Problem Solving and Suicidality Among Prison Inmates - APA PsycNET

Journal of Consulting and Clinical Psychology 1992, Vol. 60, No. 6,970-973

Copyright 1992 by the American Psychological Association, Inc. 0022-006X/92/$3.00

Problem Solving and Suicidality Among Prison Inmates: Another Look at State Versus Trait Nancy J. Smyth

Andre Ivanoff Columbia University School of Social Work

School of Social Work State University of New York at Buffalo

Sandra Grochowski

This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Albert Einstein College of Medicine / Bronx Psychiatric Center

Sung Joon Jang

Department of Sociology Ohio State University

Kenneth E. Klein Bureau of Forensic Services, New York State Office of Mental Health, Downstate Correctional Facility, Fishkill, New York This research examines the relationships between means-ends problem solving and suicidality among adult male prison inmates in light of new evidence based on inpatient and college student populations suggesting that state, rather than trait, vulnerabilities may be responsible for problemsolving deficits and differences. Using the Means-Ends Problem-Solving Procedure (MEPS) with 93 state prison inmates, we found that among inmates with a history of parasuicide, current suicidality did not affect problem-solving performance. We further found that among nonsuicidal inmates, parasuicide history had no effect on problem solving or affect-suicidality measures. Although these results support new research suggesting that trait problem-solving deficits are not causally linked to suicidality, they raise questions about the potentially unique relationships among suicidality, problem solving, depression, and hopelessness in incarcerated populations.

Over the past decade the relationship between problem solving skill deficits and suicidal behavior has been widely demonstrated across clinical and nonclinical samples (Goodstein, 1982; Linehan, Camper, Chiles, Strosahl, & Shearin, 1981; Schotte & Clum, 1982,1987). Using the Means-Ends ProblemSolving Procedure (MEPS; Platt, Spivak, & Bloom, 1971) and a variety of original and modified scoring methods, researchers have found consistent differences between suicidal and nonsuicidal groups. Most recently, Schotte, Cools, and Payvar (1990) found problem-solving deficits were a concomitant, rather than a cause, of suicidal intent, depression, and hopelessness. This contradicts Schotte and Clum's (1982, 1987) widely regarded stress-diathesis model, which posits problem-solving deficits as a predisposing trait vulnerability to suicidality. In the present study we explored problem solving and suicidality among male prison inmates and extended previous research into state versus trait differences by examining the effects of parasuicide history among suicidal and nonsuicidal inmates on interpersonal problem solving and standard affective and suicidality measures. We tested two hypotheses. The

first was whether parasuicide history would have an impact on problem-solving performance among currently suicidal and currently nonsuicidal inmates. The second was whether, among currently nonsuicidal inmates, history of parasuicide would have an effect on problem-solving or mood measures. Although poor problem-solving skills have been identified as a characteristic of incarcerated offenders (Zamble & Porporino, 1988), studies that have systematically compared the problem-solving skills of offender and nonoffender populations have found no significant differences between them (Grier, 1988; Ingram, Dixon, & Glover, 1983). Previous work on problem solving and suicidality has been conducted with college students and psychiatric inpatients. Relative to other studies of suicidality and problem solving, a comparison between the present study on prison inmates and previous studies on college students and inpatients is difficult to make because the inpatient samples in other studies ranged from almost all schizophrenics to almost all major affective disorders (arguably comparable groups). It is reasonable to assume that there are differences in the problem-solving abilities of prison inmates and psychiatric inpatients and college students; however, there is very little published literature on problem solving among prison inmates. The best research to date on suicidal behavior in inmate populations is largely qualitative (Toch, 1975); preliminary quantitative data suggest that the characteristics and interactions associated with suicidal behavior—that is, ideation and parasuicide—among prison inmates are similar to those described in nonprison psychiatric inpatient samples (Ivanoff, in press; Ivanoff & Jang, 1991; Zamble & Porporino, 1988).

Support for this project was provided in part by the New "Vbrk State Office of Mental Health's Bureau of Forensic Services and by the New York State Department of Correctional Services. We wish to thank Joel A. Dvoskin and Karl Gohlke for agency auspice and support and Marsha M. Linehan for comments on an earlier draft of this article. Correspondence concerning this article should be addressed to Andre Ivanoff, Columbia University School of Social Work, 622 West 113th Street, New York, New York 10025. 970

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PROBLEM SOLVING AND SUICIDALITY

