Michelle: In a single year in Scotland, nearly 2,000 people entering prison were immediately flagged by nurses as being a high suicide risk. Mark: Wow, that’s a huge number. Michelle: It is. But here’s the twist that caught my attention: within 24 hours, after an assessment by a doctor, over 80% of them—more than 1,600 people—were deemed to be fine and were taken off all special supervision. Mark: Hold on. 80 percent? That feels like a massive disconnect. What is going on there? Is the first person overreacting or is the second person missing something critical? Michelle: That is the central mystery. And this whole puzzle comes from a really specific but influential 1997 paper called 'Characteristics and management of prisoners at risk of suicide behaviour' by Kevin George Power and Eleanor Moodie. Mark: Right, and this wasn't some bestseller you'd find at the airport. It was a deep-dive academic study for forensic psychologists and prison staff. The authors were trying to build a data-driven picture to solve a life-or-death problem inside the Scottish prison system. Michelle: Exactly. And to understand why that 80% number is so jarring, you have to go back in time and see what "prevention" used to look like. It was, in a word, brutal.

Mark: Brutal how? What were they doing? Michelle: They were using something called a 'strip cell'. The book gives this incredibly vivid description from an earlier report. Picture this: a bare stone cell, often with no natural light. Inside, there's nothing but a mattress on the floor and a single terylene blanket. Mark: Terylene? Like, a synthetic, fire-proof material? Michelle: Precisely. The prisoner has to wear clothes made of the same stuff. They have no personal possessions. No books, no radio, nothing for intellectual or social stimulation. Sometimes, the only other piece of furniture is a cardboard chair. And a prison officer observes them through a hatch every 15 minutes. Mark: That sounds less like care and more like… sensory deprivation. How long would someone be in a cell like that? Michelle: That’s the most shocking part. The study references an official inquiry into a Scottish young offenders institution, HM Glenochil, back in the 80s. They had a formal policy called Strict Suicidal Observation, or SSO, which was exactly this. In one year, they put over 160 young inmates through it. The average stay was a few days, but some were in there for over a month. Four inmates were kept in that state for more than nine months. Mark: Nine months? Just sitting in an empty room, being watched? That’s unbelievable. I mean, I get the logic—you can't harm yourself if you have nothing to harm yourself with. But at what point does the 'cure' become its own form of torture? Michelle: That is the exact ethical tightrope. The institution's goal was, and I'm quoting the official report here, to 'ensure that no further deaths occurred either by accident or design.' It was a purely physical solution to a deeply psychological problem. Mark: But wait, let me play devil's advocate for a second. If it stopped them from dying right then and there, wasn't it, on some level, working? Michelle: In the most immediate, technical sense, perhaps. But the study, and the broader field of psychology, argues that this approach is profoundly damaging. You're taking someone who is already feeling isolated, hopeless, and dehumanized, and you're placing them in an environment that amplifies every single one of those feelings. The argument is that while you might prevent a death on Tuesday, you could be dramatically increasing the risk of one a month later by stripping away their last shreds of dignity and human connection. Mark: It’s the ultimate paradox of prevention. You’re so focused on stopping the physical act that you might be cementing the psychological state that causes it in the first place. Michelle: Exactly. The system eventually recognized that this extreme, one-size-fits-all approach was a disaster. So they tried to create a more nuanced, tiered system for managing risk… which, funnily enough, brings us right back to that bizarre 80% statistic from the start.

