U.S. BOP and state DOC’s suicide prevention and response policies. The purpose of the study was to learn the extent to which policies include language reflecting best practices identified in the literature.

Method

In 2022, the lead researcher worked to collect suicide prevention policies from all 50 U.S. states and the BOP. The initial phase of data collection involved Google searches of each DOC website. If the website did not contain a policy with suicide in the name, the next step was to search for any policy that covered mental health, health care, or vulnerable populations, as some states embed their suicide prevention guidance inside larger policy documents. If the internet searches were unsuccessful, the lead researcher contacted the DOCs and asked for assistance in locating their suicide prevention policies. Four agencies (8%) responded to our requests by sharing their policies, two (4%) replied that suicide prevention policies are confidential, one state (2%) sent a publicly available report instead of their policy, and the remaining states (5, 9%) did not reply to our requests. The search yielded policies from 39 states and the BOP (n = 40, 78%).

The lead researcher conducted the initial review of each document and searched for items listed on our data coding sheet (see Table 1). Jurisdictions vary in the extent to which they address all topics pertaining to suicide training, screening, prevention, and response in one document or disperse them throughout additional policies. For example, some states go into detail about suicide screening in their suicide prevention policy, while others briefly mention screening but then leave details for separate screening policy documents. The lead researcher conducted additional searches for policies that might cover areas that were thin or nonexistent in each department’s suicide prevention document by looking for additional potentially relevant policy documents. In addition to separate screening policy documents (17), common items that were found in policies outside of the suicide prevention and response documents were steps for responding to the death of an incarcerated individual (13), additional suicide prevention training for staff working in segregation units (8), and general staff training procedures (9). Additional documents that were necessary to complete data collection were saved in a Google folder for review by both researchers. The researchers independently read each jurisdiction’s policies, coded data, and then met to discuss our findings. In any instance where the researchers coded items differently, we reread the documents and discussed our interpretation of the items until we reached agreement.

Table 1.

Correctional Suicide Prevention Best Practices and Coding Plan.

Best practices (Based on Cramer et al., [2017]. Items added by current authors are noted with an asterix)	Variables
1. Policies: Create written prevention policies reviewed by medical or mental health staff	1. Statement that policy is reviewed by medical or mental health staff: 0 = not present; 1 = present
Training
2. Include identification, training, assessment, monitoring, housing, referral, communication, intervention, notification, reporting, review	2a. Assessment/screening: 0 = not present; 1 = present 2b. Monitoring: 0 = not present; 1 = present 2c. Housing: 0 = not present; 1 = present 2d. Referral: 0 = not present; 1 = present 2e. Communication: 0 = not present; 1 = present 2f. Intervention: 0 = not present; 1 = present 2g. Notification: 0 = not present; 1 = present
3. Trainings should be live and interactive	Not included
4. Staff should receive at least 8 hr of initial training regarding attitudes toward suicide, those factors that predispose individuals in correctional settings to suicidal behaviors, warning signs/symptoms of suicidality, and an in-depth review of the facility’s written suicide prevention plan.	4a. 8 hr of training required: 0 = not present; 1 = present 4b. Attitudes toward suicide in training: 0 = not present; 1 = present 4c. Predisposing factors/risk factors of incarcerated people: 0 = not present; 1 = present 4d. Warning signs/symptoms of suicidality: 0 = not present; 1 = present 4e. Review of existing suicide policy: 0 = not present; 1 = present
5. Training should be completed by any employee who has contact with incarcerated persons	5. Who is required to receive training: 0 = no information provided; 1 = staff with supervision responsibilities; 2 = all staff with resident contact
6. Facilities should provide a 2-hr refresher training annually	6. Refresher training: 0 = no information provided; 1 = yes, but no specified length; 2 = yes, at least 2 hr
7. Supervisors, or other individuals responsible for the training of professionals providing suicide risk services, are recommended to commence the developmental training process as quickly as possible, preferably with classroom instruction, followed by practice, and then in vivo experience within the correctional environment	Not included
8. Effective verbal communication among interdisciplinary staff within the institution should be a component of training	Not included
9. Train segregation staff on warning signs/unusual behavior and how to support inmates experiencing suicidality	9. Statement about additional suicide/mental health training for segregation staff: 0 = not present; 1 = present
10. Assist inmates in reporting at-risk peers	10. Mention that residents are encouraged to report peer at risk for suicide: 0 = not present; 1 = present
Assessment and management
11. Avoid labeling inmate expression of suicide as manipulative or negative	11. Mention that all statements/actions should be taken seriously: 0 = not present; 1 = present
12. In addition to intake assess periodically and following major events	12. Mention that screening occurs at times in addition to intake/transfer: 0 = not present; 1 = present
13. Screening should address common risk factors of suicide, such as history of suicidal behavior	13a. History of suicidal behavior/self-harm: 0 = not present; 1 = present
13b. Screening should seek information about current suicidal ideation^a	13b. Current suicidal ideation: 0 = not present; 1 = present
13c. Screening should seek information about mental illness or current symptoms^a	13c. Diagnosis of mental illness or current symptoms: 0 = not present; 1 = present
13d. Screening should seek information on alcohol/drug use^a	13d. Alcohol/drug use: 0 = not present; 1 = history of it; 2 = current use
14. Once high-risk individuals are identified, mental health staff should develop an observation and treatment plan (continuous in-person monitoring in housing that free from obvious anchoring devices and provide full visibility to security staff)	14a. Continuous, in-person observation (not CCTV): 0 = not present; 1 = present 14b: Suicide-resistant/safe cells used: 0 = not present; 1 = present 14c: Cell in area fully visible to staff: 0 = not present; 1 = present
15. Clear chain of communication between arresting officers and the facility, among facility staff, and between facility staff and the suicidal person	15a. Intersystem communication (seek information from booking/transferring officers): 0 = not present; 1 = present. 15b: Intrasystem communication (requirements for staff to communicate mental health concerns): 0 = not present; 1 = present
16. Consider the principle of “least restrictive environment” in placement decisions	16. Mention need to place people in “least restrictive environment”: 0 = not present; 1 = present
17. Assign a specific officer as support system	17. Mention that one specific officer is assigned/responsible: 0 = not present; 1 = present
17a. Only qualified mental health professionals can reduce supervision level once person is on suicide watch^a	17a. Qualified mental health professional must sign off on reduction of supervision or removal from suicide watch: 0 = not present; 1 = present
Responding to a suicide
18. Immediate intervention, emphasizing the importance of first aid and CPR training for all staff with contact with incarcerated	18a. Instruction to enter cell/give aid as soon as it is safe: 0 = not present; 1 = present 18b. Training or availability of cut-down tool: 0 = not present; 1 = present 18c. Require CPR/first aid for officers: 0 = not present; 1 = present
19. Notification of family members and officials	19a. Inform family members: 0 = not present; 1 = present 19b. Inform outside officials: 0 = not present; 1 = present
20. An official critical incident stress debriefing (CISD) for both staff and incarcerated	20. Must mention CISD or debriefing that involves staff and incarcerated individuals: 0 = not present; 1 = present
21. Psychological autopsy within 30 days	21. Mention “psychological autopsy”: 0 = not present; 1 = present