Method


Subjects Participants were 93 male (mean age = 31.14 years) inmates of the New York State prison system incarcerated at a central classification facility and serving a minimum state sentence of more than 1 year (M= 43.9 months) for crimes representing the spectrum of felony offenses. The sample was 25.8% Black, 36.6% Latino-Hispanic, 33.3% White, and 4.3% Other. The mean education level was above eighth grade but less than high school equivalent. Primary diagnoses at classification included 47 psychoactive substance abuse, 13 major affective disorder, 15 schizophrenic and psychotic disorder, 15 V code, and 33 adjustment disorder (these total more than 93 because psychoactive substance abuse was identified as a second Axis I diagnosis in 30 cases). Diagnoses were made by four forensic mental health professionals during the standard classification process. These professionals work full time in the prison for an independent state mental health agency. Classification diagnoses, equivalent to admitting diagnoses, are used for treatment instigation and to recommend the appropriate level of mental health care an inmate will need in his permanent facility. Inmates were categorized into two groups: those with a parasuicide history and those without. There were no significant differences between groups on age, race, education, or diagnostic distribution. Subjects were identified as suicidal if they self-reported suicidal ideation within the past 2 weeks in response to questions on the Prison Suicidal Behaviors Interview (PSBI; Ivanoff & Jang, 1991).

Measures Measures included the Beck Depression Inventory (BDI; Beck, Ward, Mendelsohn, Mock, & Erbaugh, 1961), the Beck Hopelessness Scale (BHS; Beck, Weissman, Lester, & Trexler, 1974), and the PSBI (Ivanoff & Jang, 1991). The PSBI, an adaptation of the Suicidal Behaviors Interview (SBI; Linehan & Nielsen, 1981), is a structured clinical interview that measures a wide range of behavior related to suicidality. For this study, individual items measuring history of parasuicide, recency of suicidal behaviors, and personal coping expectancies were used. Neither the SBI nor the PSBI has any scaled scores. The MEPS was used to assess interpersonal problem solving (Platt et al., 1971). Stories were scored on relevant means, irrelevant means, no means, no responses, and enumerations. According to Platt and Spivack (1975), and consistent with other recent usage (Linehan et al., 1981; Schotte & Clum, 1987; Schotte et al., 1990), a subset of stories was selected. Six stories, Numbers 2, 4, 6, 7, 9, and 10, were selected as a means of reducing testing time for subjects. Audiotape stimulus and response procedures were used. Interrater reliability for the five MEPS scores ranged from .88 to .98. All data were collected in a 3-hr interview conducted by trained clinical research staff. Independence of administration was assured by conducting the PSBI prior to the audiotaped MEPS so that MEPS performance would not affect PSBI administration. Blind scoring procedures were also used so that MEPS raters were unaware of PSBI performance and vice versa.

Results Four separate multivariate analyses of variance (M ANOVA) were conducted to investigate the trait versus state hypotheses of problem-solving skills and affective-suicidality measures. MANOVA were selected because of the intercorrelations among the measures of suicidality and among the measures derived from the MEPS (relevant means, enumerations, irrelevant means, no means, and no responses). The first two analyses examined state effects among subjects positive for the trait,

that is, with a parasuicide history. In the first MANOVA total scores on the BDI, the BHS, and personal coping expectancies served as dependent variables and suicidality (currently suicidal or not currently suicidal) as the independent variable among subjects with a parasuicide history (see Table 1). As expected, the results of this analysis revealed a significant effect for current suicidality, Wilks's X(3,44) = 12.09, p < .001. Currently suicidal subjects scored higher on affective-suicidality measures despite sharing the common trait of parasuicide history Subsequent analyses of variance were then conducted to test for differences on each of the individual measures between those currently suicidal and those not suicidal. These analyses revealed significant effects for current suicidality among those with a history of parasuicide on the following variables: BDI, F(l, 46) = 30.43, p < .001; BHS, F(l, 46) = 23.08, p < .001; and personal coping expectancies, F(l, 46) = 7.53, p < .01. Given these differences on affective and suicidality measures among currently suicidal and nonsuicidal subjects, the next step was to determine if there were concomitant differences in the MEPS measures between the same groups. MEPS performance scores (relevant means, enumerations, irrelevant means, no means, no responses) were used as dependent variables, and the presence or absence of current suicidality among those with a parasuicide history was the independent variable. This MANOVA failed to yield a significant main effect for current suicidality among the parasuicide history group, Wilks's X(5, 42) = 1.60, on problem-solving ability. The results of these analyses suggest no difference in problem-solving performance between currently suicidal and nonsuicidal subjects with a parasuicide history. The second set of two MANOVAs, investigating trait effects, examined the effect parasuicide history had on the BDI, the BHS, coping expectancies, and the MEPS for all subjects who were not currently suicidal. The first MANOVA, which used the BDI, the BHS, and the coping expectancies affective-suicidality variables as dependent variables and parasuicide history as the independent variable, failed to yield a main effect for parasuicide history, Wilks's A(3,37) = 0.89. The second MANOVA, which used problem-solving measures as the independent variables and parasuicide history as the dependent variable, again also failed to yield a main effect for group, Wilks's X(5, 71) = 2.11. The results of these analyses suggest no difference on affective-suicidality or problem solving measures among currently nonsuicidal inmates with and without parasuicide histories.

