What the Coalition’s own study on mental health has to say on Suicide and Self-Harm

What the Coalition’s own study on mental health has to say on Suicide and Self-Harm
Healthy or Harmful? Mental Health and the Operational Regime of the New ACT Prison released in April 2008
[link to full text and references]

Beyond a focus on preventing physical self-harm

There is no greater demonstration of the injury to mental health by the prison environment than the high level of suicide and other self harm by detainees. The extent that it happens and the degree of mental distress in prisons that it demonstrates is alarming.  

 “The rate of suicide in prisons is estimated to be between 2.5 and 15 times that of the general population. . . . It has been estimated that for every suicide there are 60 incidents of self-harming behaviour. It is evident that inmate self-harm has become endemic in many correctional institutions.” (McArthur et al. (1999) p. 1)  

 It is thus “inescapable that suicide is a longstanding, major issue for correctional authorities” (ibid.).  

 Prompted by a string of inquiries and inquests, correctional authorities have taken firm steps to reduce successful suicide attempts. Seclusion in cells without hanging points and under continuous or regular monitoring is effective in preventing this. However, the same measures may further harm the mental health of the person confined making it more likely that he or she will attempt suicide again.  

 According to a leading manual on the management of mental disorders, “individuals who have a depressive or bipolar illness are more likely to commit suicide than individuals with any other psychiatric or medical illness. The rate of death from suicide among individuals with a bipolar illness is high, with a mean of 19% (rates vary across studies) and the rates in Major Depressive Disorder may be similar” (WHOCC (2004) p. 22). Bipolar illness and depressive disorders fall into the category of affective disorders. As the table at p. 8 shows, on reception to the NSW corrections system, 33.9% of women and 21.1% of men had an affective disorder of some kind.  

 Under standard prison practices including, it would seem, those in the ACT, efforts through seclusion to prevent suicide take place at the expense of the mental health of those concerned. The words of Professor Mullen from Forensicare succinctly go to the heart of the matter:  

 “Placing potentially suicidal prisoners in isolation cells stripped of furniture, clear of hanging points and subject to the constant gaze of prison staff may be a cheap and, in the very short term, effective suicide prevention strategy, but should remain unacceptable to a mental health professional concerned with the state of mind and long term mental health of their patient” (Mullen (2001) p. 37). 

 The Human Rights Commission in its audit quoted a coroner’s report that “safe cells are generally stark, sterile environments which can in themselves engender in detainees feelings of depression and a desire to self-harm” (AHRC (2007) p. 42) 

 The same point was a matter of concern to the Senate Select Committee on Mental Health which reported: 

 “The process of isolating such persons and placing them in seclusion appears effectively to prevent suicide and may prevent disruption to other inmates, but is hardly therapeutic for people who are mentally ill. A former visiting general practitioner to the [Brisbane Women’s Correctional Centre], Dr Schrader, made the following observations about the use of the isolation cells at the Centre: 

 The treatment is the opposite of therapeutic. The use of seclusion is inappropriate for those at risk of self-harm and suicide. Observation alone does little to help the woman overcome her distress and suicidal or self-harming feelings and is alienating in itself . . . . A key element in suicide prevention is the presence of human interaction. 

 “The committee heard similar evidence about the use of seclusion facilities for prisoners assessed to be ‘at risk’in other jurisdictions. Mr Strutt, a member of Justice Action, a prisoners’ activism organisation, referring to the use of isolation cells in NSW, stated that: 

If you are a prison officer and you see a prisoner who seems to be seriously depressed your No. 1 priority is to make sure that that person does not kill themselves while you are on duty. So basically you put them in a strip cell. For all the talk about care and attention they are getting in prisons and hospitals, the way those institutions are structured means they are not getting the appropriate care and attention” (Senate (2006) §§13.110-111). 

 In fact, the practice of seclusion is the opposite of the “key element in suicide prevention”, namely human interaction, that Dr Schrader mentioned in her words that the Senate Committee quoted.  

 Positive human interaction and support are fundamental for suicide prevention (WHOCC (2004) p. 23). Prisons may not be therapeutic environments, but their operational regime should be designed to reflect therapeutic principles. The ACT Human Rights Commission identifies a recognised set of measures that should be implemented to improve suicide prevention practices: 

 “It would be preferable to focus on suicide prevention measures, including those identified by Liebling as follows:

•            family support and visits;

•            constructive activity within the prison system;

•            support from other prisoners;

•            support from prison visitors and other services;

•            having hopes and plans for the future;

•            being in a system with excellent inter-departmental communication; and

•            staff who are professionally trained and valued by the system” (AHRC (2007) p. 82).

 Suicide after release

 There is a sharp rise in the suicide deaths of men in the first weeks after release from prison. A large Australian study now supports findings of similar American and British ones. The American study found that “the risk of suicide within the first 2 weeks after release was over four times greater than that observed during other periods. In the British study, over one-fifth of all suicides occurring within 1 year of release from prison took place within 4 weeks of release (Kariminia et al. (2007) p. 389).  

 The NSW survey of all 85,203 adults who had spent some time in full-time custody in prisons there between 1988 and 2002 found that the suicide rate in men in the 2 weeks after release was 3.87 times higher than the rate after 6 months when the rate approaches that observed in custody. Male prisoners admitted to the prison psychiatric hospital had a threefold higher risk than non-admitted men both in prison and after release (Kariminia et al. (2007)). 

 “Suicide peaked in men during the first 2 weeks after release at a rate of 507 per 100 000 person-years, declining to 118 per 100 000 person-years after 6 months (adjusted relative risk, 3.87; 95% CI, 2.26–6.65). In men, the association between time after release and suicide was not uniform among different age groups. The highest increased risk in the first 2 weeks after release was for those aged 45 years or older (adjusted relative risk, 13.38; 95% CI, 5.37–33.37). The excess risk was reduced during subsequent weeks but remained significant for those aged 35 years or older. No suicides occurred among women in the first 2 weeks after release.” (Kariminia et al. (2007) pp. 388-89) 

 The NSW study observed no rise in the first 2 weeks after release in the already high suicide rate among Aboriginal Australians. 

The authors of that study commented that: 

 “Suicides in prison receive considerable attention from prison authorities. Programs, policies, and even architectural considerations are in place to minimise the risk of suicide during incarceration. In contrast, far less attention is paid to the post-release period, when the duty of care shifts from the custodial authorities to the community. Release from prison may not increase the overall risk of suicide compared with being in prison, but the first few weeks after release are a period of intensified risk.

 “Our findings suggest that the initial adjustment period after release is a time of extreme vulnerability, particularly for men. It is possible that on return to the community, historical variables associated with suicide such as hopelessness, significant loss, social isolation, lack of support, and poor coping skills are especially significant for this group, as a considerable number of them are already predisposed to suicide because of mental illness and/or substance misuse” (Kariminia et al. (2007) pp. 389)

 One might add to the comments that responsibility of the Government for the well-being of those who are detained should not end upon release, particularly in the light of the Correction Coalition’s understanding that:

•            Physical measures like seclusion taken to prevent self harm within prisons may well harm the mental health of those subject to it thus making suicide more likely when those physical safeguards are not present;

•            The detention, through the disruption it brings about of the life of those detained, itself undermines their capacity to function in the community;

•            There is a need to compensate for the disruption of detention through the provision of support in the community after release in co-ordination with support within the prison. The Corrections Coalition is concerned at an apparent lack of whole of government planning for this.