Suicide prevention in prisons: "Feeling useful saved me"

“I wasn't even crying, I was tense, with my eyes wide, checking everything, they were very difficult moments”. This is how Esther remembers her immediate entry into jail for a crime to which a desperate financial situation led her. Today, from outside, she appreciates the advice of the psychologist who -as is the norm- visited her the next day. “Don't worry about the years you have left, worry about the day to day.”

When the doors closed behind her, Esther -name assumed to guarantee her anonymity- found herself immersed in a universe that in Spain made up some 56,000 inmates at the end of 2022. Where, regardless of the seriousness of the crimes, the protection of health corresponds to the central State, except in Catalonia and the Basque Country, which have jurisdiction over penitentiary matters.

Esther defines herself as “a disciplined person who knows how to be alone”. And that, he says, helped him get ahead.. some can't. According to Penitentiary Institutions, which depends on the Ministry of the Interior, 33 inmates took their lives in prisons in 2022. To these must be added 14 in Catalonia and one in the Basque Country. It is estimated that the suicide rate in inmates is about six times higher than that of the general population.

Suicide, experts agree, is due to a combination of factors that aggravate the deprivation of liberty. “Prison can be the trigger: the risk factors that a person brings are added to being locked up, to the crime, to the feeling of guilt, to being uprooted,” explains José Joaquín Antón Basanta, who has more than 30 years of experience as a prison doctor. and president of the Spanish Society of Penitentiary Health.

What are those prior risk factors? Juan Martínez Pérez, deputy medical director of the Almería prison, reviews them – El Acebuche. “The most common is dual pathology, the mixture of a mental illness with an addiction, and it is difficult to know what has happened before. Among the personality disorders, the highest frequency is presented by psychotics, schizophrenia, bipolar “.

Esther, who made progress in reintegration with the Prolibertas Foundation, had not tried the drug and did not seek refuge in it. He made his training a protective factor. “I start giving literacy classes, that's half my life, feeling useful was wonderful, it saved me, I didn't have a free moment”. A vision ratified by sources from Penitentiary Institutions. “Time transforms, it falls on you, you have to look for spaces to abstract yourself”. Hence the importance, they point out, of occupational, productive, sports or therapeutic activities. But that option is still minority. For many, even if alternatives are offered, confinement is equivalent to a cell and a patio, tedium and waiting.

As in prison, suicidal ideation in prison is not only related to mental health. Esther went into crisis when she was transferred to a module considered very dangerous. “I did nothing but cry, a horrible stress, I was hysterical lost”. He retained, however, his hold on life. “If they had taken away my school, I don't know if I would have endured it”. There are various circumstances in which vigilance over the inmates' mood is reinforced: admission, a change like the one she experienced, the trial, the sentence, the awareness of a serious crime, a sentimental breakup, the death of a loved one. Some convicted of media crimes endure special pressure. In an environment that they did not imagine and feeling the rejection around them.

“They gave me a girl for a week,” says Esther. It was “an accompaniment”, a first measure of assistance and surveillance. The next step, which she did not reach, is inclusion in the Suicide Prevention Program (PPS). It includes, among other measures, the assignment of a support inmate who can spend up to 24 hours with the person at risk.

Penitentiary Institutions estimate the current number of support inmates at 1,577, try to make them represent between 2% and 3% of the modules where they are needed. María Rodríguez Lago, head of the Penitentiary Intervention Program of the Érguete Foundation, has trained some 230 in prisons in Galicia in a decade. They receive “a preparation in personal skills to carry out this task in the most assertive, empathetic and human way possible”. His 346 hours of learning are reflected in a psychiatric assistant qualification that improves his job placement.

“It is a very tough task and with great solidarity,” Rodríguez Lago highlights those “guardian angels” whose functions are “to be vigilant, care, prevent, and alert.”. It is not easy; they are also supported. Those accompanied sometimes do not wash, do not eat or are violent. But even in his disorder, he concludes, lies a routine. “When something changes, the first alarm goes off. The slightest change in behavior, the slightest unusual gesture is a sign of attention.”. And the support inmate is going to transmit it in the network made up of the doctor, the psychologist, the educator and the social worker. Added to this is the surveillance of officials, especially in the specific modules for psychiatric patients.

Without having performed that role, Esther noticed how a classmate was sliding down the slope.. “It's the look, there are a thousand things, the manners, I was reading him the primer until his daughters managed to arrive; as soon as they brought them, he pulled up”. Foreign visits and work with the family are part of this Prevention Program, which is evaluated periodically. It also includes medical consultations and personalized attention. “Always being accompanied, contact with the doctor, the psychologist, some antidepressant, helps to make it more difficult to take the step,” analyzes Dr. Antón Basanta. “When the risk of suicide is detected, it is usually possible to avoid it; the problem is that it is not always possible to detect it”.

As president of the Spanish Society of Penitentiary Health (SESP), he denounces the deterioration of care in prisons. A competence that the Ministry of the Interior maintains because, despite what was legislated 20 years ago, it has only assumed it -in addition to Catalonia and the Basque Country- Navarra. The last opposition in the rest of Spain covered a tenth of the places due to low salary and lack of professional prospects compared to civil health. Sources from Penitentiary Institutions admit that the transfer “would greatly improve the work” and urge the communities to make it effective.

In this limbo, the medical staff dwindles and the service suffers even though the Interior reinforces it with external services. As “a disaster” Esther describes the medical care in prison that she experienced. For Jorge Vilas, head of CSIF Prisons, “infirmaries have become undercover psychiatric hospitals”. His union demands more psychiatric prisons -there are two-, more staff and that the communities give access to the medical records of the inmates. “With two surveillance officers for 130/140 inmates it is impossible, sometimes we have an incident with an inmate with mental illness and we don't find out until it breaks out.”

Vilas also alludes to the drugs, administered by each prison. “Since we do not have enough staff, on Friday the medication for the weekend is distributed and marketing is generated”. This dealing between inmates with addictions sometimes leads to self-harm to obtain more drugs. Episodes that complicate the prevention of suicidal ideation and which sources from Penitentiary Institutions do not minimize importance. “An autolytic behavior can inadvertently lead to suicide,” they explain. José Joaquín Antón Basanta admits that these behaviors have decreased and recognizes the effort from the national coordination to reduce the prescription of medicines despite the pressure from the inmates.

Both he and Dr. Martínez Pérez, deputy medical director at Almería – El Acebuche, agree that, despite the above, medication is necessary. “Anxiety and depression, and also addictions, must be treated,” says the latter. Your balance is more positive. Believe that adequate psychiatric care is possible and observe an improvement in the treatment of addictions. “Substance use is reduced, the disruption that inmates can have is alleviated because there is a routine, individualized attention is important,” he says.

María Rodríguez Lago, from the Érguets Foundation, declares herself “idealistic” when asking that all officials and inmates receive basic notions in mental health and first aid “because the only thing that saves a person is that those of us around us know”. Jorge Vilas, head of CSIF Prisons, also requires this training, which, he says, does not come. “To prevent you have to invest, prisons cannot be considered an expense, the Constitution says that we are here to re-educate and reintegrate”. An objective, reintegration, which is signed by Penitentiary Institutions. After her time in prison, and with the reception of the Prolibertas Foundation, Esther opens a new phase. “There are bad days, good days, I see hope”.