Using Trained Inmate Observers for Suicide Watch in a Federal Correctional Setting: A Win'Win Solution

Psychological Services
In the public domain
2005, Vol. 2, No. 1, 20 –27
DOI: 10.1037/1541-1559.2.1.20
Using Trained Inmate Observers for Suicide Watch in a Federal
Correctional Setting: A Win–Win Solution
Gary Junker, Art Beeler, and Jeffrey Bates
Federal Bureau of Prisons
This study examined the impact of using inmate observers for suicide watch within a
federal correctional–mental health setting. Results indicate a signi?cant decrease in the
mean number of hours inmates remained on suicide watch ( p
.036) following the
implementation of the Inmate Observer Program (IOP). Overall, suicidal inmates with
a diagnosis of psychotic disorder remained on suicide watch signi?cantly longer ( p
.004) than did inmates in other diagnostic groups. The psychotic group, however, had
a signi?cant decrease in mean hours on suicide watch ( p
.001) following the
implementation of the IOP. Also, individuals with personality disorders had signi?-
cantly fewer watches ( p
.033) when inmate observers were used. Initial ?ndings
suggest that the use of inmate observers reduces the length of time that suicidal peers
remain on watch without compromising standard of care.
Keywords: prison, suicide, suicide watch, inmate observer
Within the United States, suicide is the 11th
lates of suicidal ideation, several psychological
leading cause of death, accounting for 29,350
disorders are associated with greater risk of
deaths in 2000 (Centers for Disease Control,
suicide, such as alcoholism, schizophrenia,
2002); these ?gures equate to one completed
mood disorders, and certain personality disor-
suicide every 17.5 min. Both the surprisingly
ders, for example, borderline personality disor-
high number of completed suicides and the hu-
der (Carson, Butcher, & Mineka, 2000). Finally,
man tragedy associated with self-in?icted
there is evidence of both biological in?uences,
deaths motivate researchers to better understand
such as reduced dopaminergic activity at D2
the correlates of this behavior. For example, one
receptors (Pitchot et al., 2001), and a genetic
of the most well-researched predictors of sui-
predisposition to suicidal behavior (Turecki,
cide is a sense of hopelessness concerning the
2001).
future (Brown, Beck, Steer, & Grisham, 2000),
Though the same predictors of suicide in the
including the inability to cope with distress and
general population apply to a correctional set-
to de?ne life problems in a way they can be
ting, additional attention has been given to ac-
solved (Dixon, Heppner, & Anderson, 1991).
curate assessment of risk in prisons. For exam-
Further, individuals with low self-esteem or low
ple, inmates who lack close friends outside
self-ef?cacy are also more likely to endorse
prison or do not take part in recreational, voca-
suicidal ideation (Dieserud, Roysamb, Ekeberg,
tional, or hobby activities are at an increased
& Kraft, 2001). In addition to cognitive corre-
risk of suicide (Cooper & Berwick, 2001). As-
sessing support systems, both in and out of the
prison milieu; activity levels; and perceptions
Gary Junker and Art Beeler, Federal Medical Center,
about hopelessness relating to their incarcera-
Federal Bureau of Prisons, Butner, North Carolina; Jeffrey
tion (Bonner, 2000) is essential in risk assess-
Bates, United States Penitentiary Beaumont Center, Federal
ment of inmates. Individuals who are incarcer-
Bureau of Prisons, Beaumont, Texas.
ated are more likely to suffer from a mental
The views presented in this article are those of the authors
and are not endorsed as an expression of the policies or
illness (Dimond, Wang, & Holzer, 2001), which
views of the Federal Bureau of Prisons.
can also increase the risk for suicide. In total,
Correspondence concerning this article should be ad-
the combination of personality factors and the
dressed to Gary Junker, Federal Medical Center, Federal
stress of being incarcerated highlights the com-
Bureau of Prisons, P.O. Box 1500, Old Oxford Highway,
Butner, NC 27509-1500. E-mail: gjunker@bop.gov
plexity of suicide risk assessment in prisons.
