Caring for Prisoners At Risk
Caring for Prisoners At Risk

Caring for Prisoners
A Gui
de fo
r Staff
At Ri
sk
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Caring for Prisoners At Risk
Caring for Prisoners At Risk

Contents

 The Department's Philosophy
 Recognising risk—when to be concerned
 Reception into a prison
 Reviewing when things change
 Mental health
 Impact of a suicide or suicide attempt on staff
 Special issues for youth offenders
 Interviewing At Risk Prisoners


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4 Stage Listening Contd.

The Department’s Philosophy
Stage Four– Check how the action worked

 Arrange another interview
The Department of Corrections acknowledges that
 You can check quickly if the action plan worked
all prisoners by virtue of being in prison pose an
 If the plan worked—fine. If not, you may need to explore why not, and
increased risk of self harm or suicide.
plan other options

 The most important part of this stage of reworking the plan is to let the
Definition of At Risk
prisoner suggest options.
 A prisoner who has been assessed as being “at risk” of harming

themselves..
\

Self harming behaviour (range of behaviours from cutting to

actions which are intended to lead to death)
5 Rules for Describing Interviews

Primary Principles

 Everyone is responsible for the early identification of a prisoner’s at
risk status and for taking immediate action when such risks are
 Focus on behaviour rather than the person
identified.
 Focus on observations rather than inference
 The level of risk presented by the prisoner should be minimised as
 Focus on description rather than judgement
quickly and safely as possible.
 Focus on the here and now rather than there and then

Key Principles of Policy
 Focus on what is said rather than why it is said.
 Care is central to everything we do and can only be achieved through
effective multi-disciplinary teamwork
 Everyone in the prison community must take immediate action when
risk is identified
 Decisions about At Risk Prisoners must be made by teams and not
individuals
 All staff are required to be vigilant and recognise that a prisoner is in
crisis and their behaviour may unsettle other prisoners
 Since assessment techniques alone are not enough to prevent
suicides, there is a need to create a context where prisoners feel safe
and confident to ask for help.
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Current Statistics
4 Stage Listening

4-Stage listening is a model to help people to solve their own problems:
 Between 2006 and 2009, there were 17 prisoner suicides in custody.
 The stages are separate and you don’t have to go through all of them
At least 190 prisoner’s lives have been saved in the same period (this
number relates to self harm incidents where the individual would been
 Often Stage 1 is enough—it will make people feel heard
unlikely to survive without intervention)
 Sometimes it is better to refer a prisoner on for stages 2 & 3, and come
 Hanging was the method most commonly used.
back for Stage 4
 Over 70% used their bed sheets as ‘rope’
 But sometimes we need to “seize the moment”.
 Air ventilation grills were the most common hanging point

 90% were committed in maximum or high security units—this is likely
Stage One—Explore the problem
to be linked to violent offenders, who are not afraid to act on these
tendencies, being more likely to commit suicide
 Just listen actively while the prisoner talks (this may take longer than
most people allow)—use your listening skills
 Male prisoners were more likely to take their own lives
 Avoid questions as far as possible
 Suicides were more likely to occur in the first six months of
incarceration. 35% were in remand; 65% sentenced
 Use “follow-ons” and encouragements only to persuade the prisoner to
keep talking.
 Prisoners with a history of suicide and self harm attempts are more
likely to take their own lives

 While not totally definitive, prisoners aged 35-39 presented as the most
Stage Two – Focus And Share Perspectives
common age group, followed by 18-19, 20-24 and 25-29
 Carry on listening actively
 Both Maori and NZ European were equally represented in the suicides
 Encourage the prisoner to focus on the most important parts of their
 41% of suicides occurred during October and November
problem
 11 of the 17 suicides were by prisoners who were drug users, either
  e.g. give some information that would help them, or ask a few more
recreational or prescribed.
questions to get them thinking

 Don’t advise or problem solve for them.

Stage Three – Help The Prisoner To Plan Action
 Carry on listening actively
 The pace may become more “business like” here
 Encourage the prisoner to take the initiative in planning what they want
to do
 You may have some suggestions, but don’t overdo it.
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Suicide Risk After Self-Harm or

Attempted Suicide
Recognising Risk—

When to be Concerned
Some people

 Use self harm as a coping strategy with no plans of suicide
Assessment of At Risk Status
 Use self harm as a way of communicating intense distress to others
Assessing suicidal risk is not an exact science especially within the prison
 Suicide risk is higher in people who make a number of suicide attempts
setting, as prisoners can present with a number of predisposing factors such
with increasing frequency and increasing seriousness
as drug misuse and mental health problems.

