Roundtable on Suicide Prevention, Assessment and Management: Report on proceedings March 7-8, 2017
Report on Proceedings
March 7-8, 2017
Table of Contents
- Executive Summary
- Roundtable Proceedings - Day 1
- Roundtable Proceedings - Day 2
- Appendix 1: Agenda
- Appendix 2: List of Participants
- Appendix 3: Guiding Principles
In response to a recommendation by the 2015 Independent Review Committee (IRC) on Deaths in Custody, Correctional Service Canada (CSC) hosted a one and a half day Roundtable forum on suicide management and prevention strategies in March 2017. The Roundtable was organized around four key topics in suicide prevention: screening and assessment; management and treatment strategies; communication; and training, with a goal of informing future CSC practices.
Thirty two participants attended the event, with representation from front-line mental and clinical
health staff, institutional and headquarters management, unions, the Correctional Investigators
Office, Parole Board of Canada, Investigations, Research, Aboriginal Initiatives, and Women
Offender Sector. External panelists included:
- Lindsay Hayes, Keynote Speaker, National Center on Institutions and Alternatives, Mansfield, MA, USA;
- Dr. Greg Brown, Nippising University, Ontario (recently completed a literature review in response to the IRC’s recommendation on CSC’s approach to suicide risk assessment tools);
- Corey Ferguson, Canadian Mental Health Association;
- Greg Zed, Horizon Health Network, New Brunswick;
- Debra Cyr Lebel, Health Services, Government of New Brunswick;and
- Chantal Robichaud, Justice and Public Safety, New Brunswick.
BackgroundIn October 2015, the IRC released its third report in a series of external reviews into federal deaths in custody. The IRC reviewed 50% of non-natural deaths in custody for the fiscal years 2011-2014. The mandate was to advise CSC on trends, contributing factors to those deaths, adequacy of corrective measures and action plans, information sharing and best practices.
The IRC provided 9 recommendations, one of which focused on convening a group to review existing screening, comprehensive assessment methods, mental health monitoring practices, training materials, and suicide intervention practices. In response, CSC committed to host a roundtable event, including external experts and internal CSC representatives along with other relevant stakeholders, to specifically examine CSC’s existing suicide prevention initiatives and produce a summary document to help inform CSC’s direction on this file. The agenda is provided as Appendix 1 and the list of participants is provided as Appendix 2.
Roundtable Proceedings – Day 1
Welcome and Introductory Remarks
Welcome and opening remarks provided by Marc Cormier, Acting Warden, Atlantic Institution, NB.
Keynote Address: ‘Guiding Principles to Suicide Prevention’
The keynote address was delivered by Mr. Lindsay Hayes, Project Director, National Center on Institutions and Alternatives, Mansfield, MA, USA, a recognized international expert in suicide prevention in correctional environments. The guiding principles, which are provided in Appendix 3, can be seen as a resource tool to create/revise policies, practices, and training curriculum on suicide prevention.
The presentation provided an opportunity to consider best practices relative to CSC’s approach to suicide and participants commented that CSC’s approach is comprehensive, supported by staff training and post-suicide reviews, and is well grounded in policy. The challenges that CSC faces are similar to those found within correctional facilities in the United States, and considerable discussion focused on the challenges providing care to inmates with complex needs. Participants highlighted the importance of an effective interdisciplinary team, a well developed treatment plan, and an appropriate risk management environment.
Topic 1: Screening and Assessment for Suicide Risk
- Dr. Greg Brown (University of Nippising, ON)
- Lise Roy (CSC Chief of Mental Health, Dorchester Complex, NB)
- Adele Meagher-MacInnis (CSC Warden, Springhill Institution, NS)
- Corey Ferguson (External participant, Canadian Mental Health Association)
- Moderator: Natalie Gabora (CSC Manager Specialized Mental Health Care, Mental Health Branch, NHQ)
A panel presented CSC's current practices regarding screening and assessment, current empirical evidence on screening and assessment tools and promising community practices. Dr. Brown’s literature review (soon to be published) conveyed that CSC tools (Columbia, Depression and Hopelessness Scale) are recognized as being among those showing evidence of utility in predicting suicidal behaviour. Dr. Brown indicated that there is no one single instrument that stands out as superior, although consideration could be given to a standardized suicide risk assessment tool, or menu of evidence based tools.
