Application: Reliability and ValidityBasic statistical concepts like reliability and validity are paramount to forensic psychology research. You need to know how reliable and valid any particular research study may be. To do so, you need a good understanding of these concepts as well as others.As you have learned this week, there are different forms of reliability and validity. Statistical reliability and validity are simply numerical descriptions of the basic concepts of each, which allows the researcher to determine if the instrument gives a consistent measurement (reliability) and if it measures what it claims to measure (validity). Even in the area of treatment, the field of psychology is moving toward evidence-based therapies. This means that the therapy used must show empirical evidence (reliability and validity) and be of help to those who are treated. Being able to show empirical support for what you do as a forensic psychology professional provides the public and legal system with a way to judge the value of your contribution as a forensic psychology professional.To prepare for this assignment:Review Chapter 5 in your course text, Research Methods for the Behavioral Sciences. Pay particular attention to the definitions of validity and reliability, the various types of validity and reliability, and how measures of each are reported.Choose an area of forensic psychology which you find interesting.Using the Library, select and review a research study/article that relates to this area and that also addresses validity and reliability.( Article to be used attached) Consider whether the validity and reliability, as reported in the research article you selected, are accurate or suspect and why.The assignment (1–3 pages): APA FORMAT ONLY!!Briefly describe the research study you selected.Explain the type(s) of validity and reliability relevant to this study.Explain whether you think the validity and reliability, as reported in the article, are accurate or suspect and why.Explain what difference validity and reliability make in the study you selected and why.Journal of Forensic Psychology Practice
ISSN: 1522-8932 (Print) 1522-9092 (Online) Journal homepage: http://www.tandfonline.com/loi/wfpp20
Suicide Risk Assessment in Jails
Brandy L. Blasko , Elizabeth L. Jeglic & Stanley Malkin
To cite this article: Brandy L. Blasko , Elizabeth L. Jeglic & Stanley Malkin (2008) Suicide
Risk Assessment in Jails, Journal of Forensic Psychology Practice, 8:1, 67-76, DOI:
10.1080/15228930801947310
To link to this article: http://dx.doi.org/10.1080/15228930801947310
Published online: 11 Oct 2008.
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Practice Vol. 8, No. 1, March 2007: pp. 1–12
PRACTICE UPDATE SECTION
Suicide Risk Assessment in Jails
Practice Update
JOURNAL
OF fORENSIC
Section
pSYCHOLOGY pRACTICE
Brandy L. Blasko
Elizabeth L. Jeglic
Stanley Malkin
ABSTRACT. Suicide is one of the leading causes of death in jails. It is
the role of the clinician to assess an inmate’s risk for suicidal behavior.
Typically this involves an assessment of an inmate’s suicidal intent coupled with their access to lethal means. However, in a jail environment there
are various environmental and psychological stressors which complicate
suicide risk assessments. This paper examines suicide risk assessments
using case examples of suicidal inmates that are typical of those found in
jails.
KEYWORDS. Suicide, assessment, jail
Brandy L. Blasko, Mercer County Correction Center.
Elizabeth L. Jeglic, John Jay College of Criminal Justice.
Stanley Malkin, Mercer County Correction Center.
Address correspondence to: Elizabeth L. Jeglic PhD, Department of Psychology,
John Jay College of Criminal Justice, 445 West 59th Street, New York,
New York 10019 USA; (E-mail: ejeglic@jjay.cuny.edu).
Journal of Forensic Psychology Practice, Vol. 8(1) 2008
Available online at http://jfpp.haworthpress.com
© 2008 by The Haworth Press, Inc. All rights reserved.
doi:10.1080/15228930801947310
67
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JOURNAL OF FORENSIC PSYCHOLOGY PRACTICE
Despite a significant decrease in the last two decades, suicide is still
one of the leading causes of death in American jails (Hayes, 1994). The
suicide rate among jail inmates is significantly higher than that of the general population (Ivanoff, Jang & Smith, 1996). Furthermore, although suicide remains the third leading cause of death in state prisons throughout
the country, the suicide rate in local jails is three times higher than that in
prisons (47 per 100,000 inmates for jails compared to 14 per 100,000
inmates for prisons) (Metzner, Cohen, Grossman & Wettstein, 1998;
Bureau of Justice Statistics, 2005).