 The risk of suicide following a suicide attempt is 100 times that of the
Assessment is a dynamic process where levels of risk often change. All
general population.
prisoners are vulnerable to some degree and often give “clues” when they

are worried. Sometimes there are “cues” in their personal histories (the
predisposing factors), which can lead us to the view that they are especially
Listening Challenges
vulnerable. We need to be aware of these “clues and cues”.

Be aware of the challenges you need to overcome:
People who attempt or commit suicide often show distress or intent that can
be detected by observing, listening and asking. Be aware that some may
 (other) prisoners putting demands on you
conceal their intent. Consider what the person says and does.
 Sorting out practicalities

 Having to do At Risk assessments in a very short time
Distress signals—ask the person about them
 Being tempted to listen “so far and no further”

 Coming up with advice or a practical solution and stop listening.
Characteristics of Prison Increasing the Risk of Suicide

 Authoritarian environment
When helping someone, try listening for longer
 No apparent control over future
 Relax
 Isolation from friends, family, community
 Slow down
 Shame of imprisonment
 Offer time
 Dehumanising effects of imprisonment
 Use active listening.
 Fears

 Staff insensitivity to arrest and imprisonment
Take time to listen before you:
 Negative expectations about short term / long term future
 Offer practical help
 Sense of hopelessness
 Discuss what the prisoner should do
 Ask about suicidal intentions (but get to this when appropriate).
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Behaviours to watch for
Factors
 Crying, emotional outbursts

 Recent suicide attempt
Factor which make suicide more likely
 Giving away possessions
 Immediate intention to carry out suicide
 Withdrawal from social contact
 Specific plan of suicide
 Self neglect (e.g. not eating)
 Choice of violent method of suicide e.g. hanging
 Not planning for release
 Access to means of committing suicide
 Increase in frequency or lethality of self harm
 Plans for death e.g. will changes, family farewells
 Alcohol / Drug abuse
 Recent escalation of:
 Irrational behaviour, out of touch with reality

Suicidal behaviour e.g. self harm
 Recklessness / fighting

Help seeking behaviour e.g. seeing the chaplain
 Hostile rejections of help


Current symptoms of mental disorder
Thoughts
 Past high-risk suicide attempt
 “There’s no point…”
 Likelihood of bad news—’the last straw’
 “I can’t take it any more.”
 A self imposed deadline passes without the good news the prisoner
hoped for.
 “I wish I were dead.”

 “Everyone would be better off without me.”
Factors which make suicide less likely
 “I just want it to be over.”
 Looking forward to future events
 “Nothing will ever get better.”
 A statement from the prisoner that he/she will not commit suicide if an
 “There’s no future for me.”
event occurs. However, this lowers immediate risk only. Beware if the
event is not under the prisoner’s control e.g. “I will not commit suicide if

my wife comes back to me before I go to court.”

 Fear of:

Death

Being left physically / mentally damaged

Attempt having no effect on family / friends

No-one to look after children / significant others

No access to means of suicide.
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Avoid Ambiguous Questions
Feelings expressed

 Desperate

 Angry
Some people are not direct enough in their questioning because they feel too

embarrassed or awkward asking about suicide plans for fear of giving the
 Sad
person the idea.
 Ashamed
 You cannot plant the idea if it was not there before
 Hopeless
 Prisoners who are feeling suicidal are more likely to be comfortable
 Worthless
talking about it if you are comfortable asking them

 Lonely
 Most reveal suicide intent when questioned directly by a sympathetic

interviewer
 Disconnected
 Only a minority of people deny suicidal intent when in fact they are
 Powerless
planning suicide.

Physical changes
Ambiguous questioning may receive an unclear answer e.g. “Have you
 Lack of interest / pleasure in everything
thought about doing something silly?”
 Lack of physical energy for no apparent reason
 A “yes” response may be interpreted as suicidal ideation when in fact
the prisoner may have been thinking of escape or picking a fight
 Disturbed sleep
 Your idea of “something silly’ may not be what the prisoner thinks on
 Change / loss of appetite, weight
as “something silly”
 Increase in minor illness
 So be clear and direct.