Note. CPR = cardiopulmonary resuscitation; CCTV = closed circuit television.

Items not in Cramer et al.’s list but deemed essential by current authors.

The coding sheet is available in Table 1. As a starting point, the authors used Cramer et al.’s (2017) list of 21 best practices as a guide for creating a data collection tool. In addition, researchers for this study reviewed the most recent accreditation and professional association standards pertaining to suicide and mental health treatment published by the APA (2016), ACA (2010, 2016, 2021), and the NCCHC (2015). The researchers also consulted research and commentaries on suicide in correctional facilities (Hanson, 2010; Hayes, 2010, 2013; Tartaro, 2019), when finalizing the list of best practices. This review of documents led the current authors to add four best practices to the coding sheet (Items 13b, 13c, 13d, and 17a).

Table 1 includes a list of all the Cramer et al. (2017) items, best practices added by the current authors, and the study’s coding plan. Three of the components of Cramer et al.’s list would have required staff interviews or even observations, so they were excluded from data collection. Those items were (3) “Training should be live and interactive,” (7) “Supervisors, or other individuals responsible for the training of professionals providing suicide risk services, are recommended to commence the developmental training process as quickly as possible, preferably with classroom instruction, followed by practice, and then in vivo experience within the correctional environment,” and (8) “Effective verbal communication among interdisciplinary staff within the institution should be a component of training.”

The first section, Policies, consisted of just one variable measuring whether the DOC required that their suicide prevention policy undergo a review by a mental health or medical authority. The second, Training, included several variables. Items 2 and 4 on Cramer et al.’s (2017) list had to be broken down into 12 separate variables measuring training components. For the 12 variables, we searched the training sections of the policy documents for the presence of the following words: assessment/screening, monitoring, housing, referral, communication, intervention, notification, at least 8 hr of training on suicide/mental health, attitudes toward suicide, predisposing factors to suicide for incarcerated individuals, warning signs and symptoms of suicidality, and review of the department’s suicide prevention policy.⁵ For each training component, mention of it in a policy was coded as 1, while its absence was coded as 0. The next item (Item 5) involved who receives training. No mention of training or who is supposed to be trained was coded as 0, training only those responsible for supervision of incarcerated people was coded as 1, and training of everyone in contact with incarcerated people was coded as 2. For yearly in-service training (Item 6), no mention was coded as 0, yearly in-service training with no specified time length was 1, and training of at least 2 hr was 2. Specific suicide/mental health training for segregation staff (Item 9) was 1 = present or 0 = not present.

For assessment and management, we divided the variables into three categories: communication, screening, and monitoring. All the communication variables were coded as 1 = present or 0 = not present. While Cramer et al. (2017) listed encouraging incarcerated people to report concerns about their peers in the training category (Item 10), we felt it was more appropriate for the communication section. The second variable (Item 11) in this section was the need to avoid negative labels such as “manipulative,” so the researchers searched for any statements instructing staff to take all comments and actions of people at risk for suicide seriously. Item 15 included communication both within the facility and between facility staff and outside personnel, so we divided this into two variables. The researchers searched for wording in the policy requiring the prison staff to collect information about suicide risk from transferring or booking officers (15a). Intrasystem communication was measured by searching for statements instructing all facility staff to share their concerns and observations with each other and/or other offices within the DOC (15b).

For screening, we collected data on whether each policy required screening to be conducted throughout incarceration, as opposed to just at initial intake or transfer (Item 12) and included asking respondents about history of suicidal behavior and self-harm (Item 13a). Given the research on predictors of suicide in custody, we decided to add three more items to the screening section of the coding sheet: current suicidal ideation (13b) (APA, 2016; Daeid & Lynch, 2000; Encrenaz et al., 2014; NCCHC, 2015; Sanchez et al., 2018; Suto & Arnaut, 2010), mental illness diagnosis or current symptoms of mental illness (13c) (APA, 2016; Baillargeon et al., 2009; Kovasznay et al., 2004; NCCHC, 2015; Patterson & Hughes, 2008; Rivlin et al., 2013; Suto & Arnaut, 2010), and current use/intoxication or history of alcohol/substance use (13d) (Hayes, 2010; NCCHC, 2015; Newcomen, 2014; Rivlin et al., 2013).