Higher suicide rates among jail inmates are the result of numerous
stressors that are unique to the jail environment. Jails hold a wide range
of both minimum and maximum-security inmates. Thus, an inmate who
is being held for unpaid parking tickets could be held in the same facility as someone who was arrested on suspicion of homicide creating a
potentially terrifying environment. Many inmates experience the
uncertainty and fear which are naturally associated with incarceration.
They could be worried about their families’ reaction to their arrest or
they could be concerned about what will become of them. Most
inmates in jails are there awaiting court dates and many are anticipating lengthy sentences. These inmates also ultimately find out the duration of their incarceration while housed at the jail (Bureau of Justice
Statistics, 2005). Inmates who are addicted to drugs and alcohol may
experience severe symptoms of withdrawal upon arrival into the jail
and approximately 64\% of inmates in a typical jail population have a
serious mental illness which could be exacerbated by the stress of
incarceration thus increasing their risk for suicide (James & Glaze,
2006). In addition, there are numerous familial, employment, and
financial sequela that come as a consequence of being changed and
convicted of a crime.
Suicide in jails is often preventable. One of the primary reasons that
there has been a sharp decline in deaths by suicide is the strong focus by
jails to train staff on how to identify and manage inmates who may be at
risk for suicide. While several jurisdictions have developed their own
suicide risk assessments, there is currently no standard suicide risk assessment that is utilized. As a consequence, jail staff is often left to use their
clinical judgment in assessing suicide risk.
In conducting a suicide risk assessment, the two main domains that
need to be assessed are intent to commit suicide and the access to lethal
means. The intent to commit suicide is multifaceted and includes the following questions:
Practice Update Section
69
1.
2.
3.
4.
Has the inmate expressed a desire to end his/her life?
Does the inmate have a plan?
Is the plan specific?
How much thought/planning has the inmate given to his/her suicide
attempt?
5. Has the inmate made a suicide attempt before?
6. Does the offender have any risk factors that are associated with
suicide such as a stressful life event, substance withdrawal, depression, a diagnosis of borderline personality disorder or command
hallucinations?
The risk that an inmate will attempt suicide increases with the number
of affirmative responses. In addition to the inmate’s intent to attempt suicide, the clinician must also consider the offender’s access to lethal means
necessary to make a suicide attempt. For example, an inmate who states
that he will hang himself on his bed sheets may be at higher risk than the
inmate who states that he is going to kill himself with a gun (as presumably an inmate would not have access to a gun). If it is determined that an
inmate is suicidal and has access to lethal means of killing themselves,
then those means should be removed immediately until the suicidal crisis
passes. This could involve putting the offender in a room without sheets
and cloth clothing, having a corrections officer conduct a thorough search
of the inmates cell to make sure there are no sharp objects accessible to
the inmate or placing the inmate on a constant or close suicide watch.
While suicide risk assessment may appear relatively straight forward,
in the jail environment there are numerous variables which may confound
a clinician’s ability to accurately assess an inmate’s suicide risk. First,
jails have limited resources. Between mid-year 2004 and mid-year 2005 the
inmate population in county jails rose 4.7\% (Bureau of Justice Statistics,
2005). With increasing numbers of inmates being housed in jails it is not
possible to identify all inmates who may be at risk for suicide. Therefore
it is often only after an inmate has made an overt gesture that they come to
the attention of mental health professionals. Second, almost half of the jail
suicides occur during the inmate’s first week in custody (Bureau of Justice
Statistics, 2005). This suggests that correctional officers and mental
health staff may not have an opportunity to know the inmate well. This
makes it difficult to notice a change in behavior as an inmate contemplates suicide. Third, once an inmate is identified as suicidal, they are
often put on one-to-one observation. It is not uncommon to have numerous inmates per shift who require constant observation. This creates the
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need for additional staffing, which is very taxing in a system that is
already overburdened. Additionally, it is often not possible to accommodate all the requirements for one to one staffing and, if not, the clinician
must decide how existing resources will be implemented. Finally, communication and discrepancies between mental health and custody staff are
potential sources for ineffective detection. Custody staff tends to be unfamiliar with treatment-related policies and procedures and treatment staff
may also be unaware of custody policies and procedures (Hayes, 1999).
