Women in Prison

Definition

Self-injurious behavior is defined as “the deliberate destruction or alteration of body tissue without conscious suicidal intent” (Favazza, 1989, p. 137). It is often used interchangeably with other terms such as “intentional self-harm” (Sho et al., 2009), “deliberate self-harm” (Maden, Chamberlain, & Gunn, 2000), “self-wounding” (Tantam & Whittaker, 1992), “nonsuicidal self-injurious behavior” (Cheng, Mallinckrodt, Soet, & Sevig, 2010), and “self-mutilation” (Matsumoto et al., 2005). Behaviors include cutting, scratching, burning the skin, hitting oneself, hair pulling, and reopening of wounds (DeHart et al., 2009; Smith & Kaminski, 2011). Tattooing, piercing, self-starvation, alcohol, or drug abuse may result in body modification or injury but are not considered to be SIB (Lundh, Karim, & Quilisch, 2007). Although there is considerable overlap between a suicide attempt and SIB, the distinguishing feature is intent. In the case of suicide attempts, the act is lethal with the conscious intent to die. SIB tends to be a coping mechanism to relieve stress and gain control over one’s environment without conscious suicidal intent (Wichmann, Serin, & Abracen, 2002). Although SIB by definition consists of low lethality, there is always the potential, regardless of the intent, that the behavior becomes a fatal act (Young, Justice, & Erdberg, 2006).

Prevalence Rates

Abundant empirical support indicates that incarcerated women are at greater risk for SIB than women in the community or incarcerated men (Borrill et al., 2003; Gray et al., 2003; Klonsky, Oltmanns, & Turkheimer, 2003). Approximately 4% of the community population (18-90 years of age) has engaged in SIB in the previous 6 months (Briere & Gil, 1998). In a study of general population male prisoners, lifetime prevalence of deliberate self-harm was estimated to be 17% (Maden et al., 2000). Women prisoners reporting a history of SIB range from 32% to 51% (Borrill et al., 2003; Maden, 1994).

Risk Factors

Risk factors associated with SIB in correctional settings have been investigated to help determine which inmates are most likely to engage in SIB and under what circumstances. Background characteristics consistently linked to SIB include being Caucasian (Maden, et al., 2006), young, unmarried, having a family history of suicide and/or self-injury (Lloyd, 1999), and being female (Borrill et al., 2003).

A low level of perceived social support, defined as perceived availability and quality of close relationships from both intimate and diffuse social relationships (Cohen, Hammen, Henry, & Daley, 2004), has been found to be a risk factor for SIB (Castille et al., 2007). It is no surprise that lengthy prison sentences and the subsequent separation from one’s social support network at home contribute to high rates of SIB in inmates (Haines & Williams, 1997). Removing the minimal social support available within a prison environment has been shown to increase the risk of SIB. In a review of medical records of 67 inmates who engaged in SIB, 51% of the incidences occurred while the inmates were in punitive or restrictive housing units (Jones, 1986). This finding suggests that an absence of social support interferes with the tenuous coping skills of many inmates resulting in destructive behaviors.

The extent of one’s criminal behavior history is associated with SIB while incarcerated. In a study of 155 incarcerated women, Wichmann et al. (2002) found that participants who engaged in SIB were more likely to have an extensive and serious criminal history, and to have been convicted as a juvenile than participants who did not engage in SIB. Women who engaged in SIB were more likely to have difficulties with institutional adjustment as evidenced by placement in disciplinary segregation, escape-related behaviors, higher levels of security, involvement in violent incidents and disturbances, and victimization. SIB is also related to correctional environmental setting stress, such as being harassed or threatened and perceived lack of freedom, boredom, isolation, and limited future options (Liebling, 1992). Liebling and Krarup (1994) found that behaviors in prison such as sleeping problems and lack of participation in activities increased an inmate’s risk of SIB.

The experience of early childhood trauma and adulthood violence has been shown to be linked to SIB, particularly for female inmates (Browne, Miller, & Maguin, 1999). In a study of 256 incarcerated women, Roe-Sepowitz (2007) found that participants who engaged in SIB were significantly more likely to have a history of emotional, sexual, and physical abuse and social services’ involvement during their childhood than a comparison group. Borrill et al. (2003) found that lifetime SIB was positively associated with a history of being physically assaulted, sexually assaulted, and experiencing violence from family and friends. It is worth noting substantiated gender differences in the cyclical nature of victimization and violence. Males exposed to abuse as boys tend to identify with the aggressor and become the abuser in adulthood. In contrast, women abused in childhood have a propensity to become involved with abusive men and expose themselves and their children to further victimization (Jaffe, Wolfe, & Wilson, 1986). A frequent psychological response to repeated trauma is dissociation, which has been identified as a key component of SIB (Levenkron, 1998).

