A Narrative Synthesis of Qualitative Studies on Self-harming Behavior in the Correctional Setting

Abstract

Non-suicidal self-injurious or deliberate self-harming behavior is a significant mental health issue, particularly among vulnerable incarcerated people experiencing the psychological stresses of imprisonment. Drawing on a database search strategy focused on 15 years of qualitative research on self harming in the forensic setting, this narrative synthesis study integrates the findings of views on self harming by inmates and prison management staff and develops the Yin-Yang of Self-Harming Behavior in Prison model to illustrate the duality. The findings support the need for intensive prison staff training in the management of self-harmers and the development of inmate programs geared towards awareness and promotion of mental health.

Keywords

incarceration non-suicidal self-injurious behavior self-harming behavior narrative synthesis qualitative studies

Introduction

Non-suicidal self-injury (NSSI), also known as deliberate self-harm, has become an emergent clinical and public health concern (Cipriano et al., 2017). It is a behavior that refers to the intentional self-inflicted destruction of body tissue without suicidal intent (Hooley & Franklin, 2018; Masana et al., 2020) as in the incidence of self-cutting and self-burning (Green et al., 2018). Addressing the issue in 2018, the International Society for the Study of Self-injury excludes socially accepted behaviors such as body piercing, tattooing, and cultural or religious rituals; risky behaviors that may result to injury such as engagement in extreme sports; behaviors that do not directly cause harm like food restriction, as the detrimental effects appear after quite some time; and suicidal thoughts and behaviors, in which the persons purposely aim to end their lives. Moreover, the Diagnostic and Statistical Manual of Mental Disorder, 5^th Edition (DSM-5) has categorized this behavior under a new diagnostic entity in Section 3 as “condition for further study“ (Hooley & Franklin, 2018), making it a distinct entity from Borderline Personality Disorder and Suicidality (Liljedahl & Westling, 2014). Clinical studies, however, suggested that self-harming behavior is comorbid with some mental disorders. Some of these include bipolar disorder (Andover et al., 2017), major depression and psychotic illness (Fazel et al., 2016), and post-traumatic stress disorder (Arthurs & Tan, 2017). Additionally, previous studies have indicated that these deviant behaviors are caused by feelings of frustration, guilt, rage, abandonment, emptiness, loneliness, low self-worth, and self-blame (Chen & Chun, 2019); negative affect, negative emotionality, deficits in emotional skills and self-derogation (Green et al., 2018), trauma, stress, familial or interpersonal strife (Mann et al., 2019), and maladaptive coping mechanisms (Oxley et al., 2017).

Persons deprived of liberty display higher rates of self-harming behavior (Winicov, 2019). Chammah and Meagher (2015) found that upon initial detention, jail inmates usually experience heightened distress. The experience in jail is found to be traumatic to inmates (Winicov, 2019). This contributes to self-injurious behavior being the most persistent problem (Wakai et al., 2014) and most common reason for mental health treatment within correctional settings (Dixon-Gordon et al., 2012). NSSI is a complex act that calls for action (Smith et al., 2019) as it poses a serious threat to the safety and well-being of detained offenders (Power et al., 2016). Research literature, specifically in the United Kingdom and United States of America, has explored much on these behaviors in the correctional setting (e.g., Kaba et al., 2014; Reid & Listwan, 2018; Winicov, 2019). Undoubtedly, an integration of the similarities and differences among the findings of these studies is both relevant and timely, as literature reviews on this topic are extremely limited (Shelton et al., 2017). The integration of descriptions and definitions which characterizes this penal system behavior is a much needed analysis. Hence, this narrative synthesis study conducted in the context of self-harming behavior in carceral settings is geared towards integrating the findings of qualitative studies by highlighting the important perspectives of both self-harmers and their caregivers to better understand the behavior in terms of its nature, functions, and management within correctional sytems over the last 15 years.