20

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USING TRAINED INMATE OBSERVERS FOR SUICIDE WATCH
21
Because of an increased percentage of com-
training in suicide assessment, or bad decision
pleted suicides in prison settings, there is
making once risk has been detected. From a risk
greater responsibility for mental health profes-
management perspective, prisons are mandated
sionals working in correctional settings to both
to act once suicide risk has been detected. How-
assess risk and develop programming to prevent
ever, little direction has been given to direct
or reduce suicide attempts (Correia, 2000).
proper action. A common prison practice is to
Ivanoff, Jang, and Smyth (1996) cited that the
place suicidal inmates in observation rooms,
percentage of individuals committing suicide in
after removing any item that may be used for
prison is much higher than in society at large,
the purpose of self-harm. It is not unusual, even
leading researchers to identify prison suicide as
within a hospital setting, for observation to con-
a “serious public health problem” (Haycock,
sist of 15 min “checks,” thereby leaving the
1991, p. 81). Similar to society as a whole,
suicidal individual unobserved for a vast major-
increased depression and hopelessness contrib-
ity of the time.
ute to increased suicidal ideation in a prison
A “community care model” within a correc-
population (Ivanoff et al., 1996). However, so-
tional setting encourages “supportive relation-
cial stressors that may lead to a sense of hope-
ships at all levels” using line staff, medical staff,
lessness are ampli?ed, which may contribute to
and peers to reduce levels of suicide (Biggar,
an increased risk of suicide in this population.
1996, p. 207). In addition to providing a com-
For example, protective factors, such as family,
munity standard of care to suicidal persons, a
employment, leisure time, and having children
team approach to suicide prevention uses the
living in the home (Sanchez, 2001), are not
skills of multiple individuals (staff and non-
immediately present for individuals who are
staff), provides opportunities for training of
incarcerated. Further, the most common sources
these individuals, and may improve the “man-
of distress for incarcerated individuals (relation-
agement of vulnerable inmates” (Cutler, Bailey,
ships, family, and discharge concerns) are dif-
& Dexter, 1997, p. 65). Regardless of the
?cult to manage while in prison (Dexter &
method of prevention, the most important factor
Towl, 1995). Certainly prison is a stressful en-
is to provide protection to the inmate from self-
vironment, and as the severity of distress and
destructive thoughts and impulsive behaviors in
worry increases, so too does suicidal ideation of
the least restrictive manner possible.
inmates (Cooper & Berwick, 2001). Individuals
The recognition of suicide in prison as a
with ineffective coping strategies are more
source of serious concern has led the Federal
likely to endorse suicidal ideation (Eidhin,
Bureau of Prisons (BOP) to create and maintain
Sheehy, O’Sullivan, & McLeavey, 2002).
an active Suicide Prevention Program through-
Stress that may be benign for some is over-
out all institutions (Federal Bureau of Prisons,
whelming to others, placing the latter group at a
2004). Because of the attention that suicide pre-
greater risk for suicide.
vention has been given within the BOP, the
From a legal perspective, suicide prevention
number of suicides for inmates in Federal cus-
in prison involves a standard of care for detect-
tody has fallen to between 12–16 per 100,000,
ing risk of suicide among inmates and then
which is lower than the percentage for adult
taking “reasonable preventive measures” (Han-
men in American society. Important compo-
ser, 2002, p. 461) to deter suicide attempts once
nents of the BOP Suicide Prevention Program
this risk has been detected. For example, in his
are continual training of staff at all levels con-
discussion of legal liability, Hanser (2002) cited
cerning risk factors and early indications of
previous litigation in the assertion that prison
suicidal behavior and the importance of actively
of?cials must search inmates and restrict access
communicating information to facilitate proac-
to potentially harmful items, in addition to pro-
tive intervention.