SIB coexists with numerous mental disorders. It is most often associated with borderline personality disorder (BPD), occurring in as many as 50% of individuals with this diagnosis (Dulit, Fyer, Leon, Brodsky, & Frances, 1994). In a study of newly admitted psychiatric inpatients, participants with a clinical diagnosis of BPD showed the highest prevalence of and most potentially lethal types of SIB (Sansone, Songer, & Gaither, 2001). A hallmark trait of BPD is the inability to tolerate emotional distress and SIB is considered to be a mechanism that reduces painful emotions. SIB also is reported at high rates among individuals with dissociative symptoms common in a diagnosis of PTSD. In a community sample of patients with PTSD, the overall rate of SIB was 66%, with higher prevalence (91%) in individuals with more severe cases of PTSD (e.g., a diagnoses of current complex PTSD; Dyer et al., 2009). Substance dependence (SD) appears to exacerbate SIB in individuals diagnosed with PTSD. Harned, Najavits, and Weiss (2006) assessed 65 outpatient women with a current diagnosis of PTSD and SD. Nearly one quarter (21.5%) of the women engaged in self-harm behavior in the past 3 months, and 61.9% of these women reported drinking alcohol or using drugs immediately before or during the episode. Other mental disorders associated with SIB include antisocial behavior (Suyemoto, 1998), eating disorders (Paul, Schroeter, Dahme, & Nutzinger, 2002), depression, anxiety, anger, and low self-esteem (Roe-Sepowitz, 2007).

Psychological Functions of SIB

A clear understanding of the multiple functions that SIB may provide to an individual is vital for effective treatment. According to Paris (2005), SIB simultaneously offers (a) relief from negative mood states; (b) a distraction by encouraging the individual to re-focus attention from psychological pain to physical pain; (c) communication of distress, as the behaviors come to the attention of significant others or therapists; (d) a way to express emotions such as guilt or anger; and (e) dissociating from current state when engaging in SIB. In a study of 63 female inmates with a history of SIB, suicide attempts (SA), or ambivalent suicide attempts (ASA), Chapman and Dixon-Gordon (2007) examined emotional antecedents and consequences of most recent acts. All the participants with a recent act of SIB reported a negative emotion prior to engaging in SIB, with the largest percentage of individuals reporting feeling anger or anxiety. In addition, boredom was more frequently reported as an antecedent to SIB than to ASA or SA. This provides some support that SIB can be an attempt to alleviate boredom and emotional numbness prevalent in a correctional environment. A sense of relief or calmness was the most common consequence of SIB. The emotional change from a negative state such as anger, anxiety, or boredom to a positive state such as relief, or calmness suggests that SIB has an emotional regulatory function. The higher lifetime frequency of SIB was associated with a positive emotional change indicating that SIB may have a reinforcing effect. The rewarding nature of SIB increases the likelihood of it occurring again and becoming a regularly used coping mechanism, albeit a maladaptive method.

Attitudes and Perceptions

SIB involves responses from medical, mental health, and custody staff. Specific departments are typically trained to respond to SIB according to their discipline. The result is that staff reactions to SIB vary widely. For instance, the priority for custody officers is to maintain the safety of the inmate and surrounding staff members. Often, custody officers have limited training on ways to meet the needs of an individual who has recently engaged in SIB. In fact, when an individual engages in chronic SIB, custody staff may have the perception that the main goal is manipulation of the system (Fagan, Cox, Helfand, & Aufderheide, 2010).

Kenning et al. (2010) conducted a small qualitative study in the United Kingdom that examined the difference in perceptions of SIB by correctional officers (n = 8), health care staff (n = 5), and female inmates (n = 15). Correctional officers indicated a common practice of labeling SIB as either “genuine” (rare instances in which SIB was due to mental illness) or “non-genuine” (manipulative behaviors and less deserving of treatment). As a result, the correctional officers were more likely to become desensitized to SIB when they viewed it as “non-genuine” or view the behavior as beyond their capabilities to handle when considered “genuine.” Either way, they tended to offer limited intervention. The inmates and health care professionals similarly noted that SIB is frequently used as an attempt to release and cope with strong emotions. Health care staff made no such distinction between “genuine” and “non-genuine” and showed more tolerance of SIB overall. The female inmates reported positive care and treatment by the health care staff.

Some SIB is motivated by attempts to achieve secondary gain. In correctional settings, inmates have limited influence over their environments and may self-injure to get attention, disrupt custody staff, or be relocated (Schwartz, Cohen, Hoffman, & Meeks, 1989). Although this type of behavior can be viewed as manipulative, SIB may be one of the few available options given that the correctional environment provides limited social and emotional support and restricts individual control over one’s life.