Narrative synthesis is perceived as an effective way to recognize the “story” behind a distinct body of evidence by providing reviewers a strategy to develop themes that bring unity to previously presented data (Briner and Denyer, 2012; Popay et al., 2006). Essentially, this study will focus primarily on forensic mental health. In this seminal undertaking, the integrated psychological concepts that will emerge will be a valuable aid in understanding the complex and challenging behavior of self-harmers in correctional facilities. Findings from this narrative synthesis will offer vital input for policy making on handling, assisting, and treating those who self-injure through the initiation of programs to enhance and promote inmate mental health and psychological well-being as well as improve the training of prison staff and professionals who are front-line in the management of self-harmers.

Method

The review was conducted using five databases, namely: APA PsycArticles, ProQuest, PubMed Central, EBSCOHost (Psychological and Behavioral Collection), and Emerald Insight aimed at examining the self-harming behavior in incarcerated environments. The search terms were “self-harm,” “self-injury,” “non-suicidal self-injurious,” “self-mutilation,” “non-fatal deliberate self-harm,” “correctional,” “inmates,” “detainees,” “prison,” “jail,” “forensic sample.” To be included in this review, research had to be: (i) Written in the English language; (ii) Qualitative in design and published from 2005 to 2020; (iii) Presented in a visual or narrative model or framework related to self-harming behavior of detainees and/or prisoners; (iv) Presented in a model or framework that is original; and (vi) able to be printed or downloaded. The protocol for the review was preregistered in the PROSPERO database (CRD42020207481).

In addition, the review process was guided by the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) Statement Guidelines, a structured approach to reporting systematic reviews and meta-analyses (Moher et al., 2009). The process followed these steps: (1) creating a protocol with clear and focused topic on what to review; (2) choosing the databases for a structured search; (3) developing a search strategy by carefully choosing what word to consider; (4) running and recording search by keeping accurate records of previous searches; (5) managing the results; (6) evaluating the results against the set inclusion criteria; and (7) synthesizing the results.

The search elicited 339 potential articles, of which 13 articles were excluded for duplication. The remaining articles were screened by title and abstract, and 300 were excluded because they were studies of self-harming behavior in general, and not related to penal system self-harming behavior. Using the eligibility criteria, the remaining 26 full-text articles were further assessed, of which eleven (11) were excluded due to the inability to meet the stated inclusion criteria. The remaining fifteen (15) articles were judged to be eligible. Data were obtained by following the three stages of narrative synthesis: (1) developing an initial synthesis; (2) investigating relationships within and between researches; and (3) assessing the strength of the synthesis (Leamy et al., 2011). In carrying out narrative synthesis on existing interpretations from the authors of the original papers and in the course of synthesizing their elucidation, there is a possibility that some details were overlooked that may reduce the richness of the findings and might silence some experiences. To safeguard against this, cross-validation with a qualitative research expert and a practicing clinician, with academic, clinical, and forensic background was conducted. In response to the experts’ recommendations, the literature on self-harming behavior in incarceration was revisited. Some subcategories were repositioned within the themes and some categories were changed. Overall, the expert consultation process provided added validity to the content and robustness of the findings (Figure 1).

Figure 1.

PRISMA flowchart of the record selection process.

Findings

Capitalizing on the promises of narrative synthesis, data from the 15 articles were analyzed following an interpretive integration of qualitative findings. Through the narrative synthesis process, the Yin Yang of Self-harming Behavior in Prison (see Figure 2) was developed. This model offers two interesting and complementary views of self harm from inmates and prison management staff. Based on the Chinese philosophy of Yin Yang, the perspectives of both were assimilated to represent the concept of dualism. This symbol is used to describe how opposing or contrary views may actually be complementary, interconnected, and interdependent related to self-harming behavior in the forensic setting, and how these views may give rise to each other as they interrelate to one another.

Figure 2.

The Yin Yang of self-harming behavior in prisons.

Theme 1: The Prisoners’ View

In this study, the first perspective on self-harming behavior came from the inmates engaged in self harming. The theme “prisoners’ view” refers to the perspectives from self-harmers. Specific perspectives classified under this view were generated to further understand the essence of self-injurious acts from the viewpoints of the self-harmers themselves.

Historical View

Included articles identified the overwhelming impact of a personal history of inmates’ past struggles. Reflecting on what they had been through, the self-harming inmates narrated turbulent personal histories characterized by chaotic and dysfunctional families, family neglect and troubled life events, identifying these as some of the factors associated with their use of NSSI.