In addition to artifacts of the environment which present challenges for
conducting suicide assessments in jail, there are often a multitude of
psychological variables that can clinically complicate suicide assessment.
Estimates of severe psychopathology among jail inmates range from
6.4\% (Teplin, 1990) to 15\% (Teplin, Abram & McClellend, 1996; Guy,
Platt & Zwering, 1985). Diagnoses frequently seen in inmates include
depression, psychosis, and Borderline Personality Disorder (BPD). In
addition, some inmates may feign or malinger suicidal intent or behavior
in an attempt to manipulate their environment or derive secondary gains,
making it difficult to identify genuine disorders from feigned disorders.
The following case presentations provide examples of inmates who may
present for a suicide evaluation at a local jail followed by an assessment
of risk factors for assessment.
DEPRESSION AND HOPELESSNESS
Case Study 1: Mr. E
Mr. E is a 49-year-old, single male who is in the county jail for
attempted robbery. A corrections officer alerted the mental health department that a noose was found in Mr. E’s locker on the pod. Mr. E was
immediately called to the mental health unit for evaluation. When he
arrived, Mr. E had no idea why he was invited to the mental health office.
When questioned about the noose, he stated it was “nothing” and that he
wished that the officer had not told the staff about the noose. He further
stated that he was awaiting a court hearing and that he was facing a
sentence of ten years. While Mr. E had a lengthy criminal history, this
time he was caught with a weapon during the commission of a burglary
and was thus facing a much longer sentence than had before. Mr. E continued to inform the staff that if he went to court and got sentenced to ten
years, he would indeed “hang up.” He stated that he had the noose ready
Practice Update Section
71
because he then did not have to think about making the noose when he
returned from court. He also reported that since his noose was taken away
he would merely make another noose. In addition, Mr. E spoke of his girlfriend and her children. He stated that he cared deeply for her children but
felt they did not care the same about him. Mr. E refused all mental health
services stating that he had nothing to live for.
Assessment: Mr. E reports high levels of hopelessness about his future.
He no longer feels as if he has any reason to live. Hopelessness is one of
the best predictors of both attempted and completed suicide (Beck,
Brown, Berchick, Stewart & Steer, 1990). In addition to anticipating a
long prison sentence, Mr. E is also facing the potential loss of his relationship with his girlfriend and his children. Significant life events such as
these can be precursors to suicide attempts. Mr. E has a specific suicide
plan and he has access to means to execute his plan (the noose and the
ability to make a new noose). This combination of factors makes Mr. E a
very high risk for a serious suicide attempt. Mr. E should be placed in a
room where he can be monitored closely and where he has no access to
means to commit suicide until the crisis passes.
BORDERLINE PERSONALITY DISORDER
Patients with BPD pose a challenge to jail mental health staff. One of
the nine diagnostic criteria for the disorder includes recurrent suicidal or
self mutilating behavior (American Psychiatric Association, 2000). While
many patients with BPD present with self harm which serves as a method
of mood regulation rather then suicide; jail staff cannot ignore patients
who are injuring themselves.
Case Study 2: Mr. A
Mr. A is a single, 21-year-old, white male, diagnosed with Borderline
Personality Disorder (BPD), Depression, and Posttraumatic Stress Disorder.
Mr. A is being held in county jail following a physical altercation with
another patient at a local psychiatric hospital and consequently he has
been charged with aggravated assault. Mr. A was physically and sexually
abused as a young child by both his mother and his father. Both of his
parents died when he was age nine. Mr. A tells the jail staff that he does
not want to hurt himself. However, when Mr. A is left alone he inflicts
harm within minutes. He has a history of chronic, unpredictable and
frequent self-injurious behavior. Mr. A cuts himself with plastic knives,
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JOURNAL OF FORENSIC PSYCHOLOGY PRACTICE
staples, or anything sharp he obtains. If he does not have a sharp object
he will bang his head on his cell door or pick his old wounds with paint
chips. Mr. A is cooperative with the clinicians, but responds to questions
about his suicidality in a flat manner, devoid of emotion. As a consequence of his impulsive self-harming behavior he has been sent to the
local crisis center on seven different occasions where he denies suicidal
thoughts or intent and thus is returned to jail in less than 24 hours. Since
his reception into the institution, Mr. A. has been on constant suicide
watch.