Discussion Consistent with Schotte et al.'s (1990) psychiatric inpatient results and contrary to the stress-diathesis model, these findings suggest that problem-solving deficits do not predispose male inmates under stress to depression, hopelessness, and suicidal ideation. We also found that parasuicide history does not have an effect on current problem-solving performance. However, unlike other studies in this area based on psychiatric inpatient and college student populations, we found no significant differences in problem-solving performance between inmates who were currently suicidal and those who were not currently suicidal. Scores on measures of affect and suicidality were con-

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IVANOFE. SMYTH, GROCHOWSKI, JANG, KLEIN

Table 1 Mean Scores and Standard Deviations for Subjects With and Without a History of Parasuicide History of parasuicide


Currently suicidal3

Not currently suicidal6

No history of parasuicide Not currently suicidal'

Measure

M

SD

M

SD

M

SD

BDI BHS Perceived coping ability MEPS Relevant means Enumerations Irrelevant means No means No responses

30.64 9.50

10.65 6.11

15.21 3.21

7.98 3.00

12.81 2.86

8.36 3.26

1.87

1.05

3.21

1.68

3.65

1.54

0.18 0.11 0.64 0.38 0.44

.29 .14 .36 .26 .52

0.36 0.30 0.95 0.60 0.50

.53 .42 .45 .54 .80

0.21 0.22 0.86 0.60 0.19

.28 .47 .59 .46 .30

Note. BDI = Beck Depression Inventory; BHS = Beck Hopelessness Scale; MEPS = Means-Ends Problem-Solving Procedure. a n = 1 4 . " « = 3 4 . c n = 43.

sistent with those of suicidal and nonsuicidal groups reported in studies of other populations. There are two primary differences between this study and Schotte et al.'s (1990) that might account for our lack of support for their alternative state hypothesis about the relationship between problem solving and suicidality. The first is that the inmate subjects in the present study were receiving the standard equivalent of outpatient mental health services within the prison system, that is, they were not residing in restrictive or segregated housing, whereas Schotte et al.'s (1990) subjects (as well as psychiatric subjects in several other studies) were acute or chronic inpatients, with potentially higher levels of distress. Although depression scores were comparable across the two studies, hopelessness scores were somewhat lower in this outpatient inmate sample. It is possible that distress must reach a particular degree of severity before problem-solving skills are impaired. Second, in this study we examined differences between subjects, whereas Schotte et al. (1990) measured the same subjects on two different occasions. It may be that subjects in the present study would also show an increase in problem-solving skills if retested in 1 month; this would be consistent with research that found increased levels of distress in most inmates when they entered prison (Zamble & Porporino, 1988). Little is known about the differences in problem solving between incarcerated offenders and the general population. Previous work on problem solving and suicidality has been conducted with college students and psychiatric inpatients, predominantly schizophrenics, and normative performance scores were not used as a basis for comparison. Given that these prison inmates were less educated than college students and Schotte et al.'s (1990) psychiatric inpatients, one would expect to find the inmates performing more poorly on problem solving on this basis alone. By virtue of their status, inmates manifest higher current social dysfunction; however, the relationships among maladaptive social support, lifetime lower socioeconomic status, higher rates of unemployment, problem solving, and suicidality have not been systematically examined. Psy-

chiatrically, this sample must be considered less acutely disordered than the inpatient samples studied because they had not been housed in special psychiatric units or placed in segregated housing for suicide watch. Diagnostically, the sample used in this article represents a broad spectrum of diagnoses, although generally less severe ones than the diagnoses reported in other studies. The overall prevalence of substance abuse was estimated at over 90% in this population (New York State Department of Correctional Services, 1991), which suggests that this concomitant may also warrant independent examination. Preliminary studies of suicidal behavior among prison inmates suggest similarities with general inpatient samples on social desirability and some psychosocial measures but marked differences on other measures (Ivanoff, in press; Ivanoff & Jang, 1991). Finally, another possibility that must be considered concerns the validity of the MEPS and other measures for use with this population. The MEPS was not developed or standardized for incarcerated offenders, and despite its wide use with other populations, published work on its use with incarcerated offenders is limited (Higgins & Thies, 1982; Platt, Scura, & Hannon, 1973). It is possible that poor problem solving is associated with suicidality in incarcerated offenders and that no differences were detected in this study because the MEPS is not sensitive enough to pick up differences between two groups of poor inmate problem solvers. It is also possible that the very low scores in this study (relative to those in Schotte et al.'s, 1990, study) on MEPS relevant means and irrelevant means reflect a floor effect. Given the lack of other prior research or data from the present study related to the issue of MEPS validity in this population, these possibilities cannot be ruled out. Finally, the modifications to administration and the idiosyncratic computational schemes that characterize many studies of problem solving and suicidality further limit the generalizability of results from one population to another. The role of problem-solving deficits in suicidal behavior is far from understood. Similarly, the degree to which suicidality in