I think it stems from when I was younger and all that ‘cos my upbringing wasn’t the best of upbringings really. (Howerton et al., 2007, p. 3)

When I was getting down and that I was thinking about the past and stuff that is happened. (John-Evans et al., 2018, p. 33)

Findings from eligible studies also reported that self-harming inmates were victims of different types of abuse and these increased their urge to engage in self-harming acts.

Mine (sexual abuse) was worse sort I think. Which makes it quite understandable that I grew up with few disorders. (Marzano, et al., 2016, p. 161)

My mum and stuff like that, what my father used to do to us. I was abused when I was a kid, everything like that just gets on top of me. (John-Evans et al., 2018, p. 33)

Ecological View

From the scientific notion of ecology, where the relationship between living things and their environment is crucial to survival, this study's ecological view yielded the self-harmers’ motivations in relation to the prison environment and its management. Within this context, harmonious relationship is sought by the self-harmers, and judgmental attitude and hostile reactions are perceived as not helping in what they are going through.

They’re cold in their voice, they’re cold in the way they speak to you, they’re cold as in when you’re crying they just shut the door in your face. (Kenning et al., 2010, p. 280)

I get no help whatsoever…they bring me downstairs. They bandage me up and they put me back in my cell. (Marzano et al., 2012, p. 6)

Additionally, the lack of faith and confidence in the system and its environment made it more challenging for self-harmers to overcome tumultuous experiences while in custody. Based on the analyzed articles, troubling environment, distrust of the system, unhelpful officers’ and healthcare staffs’ responses to their unusual behavior were contributory factors to their urge to self-harm and to their struggles for recovery.

It is not a great place to be, it do tend to make you worse, you do it more in here. (John-Evans et al., 2018, p. 33)

I don’t have trust in the system. I don’t trust the system one bit, I hate the system. All they’ve ever done is shit on my life. Why should I trust them? Probation, they’ve shit on me… course they shit on you, everybody shits on you. So, I don’t trustnothing or no one. I don’t trust my missus, I don’t trust my own mum and if I don’t trust my own mum I ain’t going to trust no one. (Howerton et al., 2007, p. 3)

Purposive View

The purposive view relates the function of self-injurious acts in inmates’ attempts to manage their overwhelming emotion during incarceration. Specifically, it is their uncontrollable and intense feelings of anger, pain, sadness, tension, and frustration that are often turned inwards, triggering the act of hurting themselves.

I start getting agitated and getting angry and then I start thinking to self-harm, that is the trigger. (John-Evans et al., 2018, p. 32)

I still have little moments where I scratch to try and get the pain out, it is frustration like…it is my way of getting those feelings out. (John-Evans et al., 2018, p. 33)

Themes from the qualified studies also described the deviant act as a coping strategy to relieve several negative emotions felt while adapting to the forensic setting. It also serves as a way to punish themselves for the perceived misdeeds they have committed—stating that they deserve to get hurt. In summary, self-harming behavior functions as an affect regulation device, coping strategy, and self-punishment act for the self-injuring inmates.

It's the way to cope. It's the way I adapted to cope, anyway (to) the situations that I’ve been in my life since I was a kid. (Marzano et al., 2016, p. 163)

I’ll just sit there thinking about my past, you know, how I’ve come to prison in the first place, I’ve let my kids down, you know, and then I just really, really, worked up and then I just have to see blood too, you know, relieve the pain. (Kenning et al., 2010, p. 278)

Deconstructive View

The deconstructive view is an examination of the barriers to effective management of self-harming behavior in prison which were revealed by inmates from the included studies. This intends to show system flaws and inconsistencies, the effect of negative staff reactions—such as being ignored or not taken seriously—which contributed to the difficulties faced by the imprisoned self-harmers.