Monitoring was measured with five variables. The first three were in Cramer et al.’s (2017) Item 14: whether the DOC requires constant, face-to-face monitoring of individuals who were acutely suicidal (14a); whether they are placed in a “safe cell,” which is a suicide prevention cell lacking protrusions or tie-off points used for hanging/asphyxiation (14b); and if the cells used are visible to staff members (14c). The final two variables in this category were whether staff are instructed to use the “least restrictive environment” for individuals dealing with suicidality (Item 16) and whether one specific officer is assigned to each patient as a support system (Item 17). Based on our knowledge of custodial suicide litigation and correctional best practices (NCCHC, 2015), the authors chose to add one more item to this section: whether qualified mental health professionals are required to sign off on all reductions of supervision levels for people at risk for suicide (labeled 17a).

The final section was for suicide response. Best practices here included instructions to enter the cell and start lifesaving measures once it is safe to do so (18a), the availability of cut-down tools (18b), and requirement for correctional staff to be trained in first aid/CPR (18c). For completed suicides, we searched for evidence that the DOCs have a policy to notify family (19a) and outside authorities (19b), offer critical incident debriefing (20), and conduct a psychological autopsy (21). Critical incident debriefing involves fact gathering about the suicide, with an emphasis on providing staff the opportunity to process their feelings of grief and stress (Hayes, 1994). Psychological autopsies include research on the mental health problems that may have factored in the individual’s death (NCCHC, 2015). Data were entered into a shared Google Sheet and then transferred into SPSS 28.01 for analysis.

Results

Researchers were unable to obtain policies from 11 state DOCs: two DOCs in the northeast (New Jersey, Rhode Island), five from the southeast (Arkansas, Florida, Mississippi, Tennessee, and West Virginia), one from the Midwest (Nebraska), and three from the west (California, Hawaii, and Utah). The data set included a total of 38 best practice items, with DOCs including a mean of 17.4 (median = 17.5, SD = 5.44) of them in their available policies, ranging from one agency with 27 included elements to one with only seven.

Results for the policies and training categories are displayed in Table 2. Of the 40 DOC policies that the researchers were able to collect, 21 (53%) included statements requiring a mental health or medical professional to review the jurisdiction’s suicide prevention plan. Seven programs (17.5%) had policies mandating at least 8 hr of initial suicide prevention training. Few (n = 9, 23%) included training requirements for assessment and screening of individuals in their suicide prevention manuals or other DOC policy documents. More commonly listed training elements were warning signs of suicide (n = 31, 78%), predisposing factors common among incarcerated individuals (n = 23, 56%), monitoring people deemed at risk for suicide attempts (n = 21, 53%), referral procedures (n = 22, 55%), and how to intervene in a suicide attempt (n = 24, 60%). Slightly less than half of the DOCs had policies requiring training on communicating information about suicide risk (n = 19, 48%). Nearly one third of the policies referred to training on housing people at risk for a suicide attempt and procedures for notification following a suicide (n = 12, 30%), and almost a quarter (n = 9, 23%) of DOCs included a review of the jurisdiction’s suicide prevention program in their training sessions. The most infrequently appearing training policy was discussing attitudes toward suicide, with only one DOC doing that. Eighteen percent (n = 7) of the jurisdictions’ policies specified that suicide training must be at least 8 hr long. Eighty-three percent (n = 33) of DOCs required refresher training on suicide prevention, but only 15% mandated the recommended minimum of 2 hr per year. Additional suicide prevention training specifically for officers working in segregation was found in 19 (25%) policies. Overall, DOCs included a mean of 5.7 (SD = 3.54) of the 14 training elements identified as best practices.

Table 2.

Suicide Prevention Program Policy Review and Components of Training Programs (n = 39).

Policy review and training characteristics	F	%
Medical or mental health professional must review the policy	21	52.5
Training
Initial training at least 8 hr long	7	17.5
No mention of training length	33	82.5
Assessment/Screening all individuals	9	22.5
Monitoring individuals at risk for suicide	21	55.0
Housing individuals at risk for suicide	13	32.5
Referral procedures	22	55.0
Communication of information regarding risk of self-harm	19	47.5
Intervening in a suicide attempt	24	60.0
Notification procedures in the event of an attempt	12	30.0
Attitudes toward suicide	1	2.5
Predisposing factors for suicide common in incarcerated individuals	23	57.5
Warning signs of suicide	31	77.5
Review of institution’s suicide policy	9	22.5
Initial training is at least 8 hr long	7	17.5
Who receives training
Correctional/Medical/Mental health staff	21	52.5
Any staff who has contact with the inmate	17	42.5
No mention	2	5.0
Refresher training
Present, no time specified	27	67.5
Present, at least 2 hr per year	6	15.0
No mention	7	17.5
Specific training for segregation staff	10	25.0
Total training elements^a (range = 0–14)	M = 5.68	SD = 3.54

Note. Some frequencies do not equal 100% exactly due to rounding error.

Departments were given one point for training everyone who comes into contact with incarcerated individuals and one point for offering in-service suicide training for at least 2 hr per year.

Table 3 includes the results for the assessment and management policy components. It was uncommon for DOC policies to include a statement about encouraging incarcerated individuals to report concerns about their peers (n = 2, 5%). Twenty percent of the DOCs (n = 8) had language instructing all staff to treat any suicidal gesture or statement as a true threat. Forty percent (n = 16) of DOC policies addressed intersystem communication about suicidality, while 75% (n = 30) included instructions about intrasystem communication.

Table 3.

Assessment and Management Best Practices.