viding a modicum of supervision. This supervi-
The BOP Suicide Prevention Program and
sion must rise to the level of “marginal protec-
speci?cally the Inmate Observer Program (IOP)
tion” (Hanser, 2002, p. 469) or a reasonable
described in this article go beyond a minimum
attempt to prevent suicide attempts. Successful
standard of protection by providing direct and
tort claims relying on 42 United States Code,
constant observation while an individual is
Section 1983, rely on faulty detection, poor
judged to be suicidal. Rather than developing a

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22
JUNKER, BEELER, AND BATES
program to avoid legal implications of “delib-
which were accounted for by 37 individuals
erate indifference” (Hanser, 2002, p. 460), the
(mean age
34.38 years, SD
10.06). The
BOP takes a proactive approach that includes
sample included 18 African American partici-
tracking of trends in self-injurious behavior,
pants, 10 Caucasian participants, and 9 His-
development of at-risk pro?les, staff training,
panic participants. A majority of the sample
and constant re?nement of the suicide watch
(51.4%) had been given a primary diagnosis
process.
involving some form of psychosis (e.g., schizo-
Despite the attention given to the topic of
phrenia, schizoaffective disorder, major depres-
suicide, there is a paucity of empirical research
sive disorder with psychotic features). Addi-
that has been completed to assess the process of
tional primary diagnoses included the follow-
observing individuals who have been placed on
ing:
personality
disorder
(24.3%),
mood
suicide watch. A vast majority of published
disorder (13.5%), malingering (5.4%), or other
research examines proper assessment, including
(5.4%; e.g., factitious disorder). Twenty-seven
development of assessment tools, and mecha-
percent of the sample were undergoing a foren-
nisms for prevention of suicidal behavior. When
sic evaluation (e.g., competency to stand trial,
individuals are found to be suicidal, the ques-
restoration to competency, criminal responsibil-
tion of how to ensure their safety during active
ity). The remainder were either federally sen-
periods of suicidal ideation has not been suf?-
tenced individuals who developed an acute psy-
ciently researched. Most interventions within a
chiatric
concern
requiring
hospitalization
prison setting involve removal of the suicidal
(62.2%) or individuals who were adjudged
person from the general population and place-
mentally ill and dangerous in Federal court,
ment in a relatively secure and isolated environ-
requiring their inde?nite commitment to a Fed-
ment, where visibility is increased and access to
eral Medical Referral Center (10.8%). Finally,
objects that could be used for self-harm is min-
for a summary of the offenses leading to the
imized (Felthaus, 1997). However, there is a
detainment of each participant, please refer to
lack of research evaluating the isolation process
Table 1.
for acutely suicidal inmates in a suicide watch
room (Bell, 1999). Additional empirical explo-
Procedure
ration is needed to de?ne who is placed on
suicide watch in a prison setting, how long they
This study was conducted at a Federal Bureau
remain on watch, and what the effects of using
of Prisons Medical Referral Center, which pro-
trained inmates to observe acutely suicidal peers
vides mental and physical health care for in-
are.
mates incarcerated in the Federal penal system.
The purpose of the present study is to analyze
Over the course of their hospitalization, inmates
the effects of using inmate observers for suicide
assessed to be acutely suicidal were placed on
watch within a correctional setting. Data pre-
suicide watch in an inpatient restricted housing
sented provide demographic characteristics of
unit. While on suicide watch, individuals are
inmates at risk for self-harm. It is anticipated
observed simultaneously through four mecha-
that ?ndings will help researchers and practitio-
nisms: (a) constant surveillance using closed-
ners understand the dynamics of suicidality
within corrections. Finally, information gleaned
from this research will hopefully ?ll a gap in the
current literature base and provide an example
Table 1
of a community oriented approach to suicide
Participant Offense Type and Frequency of Offense
prevention.