In here they don’t see it as serious. They think you might be playing with them; you are playing tricks on their mind or something…to draw attention; to make them do something…They don’t see like what is in your mind, or what you think. (Marzano et al., 2012, p. 6)

Because it's disgusting, the way they treat people on the mental health side of things. It's a joke. It really is a joke. No wonder there is so much suicide and self-harming in these places- not just this place, in all of them. Do you know what I mean? You can’t believe the way that they treat you. (Marzano et al., 2016, p. 162)

Shortage of skills needed to implement self-harm policies, lack of communication skills—particularly active listening—and social support—such as the dearth of self-help groups—were also some of the findings highlighted, emphasizing the obstacles to the effective management of these unusual acts.

Staff need to be skilled in communication, in particular in active listening. (Bennett & Dyson, 2014, p. 19)

I’m really just screaming out to see a doctor. I just want a little bit of help.(Marzano et al., 2016, p. 165)

Furthermore, this view also uncovers the difficulties encountered by the prisoners in the management of their own deviant behavior. Some of these are: fear of the social and individual consequences of diagnosis of mental illness; resisting treatment and medication; attitude and knowledge about self-injurious behavior.

I have not done it too much until recently, I am not sure why. I have started medication; they have said they might make you worse at first. (John-Evans et al., 2018, p. 34)

Like I say… it seems people are scared of mental illness. That's one of their worst fears, actually being diagnosed as mentally ill you know. (Howerton et al., 2007, p. 4)

It's like me, I get called, ‘a weirdo’ because I cut myself. (Gutridge et al., 2019, p. 174)

Theme 2: The Staff View

The theme “staff view” refers to the second perspective that emerged from the narrative synthesis which exist outside or beyond the boundaries of the self-harmers. Views were identified as part of the “outside the wall” interpretations of self-harming inmate behavior coming from the staff, healthcare workers, officials, and other support staff in prison. To further elucidate this perspective, four related views were identified.

Intentional View

The intentional view illustrates how the prison management staff view self-harming behavior. In the articles reviewed, prison staff and officials believed that inmates intend to use this behavior as a coping strategy, as an act to manipulate the system, and for attention seeking. As a coping strategy, the prison staff see self-harming behavior as a desperate but meaningful way for prisoners to process overwhelming emotion and adjusting in living with the stressors while serving their sentence.

It may well be their way of relieving that stress and that tension. Though talking can be helpful, drop-in centers can be useful, seeing psychologists can be useful, it may well boil down to the fact that cutting yourself and seeing blood oozing out is a much more visual representation of a relief of tension than talking to somebody. (Kenning et al., 2010, p. 279)

Some women will tell you that they will self-harm to get the attention of the nurse, to get the attention of the doctor. (Short et al., 2009, p. 413)

Alongside these views, they also realize that, in some instances, the act is an intentional manipulation to try to get control of situations and influence the prison environment. They also see it as an attention-seeking move to gain recognition and have their needs served over those of other inmates:

They know they’ve got us over a barrel. ‘If you don’t do that then, I’ll cut myself.’ That annoys me. Because that's a blackmail. They are blackmailing into doing things like that I say: that's your choice, if that's what you want to do. (Marzano et al., 2015, p. 247)

It's a way of manipulating the staff to get something they want or to get better treatment than someone else. (Short et al., 2009, p. 413)

Consequential View

As viewed by the people managing the prisons, self-injurious acts have secondary results or indirect consequences for the entire facility. When prisoners engage in self-harm, it gives the staff a feeling of resentment, as they have already classified genuine and non-genuine acts. By genuine, they refer to self-harmers who need authentic care and attention:

The ones that I feel genuinely do have real problems and a genuine self-harm issue. I don’t mind spending time with people who genuinely need help. I can’t be doing with the time- wasters… (Kenning et al., 2010, p. 280)

I suppose it is a cry for help…they do want attention because like it is saying ‘look I can’t, obviously cope. I’m having to do things to myself to get somebody to come to me, to help me out. (Short et al., 2009, p. 415)

In contrast, the non-genuine self-harmers intend to have a purpose of manipulating the system through getting more than what they should receive or as a response to being denied of something.

Some will come up to you and ask four officers for something and we will be like ‘no, you’re not entitled’ and they will go to the management and ask, management will give in and make us look like idiots by giving it to them because they threatened to cut up. (Short et al., 2009, p. 416)

Non-genuine self-harmers make the prison staff feel a subverted power relationship in the forms of feeling helpless and having low job control for assisting the inmates, stopping the behavior, and being able to decide how to respond.