Subsequent small group discussions focused on best practices and considerations to inform future practices. The following key points were raised:
- Clinical judgement must always be used no matter which tool is utilized.
- Suicide screening should be done at intake and at transition points where risk may be elevated. Assessments should be considered dynamic.
- A comprehensive suicide risk assessment should include a file review and collateral information from staff (e.g., Chaplain, Aboriginal Liaison Officer, Elder) and family, if possible. Roundtable participants supported an increased emphasis on protective factors. The assessor should clearly articulate how she/he weighed all of the factors in coming up with a determination of the risk.
- Participants expressed support for training for mental health professionals specific to comprehensive suicide risk assessments.
- Offender self-report /denial of thoughts or wishes to die should not be relied on as the sole source of information in determining suicide risk.
- Building rapport and establishing a relationship is key to understanding risk.
- There is limited research related to suicide risk assessment for Indigenous offenders. The importance of cultural supports during the assessment was flagged.
Topic 2: Management/Treatment Strategies for Suicidal Inmates
- Natalie Soroka (CSC Senior Project Officer, Mental Health Branch, NHQ)
- Dr. Linda Healey (CSC Senior Psychiatrist, NHQ)
- Glenn Gray (CSC Chief Psychologist, Nova Institution, NS)
- Lindsay Hayes (Project Director, National Center on Institutions and Alternatives, Mansfield, MA, USA)
- Moderator: Joelle Dionne (CSC Chief of Mental Health Services, Community, NB)
A panel presented CSC's current practices for management and treatment strategies for suicidal inmates, including the congruence between monitoring practices and suicide risk levels, use of observation in the management of suicidal inmates, and alternatives to the use of observation and restraints. Use of observation and restraint in other jurisdictions was discussed. Subsequent small group discussions focused on best practices and considerations to inform future practices. The following key points were raised:
- Best practice principles for the management and treatment of suicidal inmates are consistent with CSC policies and guidelines.
- Placement in an observation cell should be considered a safety measure and not a therapeutic intervention and should be maintained only as long as necessary.
- Therapeutic contact and activities can be put in place for individuals on high suicide/self-injury watch. Participants agreed that this is a good standard of care and should be encouraged and supported.
- When required for safety purposes to prevent imminent harm, there is a role for restraints; however, this should be time limited to the extent possible.
- Participants stressed the importance of the interdisciplinary team to support the inmate at risk. Good communication between operations and health staff is key. There is a need to identify the lead of the interdisciplinary team on higher needs cases.
- The language of high risk-high watch, moderate risk-moderate watch, low risk-low watch may be informative. For chronic high risk cases, the acute factors need to be communicated. CSC’s Interdisciplinary Management Plan (IMP) should be used for inmates who are at a chronic (elevated) risk for suicide.
- Good clinical assessments and interdisciplinary teamwork are key to managing risk effectively.
Roundtable Proceedings – Day 2
Topic 3: Suicide Prevention and Communication Between All Parties
- Christian Démoré (Chief of Mental Health, Shepody Healing Centre, New Brunswick)
- Chantal Robichaud (Justice and Public Safety, New Brunswick)
- Greg Zed (Horizon Health Network, New Brunswick)
- Moderator: Natalie Soroka (CSC Senior Project Officer, Mental Health Branch, NHQ)
- CSC should continue to develop community partnerships.
- Community organizations may be able to offer services to CSC’s population directly. Not only for access to programs but it also facilitates offender connections to the community. Communication with the family and community also assists with gathering information that will aid the assessment of risk for suicide, treatment planning, etc. There is work to be done to address barriers limiting access to information across jurisdictions.