Situations / triggers
 Relationship problems
 Recent suicide of someone close to them
 Violence, bullying or fear of these
 Parole refusal or other knock back
 Longer sentence than expected

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Times of Heightened Risk
Explore Hopelessness
 First 24 hours of confinement

 Intoxication/withdrawal
Hopelessness is the best predictor of suicide. Hopelessness is:
 Waiting for trial
 Characterised by feelings that the current situation is not only
 Pre / Post Court appearances
intolerable right now, but will never improve in the future
 Sentencing, especially if sentence likely to be harsh

“Do you think your life could ever get better?”
 Impending release
 Often associated with helplessness.
 Night and weekends – times when staff numbers likely to be lower

 Bad news from family, friends, community
 Explore whether the prisoner believes anybody can help to improve the
current situation
 First 30 days after imprisonment or movement to new facility
 If a prisoner describes a degree of hopelessness or helplessness, or if
 For pre-trial offenders, 60 days after imprisonment
you have reason to believe a prisoner to be suicidal, you should
 4-5 years for long term sentenced violent offenders
specifically ask about thoughts of suicide
 Periods of isolation
 Does the prisoner have anything to look forward to? While prisoners
who look forward to an event are less likely to commit suicide in the

immediate future, be careful when prisoners plan to live until they have

seen through a particular event e.g. birthday, before committing
suicide.

Wishes to be Dead

Active wishes to kill oneself are more serious than passive wishes to be dead
e.g. “I just wish I could just go to sleep and not wake up”.

Specific Plans for Suicide

 Has the prisoner had thoughts about harming or killing him / herself?
 Are these thoughts fleeting or persistent?
 Does the prisoner have any specific plans e.g. how, where, when,
etc.?
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Clarification of Current Problems

Making an Initial Response
Find out and clarify problems over the last few months and the last 24 hours.
(In the Residential Unit)
You should check if there are problems relating to the following that the
prisoner has not spontaneously mentioned:

 Relationship with partner, other family members, friends
 Talk to the person. Ask them about what you are concerned about.
Comment on behaviour: “You’re looking really low. Is anything
 Social isolation
wrong?”. Ask about events: “You were in court today weren’t you. How
 Bereavement
did it go?” Give broad openings: “Tell me about it…. You look like you
need to talk things over with someone.”
 Separation
 Take time to listen. Talking about a problem is a strength, not a
 Legal, including current court / police proceedings
weakness.
 Physical health
 Do not feel you need to solve the problem—support is delivered by a
 Use of illicit drugs / alcohol
good team, not just an individual.
 Mental health.
 Check out how bad the person is feeling.

 If you suspect the prisoner might be thinking of suicide, ask them as
directly as possible: “Are you thinking about suicide?” Or “Is it so bad
Specific Questioning About Suicidal
you are thinking of killing yourself?”
Intent
 If there is risk, don’t leave the person alone. Alert other staff—custodial

and Health.

 Begin a Review Risk Assessment.
 Asking someone about suicidal thoughts will not plant an idea that was

not there before
Be aware that some people may conceal their
 Most people who are contemplating suicide feel relieved to be able to
talk about it
intent. Consider both what the person says and
 You cannot assess suicide risk without specific questioning
also what they do.
 Specific information will help if you need to refer the prisoner to other
professionals—it may even speed up the process.

Talking about suicide with someone will give them the opportunity to:

 Express their feelings
 Give them a sense of relief
 Discover a reason to live

Talking about suicide will not cause someone to do it.
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Demonstrate acceptance of the prisoner
 Non-verbal communication encourages the prisoner to speak:

Nodding

Saying “uh-huh”

Eye contact (be aware of cultural norms though)
 Reflect or paraphrase what the prisoner says and empathise. This
helps the prisoner speak about difficult issues:

“I can see that things have been very difficult for you lately”

Clarify ambiguities
 Sometimes prisoners do not express themselves very clearly. Clarify a
prisoner’s subjective experience:

“What exactly do you mean by ‘wound up’?”