Offense type
Frequency
Crimes against person
9
Method
Crimes against property
2
Drug offense
10
Participants
Threatening a government of?cial
6
Felon possession ?rearm
5
Over the course of the study period (24
Illegal alien
4
Total
37
weeks), 82 suicide watches were initiated,

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USING TRAINED INMATE OBSERVERS FOR SUICIDE WATCH
23
circuit TV; (b) rounds conducted by nursing
data, inmate medical records were reviewed to
staff, every 15 min; (c) rounds by correctional
determine when suicide watches were initiated
staff, every 15 min; and (d) direct observation.
or discontinued. After data from the e-mail no-
The fourth of these mechanisms is the focus of
ti?cation system and medical records were con-
the present study. Prior to the initiation of the
solidated, there were no missing data.
IOP, suicide watches were assigned to institu-
tion staff as an overtime post. Following the
Results
initiation of the IOP, carefully selected and
trained inmates were used to provide constant
Prior to evaluating the effects of the IOP on
observation of individuals placed on suicide
trends in suicide watches, separate one-way
watch.
analyses of variance were conducted to analyze
Inmates requesting to participate in the IOP
group differences in the number of hours on
were screened by unit team, correctional ser-
suicide watch for the following independent
vice, and mental health staff for a history of
variables: ethnicity, primary diagnosis, and the
institutional misconduct that would prohibit
reason for hospitalization. The means and stan-
participation. All acceptable candidates were
dard deviations for these three independent vari-
invited to a 4-hr initial training session in which
ables are presented in Table 2.
the IOP was described in full. Information was
Because three separate analyses were con-
provided on the basic job assignment of observ-
ducted, Bonferroni correction was used to main-
ing suicidal peers, recording log entries at 15-
tain the familywise error rate at
.05. Of the
min intervals, and handling emergencies. Train-
three analyses of variance, only one yielded
ing was provided by a psychologist on types of
statistically signi?cant results, which was pri-
persons who frequently become suicidal and
mary diagnosis, F(4, 76)
4.18, p
.004. We
common behaviors of different diagnostic
conducted post hoc contrasts to assess differ-
groups. Basic communication skills, active lis-
ences between the ?ve diagnostic categories.
tening skills, and issues relating to con?denti-
Because there were no signi?cant differences
ality were also included in this initial training. It
between four of the diagnostic groups (mood,
should be noted that inmate observers were
personality, malingering, and other), these
instructed that their job was to observe and not
groups were collapsed for the purpose of this
to counsel. Also, inmate observers did not have
contrast, resulting in a comparison between in-
access to patient records or any other con?den-
dividuals diagnosed with a psychotic disorder
tial information. Follow-up training and de-
versus the remaining four categories. In these
brie?ng have been provided on at least a quar-
terly basis.
The present study evaluated the impact of the
Table 2
IOP on the suicide watch process. The evalua-
Mean Number of Hours on Watch as a Function of
tion of this program was divided into two con-
Ethnicity, Diagnosis, and Reason for
secutive 12-week intervals, separated by the
Hospitalization
initiation of the IOP. Thus, the ?rst time period
Variable
M
SD
n
consisted of using staff for constant observation
Ethnicity
of suicidal inmates, and the second time period
African American
85.75
97.27
39
consisted of using trained inmate observers.
Caucasian
73.13
70.64
21
Suicide risk assessment and clinical decisions to
Hispanic
117.13
144.8
21
initiate or discontinue suicide watch were con-
Diagnosis
ducted by a licensed psychologist or psychia-
Psychotic
145.59
141.15
31
Mood
92.60
67.80
7
trist both pre- and post-IOP and remained con-
Personality
50.89
54.45
37
stant and independent of this research study.