- Effective information sharing needs to be continually stressed, including inter-regionally, when required. All members of the team need to be informed and have access to file information.
- As the level of observation decreases there is a need for increased communication to ensure the offender’s safety.
- A practical suggestion was to schedule mental health team meetings on the same day and time to encourage attendance by other members.
- Speaking a common language (not clinical terms) may facilitate communication between staff.
- The model currently used in New Brunswick for post suicide reviews exceeds standards of practice and is considered best practice (Greg Zed).
- Recognizing that health services are accredited it would be helpful to consider options for applying quality improvement activities related to suicide prevention.
- It is important that investigation recommendations are reviewed to ensure they reflect best practice and shared with staff to review lessons learned.
- Some institutions (e.g., Nova) are known for encouraging positive interactions between offenders and staff, and fostering a humane understanding of individual and collective needs. Good leadership is key.
Topic 4: Suicide Prevention Training
- Natalie Gabora (CSC Manager Specialized Mental Health Care, Mental Health Branch, NHQ)
- Adele Meagher-MacInnis (CSC Warden, Springhill Institution, NS)
- Debra Cyr Lebel (External participant, New Brunswick Mental Health)
- Moderator: Dr. Linda Healey (CSC Senior Psychiatrist, NHQ)
A panel presented CSC's best practice principles for training and support for clinical and non-clinical staff and promising community practices. Subsequent small group discussions focused on best practices and considerations to inform future practices. The following key points were raised:
- Suicide prevention training should be done on a regular basis and considered core to knowledge required for staff working within corrections.
- Suicide assessment/management training should be taken regularly for health staff, and it should be considered a required core competency.
- Community best practice includes a comprehensive, multi-level approach, including awareness, training, and specialized support. Road to Mental Readiness (R2MR) was regarded as a best practice.
- Peer support programs, where feasible, can be beneficial.
- Focus on staff resiliency, at both the individual and management levels, is an important component of staff support.
Marc Cormier, Acting Warden, Atlantic Institution thanked external stakeholders and internal CSC representatives for the stimulating discussion on best practices and lessons learned related to screening and assessment methods, mental health monitoring practices, training materials, and suicide intervention practices. The roundtable presentations and discussions were informative and will help shape CSC’s work in this area as we continue to strive to reduce the number of deaths in custody.
|Round table on Suicide Prevention, Assessment and Management
Tuesday March 7th & Wednesday March 8th, 2017
Delta Beausejour hotel
Moncton, New Brunswick
|8:30-9:00||Welcome and Introductory Remarks
||Overall objective of Roundtable: To examine CSC’s existing suicide prevention initiatives and inform CSC’s direction on this file|
|9:00-10:30|| Keynote Address
||Best practices in suicide prevention in correctional environments|
|10:30- 10:45||Heath Break|
|Topic 1: Screening and assessment for suicide risk|
Moderator: Natalie Gabora (NHQ MH Branch)
|Considerations for panellists:
|11:30-12:00||Small Group discussion||Task: In small groups, discuss the issues raised during the panel discussion with the task of presenting key considerations to inform future practices.|
|12:00-12:30||Debrief of small groups
Moderator: Natalie Gabora
(NHQ MH Branch)
|Topic 2: Management / Treatment strategies for suicidal inmates|
Natalie Soroka (NHQ MH Branch)
Dr. Linda Healey (Senior Psychiatrist)
Glenn Gray (Chief Psychologist - Nova Institution)
