Escalation of Suicidal Spectrum Behaviors During Incarceration

• Author: Sajida Yasmeen,Jeffrey B. Stuewig,John S. Wilson,June P. Tangney,Shannon W. Schrader,Jennifer M. Loya,Sharen E. Barboza,Diane Berry,Abigail Wiser
• DOI: http://doi.org/10.1177/00938548231162109
• Published date: 01 May 2023
• Date: 01 May 2023

CRIMINAL JUSTICE AND BEHAVIOR, 2023, Vol. 50, No. 5, May 2023, 766 –782.

DOI: https://doi.org/10.1177/00938548231162109

Article reuse guidelines: sagepub.com/journals-permissions

© 2023 International Association for Correctional and Forensic Psychology

766

ESCALATION OF SUICIDAL SPECTRUM

BEHAVIORS DURING INCARCERATION

SAJIDA YASMEEN

JEFFREY B. STUEWIG

George Mason University

JOHN S. WILSON

Centurion

JUNE P. TANGNEY

George Mason University

SHANNON W. SCHRADER

JENNIFER M. LOYA

Yale School of Medicine

SHAREN E. BARBOZA

Barboza Consulting, LLC

DIANE BERRY

Centurion

ABIGAIL WISER

George Mason University

Rates of multiple episodes of suicide spectrum behaviors are higher among incarcerated individuals than community mem-

bers. Understanding the trajectory of multiple episodes of suicide spectrum behavior is important for assessment of risk and

precautionary measures. We examined escalation in terms of frequency and method among 204 incarcerated individuals who

engaged in multiple episodes of serious self-harm. Among those who did not die (n = 191), the interval between suicide

spectrum behaviors decreased across incidents and incidents became potentially more lethal over time. Findings indicate that

clinicians relying solely on intent to assess seriousness of self-harming behavior might overlook escalation risk. To effectively

prevent fatal incidents, clinicians and correctional staff working with incarcerated individuals should incorporate behavioral

measures (e.g., time between incidents and method used) and trend these measures over time.

Keywords: suicide spectrum behaviors; self-harm; escalation; suicide; multiple episodes

AUTHORS’ NOTE: This work was partially supported by funding from the National Institute on Drug Abuse

awarded to Shannon W. Schrader (Grant #1F31DA048589). Additional funding to support data analysis and

interpretation was provided by Centurion to GMU researchers through an ongoing academic affiliation. We

have no conflict of interest to disclose. Correspondence concerning this article should be addressed to Sajida

Yasmeen, Department of Psychology, George Mason University, 4400 University Drive, MSN3F5, Fairfax, VA

22030; e-mail: syasmeen@gmu.edu.

1162109CJBXXX10.1177/00938548231162109Criminal Justice and BehaviorYasmeen et al. / Escalation of Suicidal Spectrum Behaviors

research-article2023

Yasmeen et al. / ESCALATION OF SUICIDAL SPECTRUM BEHAVIORS 767

Suicide is a pressing problem in correctional settings. Incarcerated individuals1 engage in

a spectrum of suicidal behavior, including serious self-harm, suicide attempts, and death

by suicide occur at a substantially higher rate than people in the community (i.e., 49/100,000

in local jails, 25/100,000 in state prisons, and 22/100,000 in community; Carson, 2021b,

2021c). In local jails, suicide is the leading cause of preventable death, at 30% (Carson,

2021c; Wang & Sawyer, 2021). Given that approximately 12 million people cycle through

U.S. jails each year and 2.3 million people are currently incarcerated in correctional facili-

ties (Wang & Sawyer, 2021), it is imperative to better understand the trajectory of suicide

spectrum behaviors during incarceration to more effectively prevent death by suicide.

Among incarcerated individuals, multiple episodes of suicide spectrum behaviors are not

uncommon (Hakansson et al., 2011; Smith et al., 2014). Within individuals, do repeated epi-

sodes of self-harm/attempted suicide escalate, serving as an alarm bell for clinicians and cor-

rectional staff? Or are repeated episodes of self-harm stable in frequency and methods? We

empirically examine these questions in terms of frequency and lethality of method through

archival data gathered from the health records of people incarcerated in U.S. jails and prisons

who engaged in serious self-harm or attempted suicide at least twice while incarcerated. Our

primary analyses focus on people who survived multiple episodes of suicide spectrum behav-

ior. In addition, we include a description of the patterns observed among the minority of

people who died by suicide following more than one episode of suicide spectrum behavior.

TERMINOLOGY

We purposely chose the term “suicide spectrum behaviors” to reflect self-harming behav-

iors, ranging from nonsuicidal self-injury (NSSI) to non-lethal behavior that may (or may

not) be accompanied by suicidal intent to lethal self-injurious events—including deaths by

suicide and “accidental” self-inflicted deaths that may not have been intended to end in

death. This idea that a range of behaviors falls on a suicide spectrum is not new and has been

suggested by researchers in past (see O’Carroll et al., 1996; Ramsay & Bagley, 1985).

In adopting this term, we deliberately avoid inferring the individual’s ultimate intent and

focus on the behaviors themselves. We aim to assess whether self-injurious behaviors,

regardless of intent, elevated subsequent risk. From the perspective of risk management,

articulated or inferred intent may be less important than means and behavioral pattern (see,

for example, Brown et al., 2004; Dear et al., 2000; Prikola et al., 2003; Swahn & Potter,

2001). Those intent on suicide may deny it (e.g., Busch et al., 2003; Shea, 2002); con-

versely, most patients who report suicidal ideation do not act on it (e.g., Crosby et al., 2011;

Ivey-Stephenson et al., 2022; May & Victor, 2018). In short, what individuals may say

about their suicidal intent may not be the only measure of the risk and gravity of the behav-

iors (for a helpful discussion of this issue, see Bryan & Rudd, 2018). In addition, throughout

this article, we use the term “serious” to describe any suicide spectrum behavior which

required hospitalization or emergency-room care.

THE CASE FOR ESCALATION ACROSS MULTIPLE EPISODES OF SUICIDE

SPECTRUM BEHAVIORS

Borrowing from Beck (1996), Joiner (2002) argued that cognitive sensitization occurs as

a result of multiple suicide attempts because each attempt leads to more active and