Assessment: The two main criteria used to assess suicide risk are
intent and lethality. In terms of intent, based upon Mr. A’s history it
appears that he may engage in the cutting and head banging as a way to
deal with the trauma he has experienced. A history of childhood abuse correlates significantly with number of lifetime suicide attempts (Brodsky,
Malone, Ellis, Dulit, & Mann, 1997). Therefore, Mr. A may be very
ambivalent about his desire to end his life. Such behavior is congruent
with his diagnosis of BPD. However, when we look at lethality, most of
the harm he inflicts upon himself is non-lethal in nature. Some recent
evidence suggests that self injury among individuals with BPD tends to
increase in lethality over time (Soloff, Lynch, Kelly & Mann, 2000).
Furthermore, a diagnosis of BPD is a risk factor for completed suicide,
as 8–10\% of patients with BPD will eventually commit suicide. In addition, impulsivity is a hallmark characteristic of BPD, therefore it is possible that even if Mr. A denies current ideation, a sudden stressor may
precipitate a suicide attempt. Brodsky and colleagues (1997) examined
the relationship between suicide and BPD and found that impulsivity
was the only characteristic of BPD that was associated with a higher
number of previous suicide attempts even after control for lifetime diagnoses of depression and substance abuse. Sometimes it can be helpful to
look at what factors in the environment are maintaining a behavior. For
example, in Mr. A’s situation, he receives attention from jail staff when
he cuts himself, he is put on one-to-one care and then he gets sent to the
crisis center. This could be the way that Mr. A. has learned to get the
attention he craves.
Mr. A is an example of a patient who would not be required to be on
one to one suicide watch – although his access to means to engage in self
harm should be taken seriously and corrections staff should regularly
check his cell to make sure that it is free of sharp objects. If the jail is so
equipped, Mr. A could be placed in a padded room where he would not
hurt himself if he banged his head.
Practice Update Section
73
Psychosis
Patients with psychotic disorders are at greatest risk of completed
suicide. It is estimated that between 10–13\% of all patients diagnosed
with a psychotic disorder will eventually kill themselves (Caldwell &
Gottesman, 1990). In a jail setting, psychosis is difficult to manage. Psychosis may not be immediately detected and inmates with psychotic disorders may be placed within the general population which could elevate
stress levels and hence increase symptoms of psychosis such as delusions,
hallucinations, and paranoia.
Case Study 3: Ms. S
Ms. S is a 24-year-old, single, Hispanic female with no children. She
has a history of being sexually abused by her father and his friends starting at the age of nine. She is charged with the aggravated assault of a
social worker at the psychiatric hospital where she was being treated and
she is currently being held at county jail until sentencing on these charges.
Similar to Mr. A., Ms. S has been diagnosed with Borderline Personality
Disorder; however, she presents quite differently as she exhibits
psychotic symptoms. Ms. S. expresses intense feelings of irritability and
anger. During these times she frequently becomes verbally abusive. Additionally, she escalates quickly and can become aggressive without warning. She is inconsistent with medication compliance and this has made her
mental status more unstable.
As a consequence of her aggressive behavior and emotional lability,
Ms. S is a behavior management problem and has constantly had
problems on housing units as well as with custody staff. In addition, Ms. S
is often sexually provocative with staff, and at times she removes her
clothing while in her cell. She believes that she was raped by staff during
her previous hospitalization insisting that she is pregnant. However, a
pregnancy test revealed that she was not pregnant. Ms. S becomes most
disorganized and delusional at times of perceived stress when she is preoccupied with issues pertaining to hospitalization or medication. At such
times she reports that her sister is taking over her body and that she is
plagued with infectious diseases.
Ms. Ss erratic and volatile behavior has resulted in several placements
on suicide watch for suicidal and homicidal behaviors. While Ms. S has
not actually made a serious attempt to harm herself, her recurrent expression of suicidal threats poses a particular challenge in a correctional
setting.