Lindsay Hayes (Project Director -National Center on Institutions and Alternatives)
Moderator: Joelle Dionne (Chief
of Mental Health Services,
|Considerations for panellists:
|3:15-4:00||Small Group discussion||Task: In small groups, discuss the issues raised during the panel discussion with the task of presenting key considerations to inform future practices.|
|4:00-4:30||Debrief of small groups Moderator: Joelle Dionne (Chief of Mental Health Services, Community)|
|8:30-9:00||Debrief of Day 1 Moderator: Marc Cormier (A/Warden – Atlantic Institution)|
|Topic 3: Suicide Prevention and Communication Between All Parties|
||Considerations for panellists:
|9:30-10:00||Small Group discussion||Task: In small groups, discuss the issues raised during the panel discussion with the task of presenting key considerations to inform future practices.|
|10:00-10:30||Debrief of small groups Moderator: Natalie Soroka (NHQ MH Branch)|
|Topic 4: Suicide Prevention Training|
||Considerations for panellists:
|11:15-11:45||Small Group discussion||Task: In small groups, discuss the issues raised during the panel discussion with the task of presenting key considerations to inform future practices.|
|11:45-12:15||Debrief of small groups
Moderator: Dr. Linda Healey
(Senior Psychiatrist) Concluding remarks
Lindsay Hayes, presenter, Project Director, National Center on Institutions and Alternatives, Mansfield, MA, USA
Dr. Gregory Brown, Univeristy of Nippising, ON
Dr. Linda Healey, CSC Senior Psychiatrist, NHQ
Manjeet Sethi, CSC Director General, Mental Health Branch, NHQ
Natalie Gabora, CSC Mental Health Branch, NHQ
Denise LeBlanc, CSC Women’s Offender Sector, NHQ
Leslie-Anne Keown, CSC Research Branch, NHQ
Natalie Soroka, CSC Mental Health Branch, NHQ
Dr. Kathleen McKay, CSC Regional Manager Mental Health, NB
Julie Bédard, CSC Executive Director, Shepody Healing Centre, NB
Roger Ouellette, CSC Acting Regional Director Health Services, NB
Jean-Frédéric Boulais, Representative from the Office of the Correctional Investigator
Chantal Robichaud, Clinical Representative from Justice and Public Safety, NB
Debbra Cyr-Lebel, New Brunswick Mental Health
Greg Zed, New Brunswick Mental Health
Cory Ferguson, Canadian Mental Health Association
Pam Atkinson, Parole Board Canada, Atlantic Region
Tammy Lunney, CSC Acting Regional Manager Clinical Services, NB
Lise Roy, CSC Chief of Mental Health, Dorchester Complex, NB
Christian Démoré, CSC Acting Chief of Mental Health, Shepody Healing Centre, NB
Nadine Leger, CSC Acting Chief of Mental Health, Springhill Institution, NS
Joelle Dionne, CSC Chief of Mental Health, Community, NB
Tessa Collete, CSC Acting Chief of Mental Health, Atlantic Institution, NB
Glenn Gray, CSC Chief of Mental Health, Nova Institution, NS
Dwayne Fury, CSC Psychologist, NB
Adele MacInnis, CSC Warden, Springhill Institution, NS
Marc Cormier, CSC Acting Warden, Atlantic Institution, NB
Brian Chase, CSC Assistant Deputy Commissioner, Integrated Services, NB
Lucille Stewart, CSC Regional Administrator, Aboriginal Initiatives, NB
Christine Martin, Representative from the Professional Institute of the Public Service
Jackie Cormier, Representative from the Union of Solicitor General Employees
Hugo Foss, CSC Representative from Investigations, BC
GUIDING PRINCIPLES TO SUICIDE PREVENTION IN CORRECTIONAL FACILITIES
Lindsay M. Hayes
©National Center on Institutions and Alternatives, 2017
More times than not, we do an admirable job of safely managing inmates identified as suicidal and placed on precautions. After all, very few inmates successfully commit suicide on suicide watch. What we continue to struggle with is the ability to prevent the suicide of an inmate who is not easily identifiable as being at risk for self-harm. Kay Redfield Jamison, a prominent psychologist and author of Night Falls Fast - Understanding Suicide (1999), has better articulated the point by stating in her book that:
“Were suicidal patients able or willing to articulate the severity of their suicidal thoughts and plans, little risk would exist.”