Malingering
46.52
46.80
3
Suicide watches were tracked using an e-mail
Other
51.94
31.16
3
noti?cation system, which is used to notify the
Reason for hospitalization
Suicide Prevention Program Coordinator when
Study
70.13
68.21
15
inmates are placed on suicide watch and when
Sentenced
94.69
114.41
60
Inde?nite commitment
101.06
105.35
6
watches are discontinued. In the case of missing

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24
JUNKER, BEELER, AND BATES
analyses, individuals who were diagnosed with
watch pre- and postinitiation of the IOP. The
a psychotic disorder were found to remain on
mean stay on watch was 108.88 hr (SD
suicide watch signi?cantly longer than individ-
126.06) for the pre-IOP sample and 64.05 hr
uals with other mental illnesses, t(76)
2.97,
(SD
59.82) for the post-IOP sample. Because
p
.004. The post hoc contrasts presented in
the standard deviations of the two samples were
Table 3 yielded no additional statistically sig-
signi?cantly different, F(1, 81)
12.30, p
ni?cant ?ndings.
.001, Levene’s test was used to reduce the num-
To analyze the possible relationship between
ber of degrees of freedom, which conservatizes
age and length of suicide watch, we calculated a
this analysis. The resulting t test was statisti-
Pearson correlation between these two vari-
cally signi?cant, t(71.55)
2.14, p
.036.
ables. The results were not statistically signi?-
Thus, there was a signi?cant decrease in the
cant (r
.085, p
.449). Thus, no relation-
mean number of hours on watch following the
ship was found between an individual’s age and
implementation of the IOP.
the length of stay on suicide watch.
A ?nal analysis was conducted to compare
A major goal of this study was to explore the
change in length of suicide watch pre-IOP with
effects of using trained inmate observers on the
post-IOP for the separate diagnostic categories.
frequency of and number of hours on suicide
The malingering and other diagnostic groups
watch. To explore these issues, we conducted
had to be removed from this analysis. Individ-
separate statistical analyses. First, a chi-square
uals in these categories either fell in the pre-IOP
statistic was calculated, comparing the number
or post-IOP group. Without individuals in both
of watches in the 12 weeks prior to the initiation
of these groups, any comparison would be
of using trained inmate observers to the 12
meaningless. Thus, a two (pre-IOP vs. post-
weeks following. Although it is important to
IOP)
three (psychotic disorder vs. mood dis-
note that the number of suicide watches dropped
order vs. personality disorder) analysis of vari-
by 31.25%, from 48 pre-IOP to 33 post-IOP,
ance was used. There was a signi?cant interac-
this difference was not found to be statistically
tion, F(2, 75)
8.71, p
.001, warranting the
signi?cant, 2(1, N
81)
2.78, p
.096.
need for analyzing simple main effects. The
A second manner of analyzing the effects of
means for each diagnostic group, separated by
using trained inmate observers was provided by
pre-IOP and post-IOP, are graphically presented
comparing the mean number of hours on suicide
in Figure 1.
Because there were signi?cant differences in
the variances of the two samples, the resulting t
tests were again conservatized through the use
Table 3
Analysis of Variance Table Comparing Mean
of Levene’s test. The only signi?cant simple
Number of Hours on Suicide Watch for the
main effect was for individuals receiving a psy-
Independent Variables
chotic diagnosis, t(22.65)
22.65, p
.001.
Thus, there was a signi?cant decrease in the
Variable
F
df
p
mean hours on suicide watch for this group
Ethnicity
following the implementation of the IOP as
Between groups
0.98
2
.379
shown in Table 4.
Within groups
78
It is interesting to note that there was not a
Total
80
Diagnosis
statistically signi?cant decrease in the mean
Between groups
4.18
4
.004
number of hours on suicide watch for the per-
Within groups
76
sonality disorder group. Although this decrease
Total
80
was not observed, the number of individuals on
Reason for hospitalization
watch in this group dropped from 25 in the
Between groups
1.00
74
.568
pre-IOP sample to 12 in the post-IOP sample.
Within groups
6
This represents a 52% decrease, which is statis-
Total
80
tically signi?cant,
2(1, N
37)
4.57, p
Note.