Summarise
Go over what has been discussed and ask if it is correct. This:
 Enables the prisoner to correct any misconceptions or factual
inconsistencies
 Shows the prisoner you have been listening
 Shows you are taking the problems seriously
 Gives some hope to the prisoner that his/her situation can improve.
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Questioning Style

 Start off with open questions i.e. questions that get the prisoner talking
Reception into a Prison
 Avoid ‘why’ questions at first—these can involve opinion rather than

fact
 Avoid questions that can be answered with only ‘yes’ or ‘no’. These
Assessment Tools
have the effect of shutting the prisoner down
 Reception Risk Assessment
 Listen more than you question—the prisoner should do most of the

talking at first
Reception Risk Assessment
 Once the prisoner speaks about specific problems, ask direct
questions to obtain the information needed
 The Reception Risk Assessment is designed to assess the at risk
status of prisoners newly arrived at a prison. It will be administered by
 Use closed questions—able to be answered with ‘yes’ or ‘no’ - only to
Receiving Office staff.
clarify facts.
 The policy for its use and application is in the Prison Operations

Manual (POM) in section M.05.01.
Pick up verbal and non-verbal cues

Pay attention to:
Review Risk Assessment
 Key words or phrases that refer to emotional topics and social
 The Review Risk Assessment is designed to assess the at risk status
information:
of prisoners already incarcerated at a prison. It will be administered by

Receiving Office staff only when a prisoner returns from court. In all
“I have been feeling very wound up lately”
other instances, it will be administered by Unit custody staff.
 Non-verbal signs of possible emotional disorder:
 The policy for its use and application is in the Prison Operations

Tearfulness
Manual (POM) in section M.05.02.

Signs


Agitation


Restlessness

Pacing

Lack of eye contact (be aware of cultural norms though)

Slouched posture.
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Interviewing At Risk Prisoners

 Establishing rapport
 Questioning style
 Pick up verbal and non-verbal cues
 Demonstrate acceptance of the prisoner
 Clarify ambiguities
 Summarise

Establishing Rapport
“Active Listening” means:
 Introduce yourself by name
 Explain what will happen, why, and how long it will take
 Interview the prisoner in a quiet setting, if possible
 Arrange the seating appropriately—try to be on the same level
 Maintain eye contact

Beware of looking excessively at notes or the computer

Be aware of cultural norms about eye contact
 Use the prisoner’s name
 Keep the pace of the interview unhurried and not challenging
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Reviewing When Things Change

Assessment Tools
 Review Risk Assessment

Review Risk Assessment
 The Review Risk Assessment is designed to assess the at risk status
of prisoners already incarcerated at a prison. It will be administered by
Receiving Office staff only when a prisoner returns from court. In all
other instances, it will be administered by Unit custody staff.
 The policy for its use and application is in the Prison Operations
Manual (POM) in section M.05.02
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Special Issues for Youth Offenders

Introduction
Youth present a special set of conditions which can lead to suicide or self
harm.

The experience of incarceration may be particularly difficult for youth
offenders who are separated from their families and friends. Distressed
young prisoners are especially dependent on supportive relationships with
the staff. Therefore, separating and isolating young prisoners may lead to
additional risk for suicidal actions, which can happen at any time of their
confinement.

Youth offenders who are placed in adult correctional facilities should be
considered to be at particularly high risk of suicide.

An important note for recognition of risk in young people—depressed mood
may present as irritable mood.

Another consideration is that many young people are impetuous and may not
show any indication of their intention to self harm or suicide. Getting them to
talk about how they are feeling is a way of getting them to reveal what actions
they may be contemplating.

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Mental Health
Introduction
One of the risk factors for suicide is having a mental health illness. The
World Health Organisation estimates that 90% of all suicide victims have
some kind of mental health condition, often depression or substance abuse.
Suicide is a major cause of premature death amongst people with mental
illness.

Mental Health in Prison
There is a many types of mental health disorders in a prison setting. These
can include:
 Schizophrenia
 Bipolar Affective disorder (previously known as Manic Depression)
 Depression
 Anxiety disorders like:

Phobias

Obsessive compulsive disorder (OCD)

Generalised anxiety disorder (GAD)

Post traumatic stress disorder

Alcohol and drug dependence or abuse can co-exist with a mental illness..

Treatment of a mental illness can reduce suicide risk. Suicide tendency can
be treated with therapy and medication. Early intervention and effective
management appear to reduce the risk over time.
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Schizophrenia

Schizophrenia causes severe disruption to a person’s thought process.
Impact of Suicide or

Suicide Attempts on Staff
People with Schizophrenia often experience delusions or hallucinations, in

particular auditory hallucinations. Schizophrenia distorts the way a person
Introduction
thinks, feels or perceives things. This may lead to a withdrawal from reality.