With this mind, the following GUIDING PRINCIPLES FOR SUICIDE PREVENTION are offered:
- The assessment of suicide risk should not be viewed as a single event, but as an on-going process. Because an inmate may become suicidal at any point during confinement, suicide prevention should begin at the point of arrest and continue until the inmate is released from the facility. In addition, once an inmate has been successfully managed on, and discharged from, suicide precautions, they should remain on a mental health caseload and assessed periodically until released from the facility.
- Screening for suicide risk during the initial booking and intake process should be viewed as something similar to taking one’s temperature – it can identify a current fever, but not a future cold. The shelf life of behavior that is observed and/or self-reported during intake screening is time-limited, and we often place far too much weight upon this initial data collection stage. Following an inmate suicide, it is not unusual for the mortality review process to focus exclusively upon whether the victim threatened suicide during the booking and intake stage, a time period that could be far removed from the date of suicide. If the victim had answered in the negative to suicide risk during the booking stage, there is often a sense of relief expressed by participants of the mortality review, as well as a misguided conclusion that the death was not preventable. Although the intake screening form remains a valuable prevention tool, the more important determination of suicide risk is the current behavior expressed and/or displayed by the inmate.
- Prior risk of suicide is strongly related to future risk. At a minimum, if an inmate had been placed on suicide precautions during a previous confinement in the facility or agency, such information should be accessible to both direct care and health care personnel when determining whether the inmate might be at risk during their current confinement.
- In addition to the heightened risk for suicide during the first 24 to 48 hours of confinement, recent research suggests that many suicides occur in close proximity to a court proceeding, a visit, or telephone call. We must begin to devise ways in which our staff are more attentive to these risk periods. In some jurisdictions, a brief mental status exam is given to select inmates (e.g., those on a mental health caseload, those identified as having a prior history of suicidal behavior, etc.) each time they return from a court proceeding.
- A disproportionate number of inmate suicides take place in “special housing units” (e.g., disciplinary/administrative segregation) of the facility. One effective prevention strategy is to create more interaction between inmates and correctional, medical and mental health personnel in these housing areas by: increasing rounds of medical and/or mental health staff, requiring regular follow-up of all inmates released from suicide precautions, increasing rounds of correctional staff, providing additional mental health screening to inmates admitted to disciplinary/administrative segregation, and avoiding lockdown due to staff shortages (and the resulting limited access of medical and mental health personnel to the units).
- We should not rely exclusively on the direct statements of an inmate who denies that they are suicidal and/or have a prior history of suicidal behavior, particularly when their behavior, actions and/or history suggest otherwise. (If asking an inmate whether they were currently suicidal was the only indicator of suicide risk it would be unnecessary to ask any other intake screening questions.) Often, despite an inmate’s denial of suicidal ideation, their behavior, actions, and/or history speak louder than their words. For example:
In any facility, the inmate is on suicide precautions for attempting suicide the previous day. He is now naked except for a suicide smock, given finger foods, and on lockdown status. The mental health clinician approaches the cell and asks the inmate through the food slot (within hearing distance of others on the cellblock): “How are you feeling today? Still feeling suicide? Can you contract for safety?”
Will this inmate’s response be influenced by his current predicament?
How would you respond?
- We must provide meaningful suicide prevention training to our staff, i.e., timely, long-lasting information that is reflective of our current knowledge base of the problem. Training should not be scheduled to simply comply with an accreditation standard. A workshop that is limited to an antiquated videotape/DVD, or desktop-based question-answer format, or recitation of the current policies and procedures, might demonstrate compliance (albeit wrongly) with an accreditation standard, but is not meaningful, nor helpful, to the goal of reducing inmate suicides. Without regular suicide prevention training, staff often make wrong and/or ill-informed decisions, demonstrate inaction, or react contrary to standard correctional practice, thereby incurring unnecessary liability.
- Many preventable suicides result from poor communication internally amongst direct care, medical and mental health staff. Other problem areas for communication include outside law enforcement agencies and concern expressed from family members. Communication problems are often caused by lack of respect, personality conflicts, and other boundary issues. Simply stated, facilities that maintain a multidisciplinary approach avoid preventable suicides.