PROBLEM SOLVING AND SUICIDALITY incarcerated offenders parallels that in nonoffenders is only beginning to be explored. Recent work suggests that the role of problem-solving deficits in suicidal behavior may be more complex and interactive than dichotomous—that is, neither state nor trait. However, what these results most importantly suggest is that there may be a unique and complex set of relationships that explain the relationship between problem solving and suicidality among inmate populations. This study is one of the first to examine problem solving and its relationship to suicidality among prisoners. Further research on this topic is sorely needed with this population; parasuicide rates in New York's state prisons are estimated at between 2,200 and 3,760 per 100,000 inmates (Toch, 1975). Across populations, research is needed to specify the level of suicidality associated with impaired problem solving; the population differences that may account for these differences demand closer inspection. References Beck, A. X, Ward, C. H., Mendelsohn, M., Mock, 1, & Erbaugh, I. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561-571. Beck, A., Weissman, A., Lester, D., & Trexler, L. (1974). The measurement of pessimism: The Hopelessness Scale. Journal of Consulting and Clinical Psychology, 42, 861-865. Goodstein, J. (1982). Cognitive characteristics of suicide attempters. Unpublished doctoral dissertation, Catholic University of America. Grier, P. E. (1988). Cognitive problem-solving skills in antisocial rapists. Criminal Justice and Behavior, 15, 501-504. Higgins, J. P., & Thies, A. P. (1982). Social effectiveness and problemsolving thinking of reformatory inmates. Journal of Offender Counseling, Services, & Rehabilitation, 5, 93-98. Ingram, J. C., Dixon, D. N, &Glover, J. A. (1983). Problem-solving as a function of race and incarceration. Journal of Social Psychology, 120, 83-90. Ivanoff, A. (in press). Characteristics associated with parasuicide among male prison inmates I: Background characteristics. Journal of Criminal Justice and Behavior.

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Ivanoff, A., & Jang, S. J. (1991). The role of hopelessness and social desirability in predicting suicidal behavior: A study of prison inmates. Journal of Consulting and Clinical Psychology, 59, 394-399. Linehan, M., Camper, P., Chiles, J., Strosahl, K., &Shearin, E. (1981). Interpersonal problem-solving and parasuicide. Cognitive Therapy and Research, 11,1-12. Linehan, M. M., & Nielsen, S. L. (1981). Assessment of suicide ideation and parasuicide: Hopelessness and social desirability. Journal of Consulting and Clinical Psychology, 49, 773-775. New \brk State Department of Correctional Services. (1991). Executive summary of New York State Correctional Services. Albany, NY: New York State Department of Correctional Services. Platt, J., Scura, W, & Hannon, J. (1973). Problem-solving thinking of youthful incarcerated heroin addicts. Journal of Community Psychology, J, 278-281. Platt, J., & Spivack, G. (1975). Unidimensionality of the Means-End Problem-Solving Procedure (MEPS). Journal of Clinical Psychology, 31,15-16. Platt, J., Spivack, G, & Bloom, M. (1971). Means-Ends Problem-Solving Procedure (MEPS): Manual and tentative norms. Philadelphia: Hahnemann Medical College and Hospital. Schotte, D. E., & Clum, G. (1982). Suicide ideation in a college population: A test ofa model. Journal of Consulting and Clinical Psychology, 50, 690-696. Schotte, D. E., & Clum, G. A. (1987). Problem-solving skills in suicidal psychiatric patients. Journal of Consulting and Clinical Psychology, 55, 49-54. Schotte, D. E., Cools, J., & Pay var, S. (1990). Problem-solving deficits in suicidal patients: Trait vulnerability or state phenomenon? Journal of Consulting and Clinical Psychology, 58, 562-564. Toch, H. (1975). Men in crisis: Human breakdowns in prison. Chicago: Aldine. Zamble, E., & Porporino, F. J. (1988). Coping, behavior, and adaptation in prison inmates. New York: Springer-Verlag. Received September 25,1991 Revision received February 20,1992 Accepted May 26,1992 •