Louris Favril, Institute for International Research on Criminal Policy (IRCP), Faculty of Law and Criminology, Ghent University, Belgium
Freya Vander Laenen, Institute for International Research on Criminal Policy (IRCP), Faculty of Law and Criminology, Ghent University, Belgium

Due to their complex mental health needs, female inmates comprise a particularly vulnerable group, at an elevated risk for suicide. Although suicidal ideation—the early stage in the trajectory towards suicidal behavior—represents a valid target for suicide prevention, there has been little research devoted to this outcome among female inmates. In order to address this void and to inform prevention efforts, the present study sought to investigate correlates of recent suicidal ideation among women incarcerated in Flanders, Belgium. A representative sample of prisoners (N.123; aged 19–70 years) was randomly selected from all Flemish correctional facilities detaining female inmates, representing one in four incarcerated women throughout Belgium. Prevalence estimates for lifetime history of suicide ideation and attempts are 57.7% and 36.6%, respectively. Multivariate analysis indicates that women with recent suicidal ideation while incarcerated are significantly more likely than their non-suicidal peers to report a lifetime history of non-suicidal self-injury (aOR.7.36), in-prison drug use (aOR.4.72), and severe psychological distress (aOR.3.14). The findings highlight the importance of providing adequate mental health services in prison, in order to address women’s unique needs and vulnerabilities, and consequently, to reduce suicide risk.

Women, prison, mental health, suicidal thoughts, suicide prevention

“Suicide is a leading cause of mortality in custodial settings across the globe, with substantially higher rates of suicide in prisoners compared with non-incarcerated people in the surrounding community…evidence suggests that suicide rates are at least similar among female prisoners compared to their male peers…An explanation for the disproportionate high suicide rate in female prisoners is that incarcerated women, as a group, exhibit high prevalence rates of well-established risk factors associated with suicide in the general population…evidence suggests that incarcerated women are particularly disadvantaged compared to their male counterparts…abundant research indicates that women in prison have a substantial higher burden of drug dependence and psychiatric disorders than men in prison…Moreover, incarcerated women have more extensive histories and high rates of interpersonal violence and childhood abuse, either physical or sexual, than their male counterparts…Such trauma and adverse histories may negatively affect prisoner’s mental health and may contribute to adverse health outcomes among women in prison, including self-injurious behavior, both suicidal and non-suicidal” (p.85-86).

“…an extant body of research indicates that the mental health needs of female inmates are quantitatively and qualitatively different from those of their male counterparts. Consequently, and because prison regimes and practices have been primarily designed for men-yet applied to women-and do not take into account the unique needs of women prisoners, it is argued that women experience prison as more distressing than their male peers, and suffer disproportionately from imprisonment…leading to an elevated risk of suicide while incarcerated…In contrast, despite clinical concern, there remains a paucity of studies specifically examining suicidal ideation among female inmates…the purpose of the current study was to contribute to the knowledge base of an under-studied subject within a vulnerable population…Given the close association between suicidal ideation and subsequent suicidal behavior, elucidating the factors that are associated with suicidal ideation among female inmates could contribute to the early identification of prisoners at risk for suicide” (p.86-87).

“Between October 2015 and May 2016, an up-to-date census list of all female inmates detained in all four Flemish prisons was obtained…A survey was developed based on a thorough review of prior research relevant to this study, in order to cover a broad range of sociodemographic, criminological, and clinical factors…The outcome of interest in this study, suicidal ideation, was assessed using the Paykel Suicide Scale (PSS…)…The PSS consists of five questions assessing life-weariness, death wishes, suicidal thoughts, suicidal plans, and suicide attempts…” (p.87-88).

