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Investigating Suicide

Suicide is the number one killer among offenders in federal prisons. Between 1983 and 1992,(1) 128 of the 267 offenders who died while in federal custody committed suicide. At the Correctional Service of Canada, we are committed to reducing the suicide rate among offenders. Accordingly, such deaths are investigated, either at a regional or national level.

In the past, the scope of suicide investigations was quite limited. Investigators generally examined such elements as staff reactions to the incident, the timely notification of the next-of-kin and resuscitation efforts. By focusing primarily on the administrative responses to the incident, our ability to help suicidal offenders was limited, as well as our ability to learn from past experiences and investigations. Now, however, additional information is being collected during suicide investigations.

Indicators of Suicidal Intent

Corrections personnel in federal penitentiaries learn to identify and to observe two types of suicidal offenders: those who are likely to and those who show signs of intent to commit suicide. This distinction is very important. Not everyone announces their intentions with words or overt actions.

In 1990, the Commissioner of the Correctional Service of Canada revised the policy statement governing suicide investigations to reflect this distinction. Past investigators often concluded that the "offender displayed no evidence of suicidal ideation," but current knowledge suggests that many of these offenders were in a high-risk category. Previous investigators focused on the more visible signs of the offender's intent to commit suicide, such as suicide notes and wills, complaints of insomnia, crying spells or depression. In the past, our limited knowledge ensured that we were able to hear only those who literally or figuratively shouted for help. We were unable to identify more circumspect offenders who told us their worries quietly. And even now, after a myriad of studies, we are only just beginning to identify these less vocal and equally vulnerable offenders.

The Investigations and Departmental Security (IDS) Division is in the process of reassessing its role in this learning process. Investigation reports provide an excellent source of information for both researchers and clinicians who are examining suicide patterns. It has quickly become apparent that the variables affecting the decision to commit suicide are complex; our best efforts and intentions may not be enough to prevent every suicide. However, some trends relevant to correctional settings have been identified, and a rereading of past investigations suggests that sometimes we can help.

To assist investigators, most of whom have no psychological training or experience, IDS introduced three new elements into the investigation process. In February 1992, a new clause was inserted in the Convening Orders for Boards of Investigations, which asks investigators explicitly to explore "the possible existence of significant pre-indicators" of suicidal intent.

In addition, a new training program was implemented to help investigators identify the kinds of questions investigations can and should answer. With continuous training and hindsight, investigators can begin to determine more precisely those factors that converge to produce such tragic results.

Finally, IDS (in co-operation with the Research and Statistics Branch, and Health Care Division) prepared a set of guidelines outlining some of the main factors that are commonly present in situations of people who commit suicide. Essentially, these guidelines represent the findings of a number of studies on suicide combined with an analysis of our own investigations over the last three years.(2) The following table outlines the types of information that the guidelines explore. These guidelines are still being tested, but the results to date are encouraging.

Risk Factors

Past studies indicate that many issues must be considered when assessing suicide risk. They suggest that certain types of offenders are more likely than others to take their own lives. Offenders who have committed sexual offences or crimes of passion are in the high-risk category, as are victims of child molestation, sexual assault and homosexual rape. Professionals and "white collar" criminals are also vulnerable. People who suffer from chronic, fatal or debilitating diseases are also at risk. And dashed hopes -such as the refusal of a transfer application or rescinded parole - can also drive an offender to suicide.

The existence of any of these factors does not necessarily mean that the offender will commit suicide. Rather, each factor foreshadows this possibility. And each of these must be taken as seriously as more blatant indications, such as a suicide note. The investigation guidelines will remind investigators to test for the absence or presence of each of these factors.

Our Findings

The findings of these past studies are supported by our own investigations. Of 21 suicides - which is an admittedly small sample - 9 were recidivists, 12 were serving their first federal sentence and 4 were serving life sentences. Eight of these offenders had committed property offences (such as arson, robbery, break and enter), and 13 had committed offences against the person, including 6 who were incarcerated for sexual offences. In addition, 6 of these 21 offenders had previously attempted suicide, while 2 others had histories of self-mutilation. One person who committed suicide had tested HIV positive. Another had undergone testing for the virus, but did not wait for the results. Another offender had suffered brain damage following a drug overdose, and may have been unable to cope with the resulting physical limitations. One suicide victim had committed a crime of passion, for which he severely condemned himself. Three offenders committed suicide after their transfer applications had been rejected, and seven others killed themselves after feeling they had been rejected by their peers.

None of these signs definitively distinguishes those offenders who will take their own lives from those who will not. However, we have only taken the first few awkward steps toward our objective. The changes introduced by IDS into the investigation process are designed to complement information gathered by researchers and clinicians. Asking the right questions can uncover useful answers which will lead to a better understanding of suicide and ultimately improve our ability to predict and prevent such deaths among offenders.

(1)Of these deaths, 111 resulted from natural causes. Another 28 were categorized as "other," resulting from accidents or drug overdoses or occurring during escape attempts. The deaths resulting from drug overdoses have not been included in the suicide statistics mainly because it could not be determined whether or not the offenders had intended to take their own life. In drug overdoses, only the existence of a suicide note is considered sufficient evidence to warrant classification as suicide. However, the frequent absence of a suicide note in confirmed suicides suggests that we should consider the possibility that other offenders committed suicide without recording their motives.
(2)The studies include Report of the Task Force on Mental Health, commissioned by the Correctional Service of Canada; Suicide in Canada, commissioned by Health and Welfare Canada; Striking a Balance, published by Health and Welfare Canada; Report of the Study Team: Seven Suicides in the Atlantic Region, February 17-August 24, 1983, led by E.H. Botterell; and a Correctional Service of Canada briefing, entitled Suicide: 1991-04-01 to 1992-02-10.