Written by Alice Dawson, Trainee Forensic Psychologist, who previously worked as a Research Assistant in the field of suicide and self-harm in the criminal justice system.
In our earlier blog post “A brief introduction to suicidality,” we explored the prevalence of suicide and the importance of identifying treatments to reduce suicidality in groups of people who are at increased risk. Jed introduced us to the effectiveness of cognitive behavioural therapies (CBT) for treating individuals experiencing suicidality, and a specific intervention; Cognitive Behavioural Suicide Prevention (CBSP).
The CARMS project evaluates a version of CBSP in one vulnerable group; for those who experience psychosis. This blog post will summarise a study piloting the use of CBSP in prisoners. How might the therapeutic benefits of CBSP identified so far be applied to men in prison who are at a significantly higher risk of suicide than the general population?1
Prison suicides in England and Wales reached a record high in recent years,2 making the prevention of suicides in prison a government priority.3 However, the potential of CBT to reduce suicidal thoughts, plans, acts and deaths in prisons is largely unknown, and there are a number of barriers unique to this setting and population that may impact its effectiveness. The main aim of the Prevention of Suicide in Prisons (PROSPeR)4 study was to examine the acceptability and feasibility of delivering CBSP in prisons.
In a closed adult male prison in the North West of England in 2012-2013, prisoners who had been cared for under the ACCT (Assessment, Care in Custody and Teamwork) system (used to monitor and support those at risk of suicide and self-harm) within the previous month were recruited to take part.
At initial assessments, participants were randomly allocated to either the therapy group, or a treatment as usual (TAU) group. Participants were then seen again at four months (post-treatment) and at six months to complete follow up assessments.
- Received usual care and treatment (specific details of what this consisted of was not recorded).
- Included any support offered through the ACCT process, including varying levels of observations and regular case review meetings.
- Were referred to the Mental Health in Reach Team.
- Did not include access to any psychological therapy.
CBSP group (received TAU in addition to):
- Up to 20 sessions of CBSP therapy delivered over 4 months by trained clinical psychologists.
- Delivered twice weekly at first, reducing to weekly.
- Each session typically lasted one hour.
Therapists recorded therapy attendance and rated how actively participants engaged with the therapy.
Questionnaires were used to assess whether therapy made more of a difference than usual treatment to the following experiences:
- suicidal or self-harm behaviours
- suicidal ideas (e.g. Do you have strong, moderate or weak wish to die?)
- suicidal probability (e.g. I feel people would be better off if I were dead)
- perceptions of hopelessness (e.g the future seems vague and uncertain to me)
- depression (e.g. I feel like a failure)
- anxiety (e.g. feelings of nervousness/difficulty breathing)
- self-esteem (e.g. there are lots of things I’d change about myself if I could)
- psychiatric symptoms (e.g. suspiciousness, unusual thoughts/manners); and
- personality difficulties (e.g. difficulty making/keeping friends, impulsivity).
Sixty-two participants were recruited to the study, split evenly across both groups. Most (53; 85%) had a history of suicide attempts. Over half (35; 56%) were still available for the four and six month follow-up.
Suicidal and self-harm behaviours
At six months, the mean number of suicidal and self-harm behaviours had almost halved for the therapy group but had changed little for the TAU group (treatment effect = -.72); participants who had recently engaged in such behaviours reduced for both groups. No participants in the therapy group had increased suicidal and self-harm behaviours at follow-up, compared to six in TAU.
Significant improvements were found for psychiatric symptoms (treatment effect = −4.60, p = .04) and personality difficulties (treatment effect = −0.79, p = .04). Improvements were also seen in both groups for all other self-report measures; greater (though not statistically significant) for the therapy group.
At the end of the treatment, over half (10/18; 56%) of participants in the therapy group were clinically improved (in terms of suicidal ideation and suicide probability), compared to only a quarter (5/22, 23%) in the TAU group (χ2 = 4.55, p = .03), although this group difference was not maintained at follow-up.