Punitive responses such as restraints or isolation have been shown to increase the risk of SIB (Jones, 1986). More sensitive approaches such as providing a higher level of care may be viewed as rewarding inappropriate behavior and causing imitation. However, at-risk inmates, those who use avoidance behaviors and have fewer problem-solving skills (Haines & Williams, 1997), may resort to SIB as a way to seek emotional relief or meet physical needs (DeHart et al., 2009). Regardless of whether self-injury is rooted in manipulation or anxiety reduction, the potential harm is the same. With this in mind, it is essential to adopt thorough assessment strategies.

Individual Assessment

Treatment of SIB among incarcerated women begins with identifying individuals who are at increased risk for engaging in that type of behavior and assessing any SIB that occur. This can be a difficult process as SIB tends to be done in private, especially in a correctional environment where the behavior can be a punishable offense. Roe-Sepowitz (2007) found that SIB tends to be under-reported and under-recorded in prison, particularly for repeated acts by the same person. Jones (1986) reviewed records of 67 inmates who had been identified as having engaged in SIB during a 1-year period of incarceration compared with a random sample of 68 inmates with no record of SIB during that same period. The inmates in the SIB group were more likely to have wrist or forearm scars at intake (49% vs. 23%). As the most common form of SIB in the prison population is self-cutting, a notation of scars should be included in the intake form.

When SIB is observed or reported, treatment professionals must first assess the related intention and potential lethality. Many incarcerated women are accurate reporters of their SIB and are capable of informing clinicians that it represents an attempt to cope with uncomfortable internal states, without suicidal intention. At the same time, mental health professionals are advised to listen carefully to how inmates who self-injure describe their motives. Individuals who make statements about wanting to get away from their overall situation are at greater risk for high lethality SIB compared with those who report trying to cope with a particular uncomfortable emotion or thought (Dear, Thomson, & Hills, 2000). Such statements are of particular concern when the following additional factors are present: past suicide attempts requiring medical treatment, high impulsivity, and current SIB with greater risk to physical integrity. Individuals showing a combination of such factors should be monitored more closely, through possible transfer within the correctional facility, while they receive mental health treatment related to their SIB.

After an SIB episode, a functional analysis to identify antecedents and consequences is essential to note both anticipated and actual consequences (Sampl, Wakai, Trestman, & Keeney, 2008). This process requires assessing the larger situation surrounding the self-injurious actions; this may help identify secondary gains related to systemic factors. A typical example is engaging in SIB for the purpose of being transferred to another housing unit, closer to the inmate’s significant other. Another example is SIB to gain additional staff attention. Even though SIB may have an aspect of manipulation, it is often multi-determined, so a manipulative component does not rule out co-existence of impaired coping. SIB associated with manipulative motives may sometimes involve risk to life and therefore must still be taken seriously, especially when a pattern of “upping the ante” develops. When secondary gains appear to be playing a role in maintaining SIB, mental health and custody staff members may need to collaborate in finding creative solutions. For example, if two romantic partners demonstrate coinciding SIB in an apparent attempt to meet in the intensive mental health unit, they may be housed with appropriate safety measures in two separate areas. When SIB appears to be motivated by a desire for attention, any necessary medical assessment and treatment of the resulting injury should be as brief and matter-of-fact as possible. When attention seeking appears to be a motive, behavioral systems should be created to provide increased attention, such as additional one-on-one time, or admission to an additional support group, contingent on refraining from SIB and replacing it with pro-social coping.

Collaborative Management

An important step to effectively managing SIB in prisons includes collaboration between medical, mental health, and custody staff. Fagan et al. (2010) offer several suggestions about how to cope with the SIB without reinforcing the cycle. The authors suggest meeting the inmate’s needs in a modified way such as keeping them in the same housing unit after the SIB incident, and using positive reinforcement for periods of time without SIB (Fagan et al., 2010). For example, admission into an extra support group is granted to an inmate who has abstained from SIB for a determined period of time.

Paramount to the collaboration of all correctional staff is training. Staff training should include making a distinction between suicidal behaviors and non-suicidal SIB, the psychological functions of SIB, psychoeducation on comorbid disorders, and the detrimental effects of punitive responses. Once training has been completed, staff will understand that when a woman has engaged in SIB and has been assessed by clinical staff as not being suicidal, there is no need for crisis intervention. In many cases, the woman is feeling better emotionally following the act of SIB, given the emotional functions often served by this behavior. Once the wound has been medically treated, mental health staff can work with the inmate to develop healthier ways of coping.