Mark: Okay, so they moved on from the strip cell. What did the new system look like? Michelle: The Scottish Prison Service developed a three-tiered strategy. At the top, you have Strict Suicide Supervision, or SSS. This is for immediate, very high-risk individuals. It's a bit like the old model, but in a hospital setting with more staff engagement. Then there's Intermediate Suicide Supervision, ISS, which is a step-down. And finally, Basic Suicide Supervision, BSS, which is for people with a history of crisis who just need extra monitoring, maybe checked on once an hour. Mark: That sounds much more reasonable. A tiered response. So where does the 80% problem come in? Michelle: It comes from the procedure at the prison's front door. When a new inmate arrives, they are screened by a Nurse Officer. The rule at the time of the study was that if the nurse identified any potential risk—based on the inmate's history or how they were acting—they had no discretion. They had to place that person on the highest level, SSS, until a Medical Officer could do a full assessment, usually the next day. Mark: Ah, I see. So the nurse is basically forced to hit the big red emergency button every single time, and the doctor is the one who comes in later to decide if it's a real fire or just a bit of smoke. Michelle: A perfect analogy. And in 81% of cases, the doctor comes in and says, "False alarm. Turn off the siren. This person can go back to the general population." Mark: That’s wild. So what’s the core of the disagreement? What is the nurse seeing that the doctor isn't, or what is the doctor weighing that the nurse isn't? Michelle: This is the most fascinating part of the study. The authors dug into the data to find out. It seems to come down to two different types of information: present state versus past history. The nurses at reception were often flagging people based on their immediate emotional state. The data shows the most common indicators they noted were prisoners appearing 'anxious,' 'depressed,' or 'withdrawn.' Mark: Which makes total sense. You’re being admitted to prison. I’d be shocked if you weren’t anxious and depressed. Michelle: Exactly. The doctors, however, seem to have been weighing the inmate's background characteristics much more heavily. The study found a powerful statistical link between the number of background risk indicators and the likelihood of being kept on supervision. Mark: What kind of background indicators? Michelle: Things like a history of previous suicide attempts, a record of psychiatric treatment, past drug or alcohol misuse, or expecting little contact with family. The study found that the more of these boxes an inmate ticked, the more likely the doctor was to keep them on supervision, and at a higher level. Someone with four of these background factors was far more likely to stay on SSS than someone with just one, even if they both seemed equally depressed at reception. Mark: So the nurse is reacting to the immediate emotional weather, but the doctor is looking at the long-term climate forecast based on historical data. Michelle: That's it. And the study points out this runs counter to our intuition. You'd think the person crying and talking about suicide right now is the highest risk. But the system's final decision seems to be more influenced by the scars of their past.

Mark: What a mess. The old way of just locking someone in a bare room was inhumane and probably counter-productive. But the new, more "enlightened" system has this massive 80% false positive rate, which means you're flooding the system with emergency alerts and potentially misallocating resources. Michelle: It really highlights the core problem. The study concludes that trying to predict suicide with a simple checklist of risk factors is basically a fool's errand. The authors state that individual risk factors are only weakly predictive. Mark: It’s like trying to predict an earthquake. You know the risk factors—you can see the fault lines on a map, you know the history of seismic activity—but you can never, ever say with certainty that a quake is going to happen next Tuesday at 3 PM. There are just too many variables. Michelle: That’s a fantastic way to put it. And the study shows that because so many prisoners have these risk factors, a checklist approach just flags a huge portion of the population, making it unworkable. The authors argue the focus shouldn't be on refining the checklist, but on identifying specific vulnerabilities and, crucially, a person's coping abilities in that moment. Mark: So it’s less about a formula and more about clinical, human judgment. Michelle: Precisely. And the research had a real-world impact. The paper notes that following the study, the Scottish Prison Service changed its procedure. They gave Nurse Officers the discretion to place inmates on different levels of supervision—SSS, ISS, or BSS—from the very beginning, based on their professional judgment. Mark: That makes so much more sense. They empowered the person on the front line to make a more nuanced call instead of just hitting the one emergency button they had. Michelle: It’s a move away from a rigid, fear-based protocol towards a more flexible, trust-based one. The ultimate takeaway is that in these high-stakes environments, a system built purely on preventing the worst-case physical outcome can inadvertently create the very psychological conditions it’s trying to avoid. Mark: Wow. It really makes you wonder, in any system designed to help—whether it's in a prison, a hospital, or even a company—how often does our fear of the worst-case scenario lead us to create conditions that make that outcome even more likely? Michelle: That is the question that sits at the heart of this entire study. It’s a powerful reminder that sometimes the most humane approach is also the most effective. Mark: This is Aibrary, signing off.