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JOURNAL OF FORENSIC PSYCHOLOGY PRACTICE
Assessment: Patients such as Ms. S are extremely taxing on prison
resources. Her behavior is both volatile and unpredictable. While she has not
made a suicide attempt, the presence of delusions and possibly command
hallucinations (when her sister takes over her body) increase her risk for
engaging in suicidal behavior. While Ms. S does not have explicit intent to
kill herself, she has carried a diagnosis of BPD with psychotic features, both
of which increase the risk of suicidal behavior. Furthermore, Ms. S also has
unpredictable behavior and a history of self harm which increases the likelihood of serious injury as she may be somewhat desensitized to pain
(Leibenluft, Gardner, & Cowdry, 1987; Bohus, Limberger et. al., 2000).
The lifetime prevalence for suicide attempts for those with psychotic
spectrum disorders has been estimated to be as high as 70\% with between
10–13\% actually completing suicide (Caldwell & Gottesman, 1990).
While someone who is lucid is able to weigh the pros and cons of ending
their lives, when someone is psychotic they may feel as if they have no
power and control over their own behavior as they are being controlled by
a force outside of themselves. Suicidal behavior among inmates with psychotic disorders should be taken very seriously. While these inmates may
decrease their risk for suicide if appropriately medicated, it can often take
days, weeks, and even months for inmates to respond to antipsychotic
medication. When a psychotic person is suicidal, one does not have the
luxury of time, and individuals such as Ms. S should be monitored and put
in an environment where they are unable to hurt themselves such as a padded cell they become medically and psychologically stabilized.
FEIGNING OR MALINGERING MENTAL ILLNESS
Case Study 4: Mr. R
Mr. R is a 21-year-old, single male who is being held in the county jail
for hindering apprehension and resisting arrest. He has a history of minor
offenses. Mr. R has a polysubstance abuse problem, but declined
treatment. After several days in jail, Mr. R was found hiding behind a
wall in his cell with a sheet around his neck. He reported feeling suicidal
and said he wished to go to the crisis center because he “couldnt take it
any more.” When interviewed, Mr. R mumbled and his eyes were downcast. He was not able to articulate why he was feeling suicidal. He then
proceeded to tell the assessor that he was experiencing both neurological
and psychiatric symptoms. During the course of the evaluation Mr. R. shook
Practice Update Section
75
his left arm and reported that he was having a seizure. He also put this same
arm up by his ear and began to touch it as he shook and said he was unable
to stop this behavior. In addition, Mr. R reported that he was seeing
“spirits.” Mr. R told the jail staff that he had to get out of jail and go home.
Assessment: Mr. R’s presentation is vague, inconsistent, and contradictory. There are several indications that he may be feigning suicidal intent.
First, Mr. R was not able to provide intent for his actions. Generally,
individuals who are thinking of taking their own lives have a reason for
doing so. Second, Mr. R was reporting and exhibiting a motley assortment of neuropsychological impairments in which the presentation was
inconsistent. For example, someone who is experiencing a seizure is not
able to maintain a lucid conversation and stop shaking on cue. In addition,
Mr. R managed to remain focused on a variety of common jail issues such
as going home, moving to a different housing unit, being sent to crisis or
the hospital, and reducing his charges all while feeling suicidal. This is
not the typical presentation of a suicidal inmate. However, even though
Mr. R did not have the intent to commit suicide, he did have the means to
engage in a lethal suicide attempt as he was found in his cell with a noose
around his neck. While it seemed apparent that Mr. R was using the noose
for effect, it does happen that inmates can accidentally kill themselves in
an attempt to feign mental illness. Therefore, Mr. R’s behavior must be
taken seriously and he should be required to sleep in a cell without sheets or
other materials that could be used to create a noose. In addition his cell
should frequently be searched for materials that he could use to hurt himself.
CONCLUSIONS
Suicide assessments in jails are multifaceted. They involve an analysis
of the inmates intent to engage in suicidal behavior as well as their access
to lethal means. Further, the clinician is required to take into account the
resources available in a jail setting, the purpose of the suicidal behavior
(i.e. is it the manifestation of a depressive disorder or is this inmate
seeking to manipulate their environment), as well as any acute stressors
the inmate may be experiencing as a consequence of his or her incarceration. This is by no means an easy task and it requires the cooperation of
numerous entities within the prison such as the correctional officers who
monitor the offenders, the clinical staff who use their expertise to evaluate
offenders, and the administration who provide the resources necessary to
maintain a safe and secure environment for the inmates.
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between hopelessness and ultimate suicide: A replication with psychiatric outpatients.
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