MI

MI (Miller & Rollnick, 2002) can be used to develop motivation to change self-injurious behavior, working through related ambivalence. MI proceeds from a collaborative, accepting therapeutic relationship. Communicating that SIB generally starts out as an attempt to cope with emotions and hurtful situations when healthier coping options are either unknown or unavailable is a recommended starting point. Over time, SIB can become a habit, just like any other habit, remaining in place even when, in many cases, the negative results of SIB overshadow the once useful functions. Using an MI approach, the therapist may want to ask open-ended questions to explore the woman’s view of and concerns about her SIB, and respond with empathic reflective comments, for example, “It sounds like you feel cutting gives you some temporary relief from sadness, then the sadness quickly comes back along with possibly getting another scar.”

Many individuals who engage in SIB express ambivalence about their SIB; they may see the harmful aspect, yet are uncertain about their desire or ability to change it. Using MI, the therapist is encouraged to “roll with resistance” through reflective comments, rather than pressuring for change and evoking additional resistance. For example, the therapist may comment, “I hear you saying you’ve been cutting yourself for a long time, and you’re not sure that you’re ready to stop.” When a woman who self-injures is uncertain about whether she can give up SIB, the therapist may use the MI strategy of supporting self-efficacy by reminding her of other positive changes she has made, or acknowledging small gains she has made toward taking charge of SIB (e.g., starting to talk honestly and openly about her SIB). The more that a woman who self-injures hears herself verbalizing the reasons that reducing and stopping SIB would be beneficial, the more likely she is to be successful in making this change. “Elicit change talk” with incarcerated women who self-injure by asking them open-ended questions about the possible benefits of ceasing SIB. Also, many self-injuring women find a written motivational exercise, such as an encouraging letter to oneself (shown in Figure 1), to be helpful to them as they embark on a course of treatment for SIB. When a woman completes this exercise, the therapist may ask her to read the letter aloud and ask her how she feels about what she just read. Hearing herself state her motivation has the potential to further develop readiness for change (Prochaska & Norcross, 2001).

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Figure 1.

Partial example of completed “self-encouragement letter: Breaking the habit of self-injurious behavior.”

CBT

CBT is recommended to address the coping skill deficits often associated with SIB. Dear, Thomson, Hall, and Howells (1998) found that prisoners who had self-injured in the past 3 days were less likely than a comparison group to have used problem-solving or active cognitive coping strategies to handle the most significant stressor of the past week. In a subsequent study, the researchers (Dear, Slattery, & Hillian, 2001) had blind raters (prisoners, prison officers, and forensic psychologists) assess the coping responses of the participants. The coping responses of individuals who engage in SIB were found to be less beneficial, more risky, and counterproductive. Individuals who carry out SIB in prison have fewer future-oriented problem-solving and coping abilities (Haines & Williams, 2003; Matsumoto et al., 2005).

Self-monitoring is a key component of CBT. Using this approach, a woman is taught to systematically track her urges for SIB and related factors. Figure 2 shows a partial example of a completed tracking sheet. Note that the “coping behaviors you tried” section is the largest section of the tracking sheet, which reflects the message that participants are expected to try coping behaviors as an alternative to SIB. Participants are provided with a list of alternative behaviors to self-injury that other incarcerated women have found to be helpful. Examples include interacting with supportive people (staff or peer), self-soothing (e.g., deep breathing, positive visualization, listening to calming music, drawing, and yoga), or distracting oneself through activities (e.g., reading, playing cards, singing dancing, taking a shower, exercising, watching television, and tidying up room/cell). During the weeks of treatment, the therapist works with the participant to further identify and teach a range of these coping skills. For example, during one of the sessions, the therapist may teach and demonstrate how to use deep breathing or visualization, if the participant is not familiar with those skills. Also, special attention is given to self-talk as a coping behavior, given that many women find this skill to be useful toward reducing SIB. If self-talk is listed as one of the coping strategies she used, the therapist may want to elicit a quote of what she said to herself, utilizing the reverse side of the tracking sheet for longer comments, listed by date and time.

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Figure 2.

Partial example of completed “tracking urges for self-injurious behavior.”

The tracking sheet has additional areas to help identify other factors of a woman’s SIB. She is asked to rate the extent of her urges, both before and after attempting to use coping behaviors. The example shows a woman who uses ranges to rate urges, for example, “3-4”; however this is not necessary. Also, note that women are asked to record what they perceived as the triggers and consequences of their SIB.

In subsequent sessions, the therapist and participant carefully review these sheets together, to identify and discuss patterns, focusing particularly on the patterns of triggers, coping behaviors used, self-talk, and patterns of change over time. Each of these areas are discussed below. In the next session, the therapist and participant carefully review these sheets together, to identify and discuss patterns.