- One size does not fit all and basic decisions regarding the management of a suicidal inmate should be based upon their individual clinical needs, not simply on the resources that are said to be available. For example, if an acutely suicidal inmate requires continuous, uninterrupted observation from staff, they should not be monitored via CCTV simply because that is the only option the system chooses to offer. A clinician should never feel pressured, however subtle that pressure may be, to downward and/or discharge an inmate from suicide precautions because additional staff resources (e.g., overtime, post transfer, etc.) are required to maintain the desired level of observation. Although they would rarely admit it, clinicians have prematurely downgraded, discharged, and/or changed the management plan for a suicidal inmate based upon pressure from facility officials.
- By far the most important decision in the area of suicide prevention is the determination to discharge an inmate from suicide precautions. That determination must always be made by a qualified mental health professional (QMHP) following a comprehensive suicide risk assessment. The assessment should include sufficient description of the current behavior and justification for either placement on, or discharge from, suicide precautions. Specifically a:
- Brief mental status examination (MSE),
- Listing of chronic and acute risk factors (including prior history of suicidal behavior),
- Listing of any protective factors,
- Level of suicide risk (e.g., low, medium, or high),
- Disposition, and
- Treatment Plan
- Decisions by non-QMHPs that result in bad outcomes incur unnecessary liability.
- We must avoid creating barriers that discourage an inmate from accessing mental health services. Often, certain management conditions of a facility’s policy on suicide precautions appear punitive to an inmate (e.g., automatic clothing removal/issuance of safety garment, lockdown, limited visiting, telephone, and shower access, etc), as well as excessive and unrelated to their level of suicide risk. As a result, an inmate who becomes suicidal and/or despondent during confinement may be reluctant to seek out mental health services, and even deny there is a problem, if they know that loss of these and other basic amenities are an automatic outcome. As such, these barriers should be avoided whenever possible and decisions regarding the management of a suicidal inmate should be based solely upon the individual’s level of risk.
- Few issues challenge us more than that of inmates we perceive to be manipulative. It is not unusual for inmates to call attention to themselves by threatening suicide or even feigning an attempt in order to gain a housing relocation, transfer to the local hospital, receive preferential staff treatment, or seek compassion from a previously unsympathetic family member. Some inmates simply use manipulation as a survival technique. Although there are no perfect solutions to the management of manipulative inmates who threaten suicide or engage in self-injurious behavior for a perceived secondary gain, the critical issue is not how we label the behavior, but how we react to it. The reaction must include a multidisciplinary treatment plan.
- A lack of inmates on suicide precautions should not be interpreted as meaning that there are no currently suicidal inmates in the facility, nor a barometer of sound suicide prevention practices. We cannot make the argument that our correctional facilities are increasingly housing more mentally ill and/or other high risk inmates and then state there are not any suicidal inmates in our facility today. Correctional facilities contain suicidal inmates every day; the challenge is to find them. A lack (or small number) of inmates on suicide precautions might be the result of inadequate identification practices.
- We must avoid using the terms “WATCH CLOSELY” or “KEEP AN EYE ON HIM” when describing an inmate we are concerned about, but have not placed on suicide precautions. If we are concerned about them, then they should be on suicide precautions.
- We must avoid the obstacles to prevention. Experience has shown that negative attitudes often impede meaningful suicide prevention efforts. These obstacles to prevention often embody a state of mind (before any inquiry begins) that inmate suicides cannot be prevented.
- We must create and maintain a comprehensive suicide prevention program that includes the following essential components: staff training, intake screening/assessment, communication, housing, levels of observation/management, intervention, reporting, follow-up/morbidity-mortality review.
- The success of a suicide prevention program is not simply measured by the lack of suicides, but rather on sound practices that mirror policies as determined by a fully transparent Continuous Quality Improvement process.
FOR MORE INFORMATION
Lindsay M. Hayes
National Center on Institutions & Alternatives
40 Lantern Lane
Mansfield, MA 02048
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