Communication, screening, and housing policies	F	%
Communication
Encourage other incarcerated individuals to report concerns about peers	2	5.0
Staff are to take every statement and gesture seriously	8	20.0
Procedures for intersystem communication (information from police, transferring officers, etc).	16	40.0
Procedures for intrasystem communication about suicide risk	30	75.0
Screening
History of suicide behavior	32	80.0
Current suicide ideation	32	80.0
Mental health diagnosis/symptoms	30	75.0
Substance use
History	9	22.5
Current	14	35.0
No mention	17	42.5
Screening at times in addition to intake/transfer	9	23.1
Housing and monitoring
Constant, face-to-face monitoring	30	75.0
Use of cell free of tie-off points or protrusions, “safe cell”	25	62.5
Inside of cell visible to staff	11	27.5
Mention of need to use “least restrictive environment”	7	17.5
DOC assigns a specific officer to serve as a support person	3	7.5
Qualified mental health professional approval required for reduction of supervision/removal from suicide watch	30	75.0
Total assessment and management elements^a (range = 2–14)	M = 6.73	SD = 2.41

Note. Some frequencies do not equal 100% exactly due to rounding error.

Departments were given one point for collecting any information on current or history of substance use during screening.

Most DOCs (n = 32, 80%) screened for both history of suicidal behavior and current suicidal ideation, while three quarters (n = 30, 75%) required staff to inquire about mental health diagnoses and current mental illness symptoms. Thirty-five percent (n = 14) of DOCs screened for current drug or alcohol use, and 23% (n = 9) asked only about history of substance misuse. Seventeen (43%) did not screen for alcohol or drug use. Less than a quarter (n = 9, 23%) had policies mandating that suicide screening occur at times in addition to facility intake or transfer.

Once individuals were identified as being acutely suicidal, three quarters (n = 30) of departments required them to be under constant, face-to-face monitoring. The majority (n = 25, 63%) of DOCs required the use of “safe” cells free of protrusions and tie-off points. Only 11 DOCs (28%) required that acutely suicidal individuals be placed in cells that are visible to staff at all times. Few departments emphasized placement of individuals in “least restrictive environments” (n = 7, 18%), and only three DOCs had a policy to assign one specific officer as a support system for a suicidal individual. Three quarters (n = 30) of policies mandated the approval of a qualified mental health professional before reducing supervision levels or removing someone from suicide watch. On average, DOCs offered 6.7 (SD = 2.41) of the 14 assessment and management items included in the best practices.

Table 4 includes results for the suicide response best practices. Twenty-one DOCs (53%) mentioned the use of cut-down tools in their policies and instructed staff to enter the cell and offer aid as soon as it is safe to do so. Seventy percent (n = 28) included a requirement for officers to be trained in CPR/first aid. In the event of a death, two thirds (n = 27) of facilities required staff to notify outside authorities, and 58% (23) had a policy for notifying next of kin. Sixty percent (n = 24) of department policies included critical incident stress debriefing, but only 43% (n = 17) required psychological autopsies. There were seven items on the data collection sheet for suicide response best practices, and facilities included a mean of 4.03 (SD = 1.85) in their policies.

Table 4.

Suicide Response Best Practices.

Response type	F	%
Instruction to enter cell/give aid once safe	21	52.5
Mention of availability of cut-down tool	21	52.5
Require CPR/first aid training for officers	28	70.0
Policy to notify outside authorities of death	27	67.5
Policy to notify family	23	57.5
Critical incident debriefing	24	60.0
Psychological autopsy policy	17	42.5
Total response elements (range = 0–7)	M = 4.03	SD = 1.85

Note. Some frequencies do not equal 100% exactly due to rounding error. CPR = cardiopulmonary resuscitation.

Discussion

Prisons in the United States are likely to continue to be required to house people with mental illness and co-occurring disorders for the foreseeable future. The stressful and depressing nature of incarceration can test the resilience of all prisoners and contribute to the onset of a suicidal crisis, even among those who are not mentally ill. The recent uptick in prison suicides necessitates a review of what we know about effective suicide prevention and response programs and an examination of the components of existing policies. Scholars (Barker et al., 2014; Cramer et al., 2017; Hanson, 2010; Hayes, 2013; Tartaro, 2019) and governing bodies of professional correctional and mental health organizations (ACA, 2021; APA, 2016; NCCHC, 2015) recommend that prison systems develop comprehensive suicide prevention and response policies. The decentralized nature of DOCs in the United States has resulted in 51 different approaches to preventing and responding to suicides of incarcerated individuals.

While some DOCs had rather robust suicide prevention and response policies, there were some policies that were absent from DOC documentation. Some of the least-mentioned recommended policies were those that may help shape the DOC staff culture. First, only one jurisdiction had a written policy mandating discussion and reflection on staff attitudes toward suicide. This conversation is an important step for establishing a department standard that (a) views incarcerated individuals as being in prison for punishment, not for additional punishment,⁶ (b) understands that people have a constitutional right to be kept safe, even from themselves, and (c) views suicide as preventable. Second, another rarely found policy was prohibition against staff labeling potential risk signs of suicide as “malingering” or “manipulative.” Preoccupation with malingering can result in staff dismissing important warning signs of suicide. In addition, even suicidal gestures intended to be manipulative can accidentally turn deadly in correctional settings, particularly those involving hanging or asphyxiation (Tartaro, 2019). Nonclinicians should refrain from attempting to discern whether someone is truly suicidal and defer to qualified mental health professionals. This is why it is important for medical and mental health staff to (a) review facility suicide prevention policies and (b) have the final word in supervision and treatment plan decisions for people in crisis. It might also be helpful to have medical and mental health staff, and even professional organizations (ACA, NCCHC) and academic experts, provide input when writing policies. Third, only three DOCs assigned a specific officer to act as a support for the suicidal individual. Having such a policy provides the unwell person more personal contact, may reduce the possibility that care “falls through the cracks,” and communicates that suicide prevention and wellness are the responsibilities of everyone, not just the medical and mental health personnel. These policy recommendations have the potential to shape staff attitudes and foster an atmosphere where help-seeking is encouraged. Richard Forbus, Vice President of Program Development for the NCCHC, and a retired corrections officer, argued that the success of correctional suicide prevention programs hinge on institutional culture and getting all staff to believe that prison suicides are preventable (Forbus, 2023).