Results from PROSPeR suggest that delivery of CBSP therapy within prison is feasible because most participants who started therapy chose to complete it. However, the authors propose recommendations to better support participant engagement with material, such as, additional support from prison staff or a workbook for use between sessions.
CBSP therapy was associated with improvement in suicidal and self-harm behaviours and psychiatric symptoms, consistent with other trials in the community comparing CBT to routine care.5-7 The key message offered from the authors is that this is the first study to demonstrate that this can be extended to prisons.
Overall, these results are encouraging and warrant further investigation in prison settings as to the effectiveness of CBSP.
Strengths and Limitations
As a small-scale pilot study, the PROSPeR trial didn’t aim to conclusively state the effectiveness of CBSP in prisons, but to explore its potential. The results in this context give a reasonable indication of some therapeutic benefit in a relevant sample, using ‘blind’ randomisation to limit bias from researchers. The authors address limitations offering suggestions to overcome these in future research as follows.
Prisoner groups are known to have high rates of refusal to enter therapy/group programmes (up to 70%)10,11 and treatment drop-outs (up to 93%).12 therefore it’s unsurprising that the current study had similar issues, because 64% of eligible participants chose not to participate in the trial. It follows that future trials could benefit from paying more attention to motivational aspects of treatment and, in particular, how this can be effective in prison-based trials (i.e. involvement of prison staff). Another limitation to consider is that, although all prisoners were referred to the mental health team, there was no standardisation or recording of exactly what TAU consisted of. It’s therefore difficult to know if variation in things such as medication or additional support could have impacted on outcome measures, though it’s acknowledged that this may be difficult to mediate in a prison setting.
Lastly, we note that this study used an outcome measure of ‘suicidal or self-injurious behaviour’, combining separate acts which often distinctly differ in their intent and outcome. Recognising these differences may be important in the development of evidence for what works in terms of treatment by acknowledging the spectrum of suicidal/self-harm behaviour and what these represent.13
The current ACCT system in prisons provides a process of support and risk management, but offers little in the way of structured, targeted interventions. Findings here encourage consideration at the policy level for provision of a cognitive therapy which could be key in helping prevent suicides in prisons.
The authors also note that an in-depth evaluation of the social and economic implication of ineffective treatment could be useful for rationalising the value of implementing such interventions on a broader scale. The inclusion of additional outcome measures, such as violence and prison disciplinary actions, have the potential to provide further support to such evaluations where additional benefits are identified.
PROSPECT (Prevention of suicide behaviour in prison: enhancing access to therapy)
In conclusion, the PROSPeR pilot study highlights the potential of CBSP in reducing suicidal and self-harm behaviours, psychiatric symptoms and personality difficulties, but a large scale multi-site trial is needed for more conclusive results. The PROSPECT project will employ a Randomised Control Trial (RCT) of CBSP in prisons aiming to address some of the issues identified in PROSPeR with four main aims:
- Co-producing a therapy engagement resource with service user experts, to address improving motivation and engagement with therapy .
- Developing a model of how the intervention works, by working with prisoners, staff and psychologists to address any barriers to delivery.
- Evaluating the effectiveness of the intervention, considering both clinical and economic effectiveness of the therapy.
- Embedding evaluation of the delivery of the intervention within the RCT.
* This article contains references to suicide that some people may find distressing so if at any point you require urgent support with your mental health please contact your GP, care coordinator or crisis team. Other help can be found here:
- Samaritans: Phone 116 123; Email firstname.lastname@example.org; Text 07725 90 90 90; Or visit your local branch
- Anxiety UK
- Self-Help Services: Online crisis support www.selfhelpservices.org.uk/the-sanctuary; Phone 0300 003 7029
- Rethink (Mon-Fri 9.30AM-4PM): Phone 0300 5000 927
- Saneline (4.30PM-10.30PM): Phone 0300 304 7000
- Mind (9AM-6PM): Phone 0161 236 8000 (local rates and mobile charges apply); Email email@example.com; Text 86463
- The University of Manchester Counselling Service
- The CALM Zone
A bit about Alice Dawson
“I graduated MSc in Forensic Psychology in 2014 shortly before starting my first job working in Probation as a programmes facilitator, delivering groupwork sessions to offenders serving sentences in the community. I was seconded to work in a Category B men’s prison for a year and a half as part of the ‘Through The Gate’ project to help support prisoners in their resettlement following release, before returning to the community as probation service officer.