Inmates with a psychotic disorder (n
31) were on
.033. Thus, though the mean number of hours
suicide watch signi?cantly longer (M
145.59 hr, SD
for this group did not decrease, there were a
141.15 hr) than were inmates who were not psychotic
(M
56.53 hr, SD
55.57 hr; p
.004).
signi?cantly lower number of individuals with

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USING TRAINED INMATE OBSERVERS FOR SUICIDE WATCH
25
Figure 1.
Mean number of hours on suicide watch as a function of diagnostic category and
whether it was before or after initiation of the Inmate Observer Program (IOP).
personality disorders placed on suicide watch
Questions remain as to why such a program
following the implementation of the IOP.
would have a drastic effect on suicide watches
in a correctional setting. Prior to the initiation of
Discussion
the IOP, suicidal inmates were directly moni-
tored by staff members. Thus, inmates on sui-
With the identi?cation of suicide in prison as
cide watch had unfettered access to staff. One
a problem warranting further clinical and em-
possible explanation for a reduction in the num-
pirical attention (Haycock, 1991), examining
ber of hours individuals spent on suicide watch
the effects of innovative programs addressing
is the elimination of direct attention provided by
this concern will continue to be of utmost im-
staff. Past studies have cited up to 50% of
portance in a correctional setting. Although the
self-in?icted injuries in a prison mental health
results of this study cannot be generalized out-
setting that were manipulative in nature (Frank-
side of a federal medical center context, the
lin, 1988). There are fewer opportunities for
potential positive effects of an IOP in similar
staff manipulation if suicidal inmates are di-
environments such as state prison or county jail
rectly observed by peers. Further, the IOP al-
is hopeful.
lows for contact between the suicidal inmate
and the observer. Such contact between peers
has been suggested as a helpful strategy in re-
Table 4
ducing self-injurious behavior among inmates
Analysis of Variance for Interaction Between Time
(Rakis & Monroe, 1989). As noted in the Re-
(Before or After Implementation of the IOP) and
sults section of this article, there was a signi?-
Diagnosis (With Signi?cant Simple Main Effect)
cant decrease in the number of hours individuals
Variable
F
df
p
with a psychotic disorder spent on suicide watch
following the initiation of the IOP. Several of
Time
7.06
1
.01
Diagnosis
6.83
2
.002
these individuals were actively delusional while
Time
Diagnosis
8.71
2
.001
on watch. The use of an inmate observer (rather
Error
75
than an authority ?gure) may provide a safer
Total
80
venue for the suicidal inmate to converse and
Note.
For inmates with a psychotic disorder, before im-
identify with a peer. Finally, prison is a stressful
plementation of the Inmate Observer Program (IOP; n
environment, in which suicidal ideation is more
17), they spent signi?cantly longer on suicide watch (M
common than in society as a whole (Ivanoff et
213.92 hr, SD
151.32 hr) than they did after implemen-
al., 1996). The support of a peer who is coping
tation of the IOP (n
14; M
65.38 hr, SD
14.78 hr;
p
.001).
more effectively may serve as an encouraging

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26
JUNKER, BEELER, AND BATES
protective factor for the suicidal inmate.
1996, p. 207) while providing potential bene?t
Through social modeling, triggers for suicidal
to administrators, inmate observers, and the sui-
and parasuicidal behavior may be normalized,
cidal or parasuicidal inmates themselves. There-
thereby reducing the need for a continued stay
fore, as one component of a multitier approach
on watch. If these ?ndings are replicated in
to suicide prevention, the use of inmate observ-
future research, a next step would be to explore
ers provides correctional institutions with a
in greater depth the relationships among these
cost-effective mechanism while ensuring the
variables.
safety of at-risk inmates. The mutual bene?t
Perhaps even more important, anecdotal evi-
experienced by all who join in this process
dence suggests that inmate observers realize
comprises the win–win solution of using trained
personal gain by having an opportunity to give
inmate observers for suicide watch.
back to the community in which they live. In-
mate observers are able to display social inter-
est, which is de?ned as “the willingness to
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