A training component largely absent from the policy documents was a review of the DOCs’ prevention and response policies. Earlier, we discussed the ACCT Program in England and Wales as an example of comprehensive suicide prevention policy. ACCT also serves as an example of what can happen when policies do not match practice. Newcomen (2014) researched implementation of ACCT by examining the ACCT files of 60 individuals who suffered self-inflicted deaths in custody. For half of the deceased, the ACCT process was not correctly implemented or monitored. Specifically, 16 of the CAREMAPs were inadequate and included notes that it was the patient’s responsibility to achieve certain goals without any support services offered. S. Shaw (2017) noted that the ACCT policy was written at a time when prisons had adequate staffing, but staff shortages made the plans too difficult to implement. DOCs can write the most comprehensive policies, but departments must review plans, provide adequate staffing, and periodically remind staff of existing procedures to maximize the possibility of proper implementation.

Communication is a vital tool in preventing suicides. Incarcerated individuals spend the most time in each other’s company, yet only two DOCs had policies to encourage incarcerated people to share concerns about their peers. Fostering such communication can be difficult, particularly in male, higher security institutions, because this might be interpreted as interfering with the business of others or snitching (Rotter & Steinbacher, 2001). Just as the corrections departments need to work to change staff attitudes about suicide, efforts to normalize help-seeking for oneself and others among incarcerated people can save lives.

Another group that is in frequent contact with incarcerated individuals is the corrections officers. While a majority of departments outlined policies mandating intradepartmental communication within prisons, less than 40% did the same for communication between institutions and transferring officers. As was noted earlier, individuals have died after transferring officers failed to share their knowledge of suicide risk with custody staff (Cavalieri v. Shepard, 2003; Conn v. City of Reno, 2010).

Screening should be required at all high-risk periods of incarceration, but more than three quarters of responding DOCs mandated screening only upon prison admission or transfer. In an analysis of state and federal prison suicides in the United States, Mumola (2005) found that only 7% of prisoners died by suicide within the first month of incarceration, and this suggests a clear need to continue screening beyond prison admission.

Once someone is identified as being acutely suicidal, it is essential to monitor the individual closely. Three quarters of policies required constant face-to-face observation, and 62% mandated the use of safe cells for suicidal individuals, but only one quarter of the jurisdictions called for placement of people in cells that are fully visible to correctional staff at all times. Given that the predominant method of suicide in prison is hanging/asphyxiation, and that can be done very quickly, policies should require staff to maintain constant in-person contact with people having a suicidal crisis.⁷

While ensuring physical safety is a necessary goal of suicide prevention, the isolating nature of suicide cells and the areas where they tend to be located is likely to do little to improve one’s mental health. That is why one recommendation for suicide prevention is to use the least restrictive housing environment necessary to maintain safety while balancing concerns for the need for stimulation and social interaction. Only seven of the DOCs noted the use of least restrictive housing as a policy for their jurisdictions. Corrections agencies have a history of treating self-harm as rule infractions (Applebaum et al., 2011; Smith & Kaminski, 2010) and over-relying on isolation cells, elimination of privileges and programming, and use of special lothing that stigmatizes suicidal individuals (Skogstad et al., 2005; Tartaro, 2019).⁸ Suicide policies should never be designed with the intention of deterring help-seeking.

Limitations

Reviews of policies always carry the limitation that actual practice may deviate from what is documented, so policies may not translate into effective practice. In addition, practices may not become written policy, especially if policies are updated once every few years. Another limitation is that this analysis was conducted at the DOC level rather than studying individual institutions. Individual prisons may differ in their policies and practices relating to suicide prevention and response depending on the facility’s designated security level and the institutional culture. Some policy recommendations could not be included in this study because observations of DOC trainings would have been necessary to determine how interactive they are. While the researchers conducted extensive searches of online DOC documents and reached out to departments when necessary, it is still possible that policies for some best practices did exist, but we failed to find them. For example, it is possible that the training policies for suicide screening are covered in private medical vendor contracts instead of DOC-level documents because mental health staff are often employed by non-DOC entities to handle screening and assessment. Finally, the list of recommended policies used here was not exhaustive. One significant element that was missing from the list was therapeutic options for people who are suicidal inside prisons. Specific therapeutic decisions are likely to be made on an individual basis, and whatever existing policies relevant to this are likely to be in contracts with medical vendors.

Conclusion

This study represents the first review of state- and federal-level suicide prevention policies for prisons in the United States. Prison policies included an average of half of the items that the authors identified as best policies for suicide prevention and response. DOCs were more likely to have polices for monitoring people identified as suicidal and responding to suicide attempts in progress than policies targeting a culture of help-seeking and shared responsibility for suicide prevention. Future research should seek to analyze the extent to which departments adhere to their policies, particularly at the individual prison level.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Data Availability

Data sharing not applicable to this article as no data sets were generated or analyzed during this study.

ORCID iD

Christine Tartaro

Notes

Author Biographies

Christine Tartaro is a distinguished professor of criminal justice at Stockton University. Her research intersts include institutional corrections, mental health, suicide, and mental health diversion programs.