My experience working in prison and probation was key when I started my first job as a Researcher at the University of Manchester in 2018 investigating suicide and self-harm in the criminal justice system. I have now started training as a Forensic Psychologist in the women’s prison estate.”
- Fazel S, Grann M, Kling B, Hawton K. Prison suicide in 12 countries: an ecological study of 861 suicides during 2003-2007. Social psychiatry and psychiatric epidemiology. 2011; 46:191–195. doi: 10.1007/s00127-010-0184-4
- Ministry of Justice. A review of self-inflicted deaths in prison custody in 2016. London: Ministry of Justice; 2018.
- HM Government. Preventing suicide in England: fourth progress report of the cross-government outcomes strategy to save lives. London: HM Government; 2019.
- Pratt, D.; Tarrier, Nicholas; Dunn, G.; Awenat, Y.; Shaw, J.; Ulph, F.; Gooding, P. Cognitive-behavioural suicide prevention for male prisoners : A pilot randomized controlled trial. Psychological Medicine. 2015; 45(16): 3441-3451. doi: 10.1017/S0033291715001348
- Brown GK, Ten Have T, Henriques GR, Xie SX, Hollander JE, Beck AT. Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. Journal of the American Medical Association. 2005; 294:563–570. doi: 10.1001/jama.294.5.563
- Slee N, Garnefski N, van der Leeden R, Arensman E, Spinhoven P. Cognitive-behavioural intervention for self-harm: randomised controlled trial. British Journal of Psychiatry. 2008; 192:202–211. doi: 10.1192/bjp.bp.107.037564
- Tarrier N, Kelly J, Maqsood S, Snelson N, Maxwell J, Law H, Dunn G, Gooding P. The cognitive behavioural prevention of suicide in psychosis: a clinical trial. Schizophrenia Research. 2014; 156:204–210. doi: 10.1016/j.schres.2014.04.029
- Davidson K, Norrie J, Tyrer P, Gumley A, Tata P, Murray H, Palmer S. The effectiveness of cognitive behavior therapy for borderline personality disorder: results from the borderline personality disorder study of cognitive therapy (BOSCOT) trial. Journal of Personality Disorders. 2006; 20:450–465. doi: 10.1521/pedi.2006.20.5.450
- Morley KC, Sitharthan G, Haber PS, Tucker P, Sitharthan T. The efficacy of an opportunistic cognitive behavioral intervention package (OCB) on substance use and comorbid suicide risk: a multisite randomized controlled trial. Journal of Consulting and Clinical Psychology. 2014; 82:130–140. doi: 10.1037/a0035310
- Black G, Forrester A, Wilks M, Riaz M, Maguire H, Carlin P. Using initiative to provide clinical intervention groups in prison: a process evaluation. International Review of Psychiatry. 2011; 23:70–76. doi: 10.3109/09540261.2010.544293
- Dalton R, Majoy S, Sharkey M. Nonattenders and attrition from a forensic psychology outpatient service. International Journal of Offender Therapy and Comparative Criminology. 1998; 42:174–180. doi: 10.1177/0306624X9804200209
- Gondolf EW, Foster RA. Pre-program attrition in batterer programs. Journal of Family Violence. 1991; 6:337–349
- Butler AM, Malone K. Attempted suicide v. non-suicidal self-injury: behaviour, syndrome or diagnosis? British Journal of Psychiatry. Cambridge University Press; 2013;202(5):324–5. doi: 10.1192/bjp.bp.112.113506