“…The results show that more than half (57.7%) of all participants reported a lifetime history of suicidal ideation, and one-third (36.6%) had ever attempted suicide. These findings strongly align with prior estimates for suicidal ideation (39-55%) and attempts (26-46%) found in studies with large and unselected samples of incarcerated women…suggesting that this issue extends well beyond the Belgian correctional context…During their current incarceration, past-year suicidal ideation was reported by one-third (36.6%) of all respondents, which was significantly associated with several factors. First, illicit drug use in prison, reported by one-third (32.5%) of all respondents, was found to be a significant correlate of suicidal ideation while incarcerated…A lifetime history of NSSI [non-suicidal self-injury] was self-reported by a quarter (25.2%) of all participants…a history of NSSI was significantly related to suicidal ideation in female prisoners…” (p.90-91).

“…In our study, nearly one-fifth (18.7%) of the total sample reported a lifetime history of both NSSI and attempted suicide. This overlap of self-injurious behaviors is of importance since evidence suggests that individuals who engage in both types of self-harm report higher levels of suicidal ideation and are generally at a higher risk of suicide than the group with a history of NSSI or suicide attempt only…In the current study, however, a history of attempted suicide in itself was not significantly related with recent suicidal ideation, which is at odds with findings from a mixed-gender study conducted in a single U.S. jail (Schaefer et al., 2016)…a lifetime history of psychiatric diagnoses was not significantly associated with recent suicidal ideation while incarcerated…A plausible explanation for this discrepancy is that we assessed prisoners’ lifetime history of diagnoses, rather than current disorders…” (p.91-92).

“…both NSSI…and drug use…two factors strongly related to suicidal ideation-can be regarded as maladaptive strategies to cope with distress, (in part), caused by the hardships of imprisonment. In the absence of protective factors (e.g., social support, positive staff-prisoner relationships, and opportunities for purposeful activity), or when prisoners are not supported to develop more effective coping skills, such prison-induced distress and maladaptive coping strategies may exacerbate an underlying (imported) vulnerability to suicide in female offenders. Future (longitudinal) research should further examine how coping strategies and prison-specific characteristics, and their interactions, are related to distress and suicidal ideation in female prisoners” (p.92).

“This study underlies the need to screen incarcerated women for suicide risk and mental health needs…Based on our findings, indicators of substance use, self-harm, and psychiatric comorbidity appear to be particularly relevant to the risk of suicide among prisoners, and should be given attention as part of risk assessments…Following a positive screening result, appropriate follow-up should be in place by referring inmates to available clinical services and other sources of care, in order to further assess their risk of suicide. Since suicidality is a dynamic process…risk assessments should not be limited at intake but should also occur during the course of incarceration, especially when prisoners’ circumstances or conditions change” (p.93).

“On a more informal level, prison staff should be vigilant for changes in female prisoners that suggest they may be experiencing increased levels of distress, in order to provide appropriate support…Specific training and support for prison officers may improve their ability to identify those at risk of suicidal behavior…which may also be facilitated by positive staff-prisoner relationships…women prisoners should have sufficient access to integrated treatment that addresses psychiatric morbidity and substance use disorders…Adequately addressing drug use in female prisoners is crucial in order to reduce drug-related health issues…and criminal recidivism…and is likely to be an important component of effective suicide prevention in prison…Given the multiple needs of female prisoners at-risk of suicide, complex psychosocial interventions are likely to be required…for example, trauma-informed therapies for those with posttraumatic symptoms…” (p. 93-94).

“…identifying and managing vulnerable prisoners requires the building of positive relationships between staff and prisoners, characterized by empathy and support, among other factors. With respect to NSSI, for example, research has illustrated that prison officers often perceive NSSI as manipulative or attention-seeking, rather than attributing its motives to (coping with) mental distress in prisons, which may negatively impact inmates’ help-seeking behavior and subsequently increase the risk of NSSI…Hence, better support and training for frontline correctional staff dealing with inmates who engage in such behavior is a meaningful prevention strategy…not least because individuals who engage in (repetitive) NSSI are at increased risk of suicide…More generally, more staff support and training is needed as a bedrock of any suicide prevention program” (p.94).

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