Emily Alas earned a Master’s Degree in Criminal Justice from Stockton University. She is currently a PsyD candidate at Widener University.

References

American Correctional Association. (2010). Core jail standards.

American Correctional Association. (2016). 2016 Standards supplement. https://www.aca.org/common/Uploaded%20files/2016%20Standards%20Supplement.pdf

American Correctional Association. (2021). Performance-based standards for correctional health care in adult correctional institutions (5th ed.).

American Psychiatric Association. (2016). Psychiatric services in correctional facilities (3rd ed.).

Applebaum

K. L.

Savageau

J. A.

Trestman

R. I.

Baillargeon

(2011). A national survey of self-injurious behavior in American prisons. Psychiatric Services, 62(3), 285–290.

Austin

A. E.

van den Heuvel

Byard

R. W.

(2014). Prison suicides in south Australia: 1996–2010. Journal of Forensic Sciences, 59(5), 1260–1262.

Baillargeon

Williams

B. A.

Mellow

Harzke

A. J.

Hoge

S. K.

Baillargeon

Greifinger

R. B.

(2009). Parole revocation among prison inmates with psychiatric and substance use disorders. Psychiatric Services, 60(11), 1516–1521.

Barker

Kolves

De Leo

(2014). Management of suicidal and self-harming behaviors in prisons: Systematic literature review of evidence-based activities. Archives of Suicide Research, 18, 227–240.

Binswanger

I. A.

Stern

M. F.

Deyo

R. A.

Heagerty

P. J.

Cheadle

Elmore

J. G.

Koepsell

T. D.

(2007). Release from prison. New England Journal of Medicine, 356, 157–165.

10.

Boren

E. A.

Folk

J. B.

Loya

J. M.

Tangney

J. P.

Barboza

S. E.

Wilson

J. S.

(2018). The suicidal inmate: A comparison of inmates who attempt versus complete suicide. Suicide and Life-Threatening Behavior, 48(5), 570–579.

11.

Boston congress of correction policies and resolutions. (2016). Corrections Today, 78(6), 72–76.

12.

Bronson

Berzofsky

(2017). Indicators of mental health problems reported by prisoners and jail inmates, 2011-12. U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics. https://bjs.ojp.gov/content/pub/pdf/imhprpji1112.pdf

13.

Carson

E. A.

(2020). Prisoners in 2019. U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics. https://bjs.ojp.gov/content/pub/pdf/p19.pdf

14.

Carson

E. A.

(2021). Suicide in local jails and state and federal prisons, 2000-2019—Statistical tables. U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics. https://bjs.ojp.gov/sites/g/files/xyckuh236/files/media/document/sljsfp0019st.pdf

15.

Carson

E. A.

(2022). Prisoners in 2021—Statistical tables. U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics. https://bjs.ojp.gov/sites/g/files/xyckuh236/files/media/document/p21st.pdf

16.

Cavalieri v. Shepard 321 F. 3d 616. (2003).

17.

Committee on Homeland Security and Governmental Affairs. (2022). Uncounted deaths in America’s prisons and jails: How the Department of Justice failed to implement the Death in Custody Reporting Act. Permanent Subcommittee on Investigations, Committee on Homeland Security and Governmental Affairs, United States Senate. https://www.hsgac.senate.gov/subcommittees/investigations/library/files/majority-and-minority-staff-report_-uncounted-deaths-in-americas-prisons-and-jails-how-the-department-of-justice-failed-to-implement-the-death-in-custody-reporting-act/

18.

Conn v. City of Reno 591. F.3d 1081. (2010).

19.

Coppersmith

D. D. L.

Ryan

Oisin

Fortgang

R. G.

Nock

M. K.

(2023). Mapping the timescale of suicidal thinking. PNAS, 120(17), e2215434120. https://doi.org/10.1073/pnas.2215434120

20.

Cramer

R. J.

Welchsler

H. J.

Miller

S. L.

Yenne

(2017). Suicide prevention in correctional settings: Current standards and recommendations for research, prevention, and training. Journal of Correctional Healthcare, 23(3), 313–328.

21.

Daeid

N. N.

Lynch

(2000). Are prison staff effective in recognizing the suicidal prisoner? Journal of the Irish College of Physicians & Surgeons, 29, 135–137.

22.

Daigle

M. S.

Naud

(2012). Risk of dying by suicide inside or outside prison: The shortened lives of male offenders. Canadian Journal of Criminology and Criminal Justice, 54(4), 511–528.

23.

Devilly

G. J.

Sorbello

Eccleston

Ward

(2005). Prison-based peer-education schemes. Aggression and Violent Behavior, 10(2), 219–240. https://doi.org/10.1016/j.avb.2003.12.001

24.

Dhaliwal

Harrower

(2009). Reducing prisoner vulnerability and providing a means of empowerment: Evaluating the impact of a listener scheme on the listeners. The British Journal of Forensic Practice, 11(3), 35–43. https://doi.org/10.1108/14636646200900021

25.

Drum

J. D.

Brownson

Burton Denmark

Smith

S. E.

(2009). New data on the nature of suicidal crises in college students: Shifting the paradigm. Professional Psychology: Research and Practice, 40(3), 213–222.

26.

Eigenberg

H. M.

(1994). Male rape in prisons: Examining the relationship between correctional officers’ attitudes toward male rape and their willingness to respond to acts of rape. In Braswell

Montgomery

Lombardo

(Eds.), Prison violence in America (2nd ed., pp. 145–165). Anderson.

27.

Encrenaz

Miras

Contrand

Galera

Pujos

Michel

Lagarde

(2014). Inmate-to-inmate violence as a marker of suicide attempt risk during imprisonment. Journal of Forensic and Legal Medicine, 22, 20–25.