Stress reactions in staff following a suicide or suicide attempt are common
Symptoms of schizophrenia may include:
and are normal reactions to an abnormal event.
 Changes in personality and thought process

Common Stress Reactions
 He or she has difficulty separating what is real from what is not
 Constant thoughts of the suicide incident
 Can become isolated and withdrawn
 Reluctance to go back to the place it occurred in
 Deterioration in personal hygiene and how they relate to others.
 Tension

 A numbness to surroundings
Acute symptoms of schizophrenia:
 Inability to eat or sleep
 Bizarre delusions
 Constant tiredness
 Exaggerated religious beliefs
 Apathy, depression
 Paranoid ideals
 Irritability, outbursts of anger
 Hallucinations

 Extreme withdrawal
What to do to minimise the effects of stress
 Sleep disturbance
 Recognise that stress is a normal reaction
 Threats of harm to self or others
 Accept that taking care of yourself is a strength, not a weakness
 Disruptive, aggressive, suspicious behaviour.
 Talk about the experience with a colleague, friend, family member or

PIRT team
 Take part in debriefing sessions
 Get back to your normal routine as soon as possible. Time out from
working with prisoners can sometimes be more helpful than time off
work
 Get enough sleep and regular exercise, and eat a healthy diet
 Be more careful when driving or operating machinery. Accidents are
more common after severe stress
 Call your PIRT team or EAP.
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Six Resiliency Factors
Depression
Resilience is the process of adapting well to adverse situations. These
Many people who attempt suicide have experienced depression which may
factors contribute to counteracting the negative impact of the adverse
also be the result of another mental illness. Types of depression include
situations:
major depression, bipolar affective disorder and dysthymic disorder.
 Pro-social bonding

 Clear and consistent boundaries
Symptoms of depression may include:
 Life skills
 Lethargic or lack energy
 Poor concentration and memory
 Caring and support
 Changes in appetite—a considerable loss or gain in weight
 High expectations
 Disturbed sleep
 Meaningful participation
 Denial
 Average or above intelligence.
 Thoughts of suicide—thoughts of worthlessness or extreme guilt
 Reduced level of interest or pleasure in most or all activities.

Major Depression
This is a major mental illness where the person experiences a drop in mood,
energy and initiative. They may become so depressed that they consider or
attempt suicide. The potential serious consequences of untreated
depression and the success of treatment make this an important mental
illness to identify.

Bipolar Affective Disorder
Bipolar which means Bi – two; and polar – directly opposite in tendency or
nature. The person’s mood can cause extremes from deep lows
(depression) to highs (mania).

Symptoms of bipolar disorder (mania) may include:
 Increased physical activity
 Becoming interfering or intrusive
 Making elaborate and grand plans
 Spending lavishly and foolishly
 Writing endless letters of complaint
 Reacting violently if beliefs are challenged
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Caring for Prisoners At Risk
Caring for Prisoners At Risk

Hallucinations

Symptoms of bipolar disorder (depressive) may include:
The person may hear, smell, taste or feel something that has no basis in
 Lethargic – no energy
reality. This may include the following:
 Feeling worthless and or helpless
Visual
 Changes in appetite
 seeing and talking to others.
 Difficulty sleeping
Tactile
 Poor memory
 feeling insects under the skin.
 Thoughts of suicide
Auditory
 Anxious or irritable.
 voices instructing the person to carry out certain actions.

Psychosis
Obsessive Compulsive Disorders
Psychosis describes a severe form of mental illness that disorganises and
Obsessive compulsive disorder or OCD is an anxiety disorder. Persistent
changes the whole personality. People begin to say and do things that other
thoughts, impulses and images that cause anxiety and stress.
people cannot accept as normal. Reality becomes distorted, judgement and

reasoning deteriorate, and mood becomes abnormal experiencing
Behaviours that act to reduce the stress include:
hallucinations.
 Continual hand washing
Symptoms of psychosis may include:
 Checking routines
 Delusions
 Repetitive praying
 Hallucination

 Repetitive counting.
Delusions
Three types of delusional behaviour are:
 Grandeur

the person may believe that they are impossibly rich, talented,
powerful or titled.
 Persecution, paranoid

the person may believe they are being spied on, poisoned,
sexually assaulted, talked about, or having thoughts inserted or
removed from their mind.
 Hypochondriac

related to bodily functions, for example can’t swallow, have
cancer.
Page 17  © Department of Corrections

Version 2 August 2010
Version 2 August 2010

© Department of Corrections Page 18

Document Outline