28.

Fagan

T. J.

Cox

Helfand

S. J.

Aufderheide

(2010). Self-injurious behavior in correctional settings. Journal of Correctional Health Care, 16(1), 48–66. https://doi.org/10.1177/1078345809348212

29.

Favril

Wittouck

Audenaert

Laenen

(2018). A 17-year national study of prison suicides in Belgium. Crisis, 40(1), 42–53. https://doi.org/10.1027/0227-5910/a000531

30.

Felthous

A. R.

(1994). Preventing jailhouse suicides. Bulletin of the American Academy of Psychiatry and the Law, 2, 477–488.

31.

Forbus

(2023). Suicide prevention: An essential element of custody and care. American Jails, 38(3), 11–13.

32.

Frederick

O’Connor

Koziarski

(2018). Police interactions with people perceived to have a mental health problem: A critical review of frames, terminology, and definitions. Victims & Offenders, 13(8), 1037–1054. https://doi.org/10.1080/15564886.2018.1512024

33.

Haglund

Tidemalm

Jokinen

Langstrom

Lichtenstein

Fazel

Runeson

(2015). Suicide after release from prison—A population-based cohort from Sweden. Journal of Clinical Psychiatry, 75(10), 1047–1053.

34.

Hanson

(2010). Correctional suicide: Has progress ended? The Journal of the Academy of Psychiatry and the Law, 38(6), 6–10.

35.

Hawton

Linsell

Adeniji

Sariaslan

Fazel

(2014). Self-harm in prisons in England and Wales: An epidemiological study of prevalence, risk factors, clustering, and subsequent suicide. The Lancet, 383, 1147–1154.

36.

Hayes

L. M.

(1983). And darkness closes in. Criminal Justice and Behavior, 10, 461–484.

37.

Hayes

L. M.

(1994). Developing a written program for jail suicide prevention. Corrections Today, 56(2), 182–185.

38.

Hayes

L. M.

(1997). From chaos to calm: On jail system’s struggle with suicide prevention. Behavioral Sciences and the Law, 15, 399–413.

39.

Hayes

L. M.

(2005). A practitioner’s guide to developing and maintaining a sound suicide prevention policy. Jail Suicide/Mental Health Update, 13(4), 1–20.

40.

Hayes

L. M.

(2010). National study of jail suicide: 20 years later. U.S. Department of Justice National Institute of Justice. https://nicic.gov/national-study-jail-suicide-20-years-later

41.

Hayes

L. M.

(2013). Suicide prevention in correctional facilities: Reflections and next steps. International Journal of Law and Psychiatry, 36(3–4), 188–194. https://doi.org/10.1016/j.ijlp.2013.04.010

42.

Hayes

L. M.

Rowan

J. R.

(1988). National study of jail suicides: Seven years later. National Center on Institutions and Alternatives. https://www.semanticscholar.org/paper/National-study-of-jail-suicides%3A-seven-years-later.-Hayes-Rowan/c2138353769b10ad9e061d1b315afb25e7666c34

43.

Hedegaard

Curtin

S. C.

Warner

(2021). Suicide mortality in the United States, 1999–2019 (NCHS Data Brief, No 398). National Center for Health Statistics. https://doi.org/10.15620/cdc:101761

44.

Johnson

W. W.

(2011). Rethinking the interface between mental illness, criminal justice, and academia. Justice Quarterly, 28(1), 15–22.

45.

Junker

Beeler

Bates

(2005). Using trained inmate observers for suicide watch in a federal correctional setting: A win-win solution. Psychological Services, 2(1), 20–27. https://doi.org/10.1037/1541-1559.2.1.20

46.

Klein

A. R.

Klein

J. L.

(2022). Death before sentencing. Rowman & Littlefield.

47.

Klonsky

E. D.

(2007). The functions of deliberate self-injury: A review of the evidence. Clinical Psychology Review, 27, 226–239.

48.

Klonsky

E. D.

May

A. M.

Glenn

C. R.

(2013). The relationship between non-suicidal self-injury and attempted suicide: Converging evidence from four samples. Journal of Abnormal Psychology, 122(1), 231–237.

49.

Kolodziejczak

Sinclair

(2018). Barriers and facilitators to effective mental health care in correctional settings. Journal of Correctional Health Care, 24(3), 253–263.

50.

Kovasznay

M. D.

Miraglia

Beer

Way

(2004). Reducing suicides in New York State correctional facilities. Psychiatric Quarterly, 75(1), 61–70.

51.

Liebling

(1992). Suicides in prison. Routledge.

52.

Liebling

(1993). Suicides in young prisoners: A summary. Death Studies, 17, 381–409.

53.

Liebling

(1999). Prisoner suicide and prisoner coping. In Tonry

Petersilia

(Eds.), Crime and justice (Vol. 26, pp. 283–358). University of Chicago Press.

54.

Liebling

Ludlow

(2016). Suicide, distress, and the quality of prison life. In Jewkes

Crewe

Bennett

(Eds.), Handbook on prisons (pp. 224–245). Routledge.

55.

Looman

M. D.

Carl

J. D.

(2015). A country called prison. Oxford University Press.

56.

Montross

(2020). Waiting for an echo. Penguin Press.

57.

Mumola

(2005). Suicide and homicide in state prisons and local jails. U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics.

58.

National Center on Addiction and Substance Abuse. (2010). Behind bars II: Substance abuse in America’s prison population. The National Center on Addiction and Substance Abuse at Columbia University.

59.

National Commission on Correctional Health Care. (2015). Standards for mental health services in correctional facilities.

60.

National Institute on Drug Abuse. (2020). Criminal justice drug facts. https://nida.nih.gov/publications/drugfacts/criminal-justice

61.

Newcomen

(2014). Learning from PPO investigations: Self-inflicted deaths of prisoners on ACCT. Prisons and Probation Ombudsman.

62.

Newcomen

(2016). Learning from PPO investigations: Mental health. Prisons and Probation Ombudsman.

63.

Office of the High Commissioner Human Rights Council. (2023). A/HRC/53/29: Deaths in prisons: Report of the Special Rapporteur on extrajudicial, summary or arbitrary executions, Morris Tidball-Binz. https://www.ohchr.org/en/documents/thematic-reports/ahrc5329-deaths-prisons-report-special-rapporteur-extrajudicial-summary

64.

Patterson

R. F.

Hughes

(2008). Review of completed suicides in the California Department of Corrections and Rehabilitation, 1999 to 2004. Psychiatric Services, 59(6), 676–682.

65.

Pike

George

(2019). The Assessment, Care in Custody and Teamwork (ACCT) process in prison: Findings from qualitative research. Ministry of Justice. http://www.justice.gov.uk/publications/research-and-analysis/moj

66.

Pompili

Lester

Innamorati

Del Casale

Girardi

Ferracuti

Tatarelli

(2009). Preventing suicide in jails and prisons: Suggestions from experience with psychiatric inpatients. Journal of Forensic Sciences, 54(5), 1155–1162.

67.

Pratt

Piper

Appleby

Webb

Shaw

(2006). Suicide in recently released prisoners: A population-based cohort study. The Lancet, 368, 119–123.

68.

Reeves

Tamburello

(2014). Single cells, segregated housing, and suicide in the New Jersey Department of Corrections. Journal of the American Academy of Psychiatry and the Law, 42(4), 484–488.

69.

Rivlin

Ferris

Marzano

Fazel

Hawton

(2013). A typology of male prisoners making near-lethal suicide attempts. Crisis, 34(5), 335–347.

70.

Roma

Pompili

Lester

Girardi

Ferracuti

(2013). Incremental conditions of isolation as a predictor of suicide in prisoners. Forensic Science International, 233, e1–e2.

71.

Rotter

Steinbacher

(2001). The clinical impact of “doing time”—Mental illness and incarceration. In Landsberg

Smiley

(Eds.), Forensic mental health (pp. 16.1–16.6). Civic Research Institute.

72.

Sanchez

F. C.

Fearn

Vaughn

M. G.

(2018). Risk factors associated with near-lethal suicide attempts during incarceration among men in the Spanish Prison System. International Journal of Offender Therapy and Comparative Criminology, 62(6), 1452–1473.

73.

Schlosar

Carlson

L. W.

(1997). Befriending in prisons. Crisis, 18(4), 148–149, 151. https://doi.org/10.1027/0227-5910.18.4.148

74.

The Sentencing Project. (2022). Growth in mass incarceration. https://www.sentencingproject.org/research/

75.

Shaw

Appleby

Baker

(2003). Safer prisons: A national study of prison suicides 1999-2000 by the National Confidential Inquiry into Suicides and Homicides by People with Mental Illness. National Confidential Inquiry.

76.

Shaw

Turnbull

(2009). Suicide in custody. Psychiatry, 8(7), 265–268.

77.

Shaw

(2017). Independent professional advice on the prevention of self-inflicted deaths and self-harm at HMP Woodhill.

78.

Skogstad

Deane

F. P.

Spicer

(2005). Barriers to help-seeking among New Zealand prison inmates. Journal of Offender Rehabilitation, 42(2), 1–24.

79.

Smith

H. P.

Kaminski

R. J.

(2010). Self-injurious behavior in state prisons: Findings from a national study. Criminal Justice and Behavior, 38(1), 26–41.

80.

Spittal

M. J.

Forsyth

Pirkis

Alati

Kinner

(2014). Suicide in adults released from prison in Queensland, Australia: A cohort study. Journal of Epidemiology and Community Health, 68, 993–998.

81.

Stohr

M. K.

Johnson

C. L.

Cullen

F. T.

(2014). Lessons learned. In Cullen

F. T.

Johnson

C. L.

Stohr

M. K.

(Eds.), The American prison: Imagining a different future (pp. 257–268). Sage.

82.

Suto

Arnaut

G. L. Y.

(2010). Suicide in prison: A qualitative study. The Prison Journal, 90(3), 288–312.

83.

Sykes

(1958). Society of captives. Princeton University Press.

84.

Tartaro

(2019). Suicide and self-harm in prisons and jails (2nd ed.). Lexington Books.

85.

Tartaro

Klenk

(2023). Utilizing peer education and support to prevent suicide in prisons. Journal of Correctional Health Care, 29(6), 421–429.

86.

Tomczak

Bennett

(2020). Evaluating voluntary sector involvement in mass incarceration: The case of Samaritan prisoner volunteers. Punishment & Society, 22(5), 637–657. https://doi.org/10.1177/1462474520915823

87.

Tomczak

Mulgrew

(2023). Making prisoner deaths visible: Towards a new epistemological approach. Incarceration, 4, 263266632311603. https://doi.org/10.1177/26326663231160344

88.

Torrey

E. F.

(2016, February 25). The dearth of psychiatric hospital beds. Psychiatric Times, 33(2). http://www.psychiatrictimes.com/psychiatric-emergencies/dearth-psychiatric-beds

89.

Turney v. Waterbury, 375 F. 3d 756 (8th Cir. 2004).

90.

Willis

Baker

Cussen

Patterson

(2016). Self-inflicted deaths in Australian prisons (Trends and Issues in Crime and Criminal Justice No. 513). Australian Institute of Criminology. https://aic.gov.au/publications/tandi/tandi513