My experience of working (with repetitive self-harm), it's quite frustrating obviously. It's a very frustrating experience, because you will find that there is not, there is not a great deal of ehm, I just think I would approach it differently. I don’t know where, which way I’d like to go with them, but the way we are going now is not working, because of, constantlyrepeating it. You know, self-harm. So, either we are doing it and we are not doing it right. (Marzano et al., 2015, p. 247)

Further, self-injurious acts contribute to the depletion of facility limited resource as they require staff and medical attention. For an understaffed facility, attending to the self-harmers will consume time and, hence, cause divided attention to the multiple tasks assigned to them. Medical treatment also consumes financial resource; more so, repeated self-harm as challenging, frustrating, and stressful as it is, drains prison staff patience in the face of resource issues like overcrowding and limited personnel.

The impact on staff is predominantly in costs. Inmates who do self-injurious behaviors cost a lot. There is the cost of traveling by ambulance, emergency room, the surgeon, also there are guys who get infections after cutting, and they can be resistant to the antibiotics given. The cost for a single hospital trip can be $85, 000–100, 000.(Smith et al., 2018, p. 13).

It affects security staff and medical staff because it slows down the daily routine for everyone. Initially it (self-harm) gets to you, then you become detached, maybe sometimes too detached… The only way to deal with inmates who do self-injure is to follow the cardinaltenant; that is, ‘I cannot take responsibility for what an inmate does…I can only take precautions. (Smith et al., 2018, p. 13).

Strategic View

Although bombarded with obstacles in the management of self-harm, prison officials and support recognize strategies to ease this rampant problem. The eligible articles yielded a strategic view by prison management staff, premised on building a prison environment where trusting relationships are honed, collaborative works are performed and non-judgmental attitudes are shown.

It (listener scheme) is the most valuable scheme in the prison service, it does save lives and help staff cut our workload significantly. (Griffins et al., 2019, p. 117)

Having me there…means that they (imprisoned women) feel supported, and it's being consistent and not promising something that you can’t possibly do.(Walker et al., 2016, p. 177)

In this view, managers also see the need for a “champion role,” a leader who initiates and develops interventions, self-help strategies, reflective practice, prisoner engagement, and professional relationships.

It just needs somebody to be there if on an evening, or something you’ve got a problem, you know someone who can go to and say, look, I’m having this problem with this, any advice on it? ‘Supported by a peer mentor, …which is fine, maybe that's… theway forward, I don’t know, but it… it did seem that like we’re being…that was just recovering stuff that we… we have already covered in the past. (Perry et al., 2019, p. 10)

Dispositional/Structural View

In the forensic setting, a number of difficulties are confronted on a daily basis, not only by the inmates themselves, but also by prison management staff. In crafting an efficient way to handle NSSI in custody, it is essential to analyze the dispositional and structural hurdles met by the caregivers of self-injuring prisoners. The dispositional view as disclosed by the assessed eligible studies posits the prevailing management challenges faced by officials and other support staff in supervising self-harmers. The staff expressed their view on prolific self-harmers and their negative feelings about the added burden of having to perform dual roles of both securing custody and providing care.

A lot of the problems with the people on here are mental health problems, which is something we can’t really do a lot about. (Kenning et al., 2010, p. 279)

When you get someone self-harming, continuously, it just messes up the whole regime. An then makes your job so much harder. (Marzano et al., 2015, p. 247)

Prison staff attributed these negative feelings based on the uncertainty of appropriate response from perceived mixed, insufficient, and/or lack of appropriate training.

Most of it (training) is probably trial and error and support from people who are around you,..staff, the prison officers, and…the mental health team. (Walker et al., 2016, p. 180)

Training is mixed. There is a common belief that staff would benefit from more in-depth training about self-injuriousbehaviors;suicide prevention training is just too generic. Staff need training that is specially aimed at female inmates who self-injure. Right now, we are operating off the top of our heads, we use the internet to look for solutions (Smith et al., 2018, p. 12)

Furthermore, the structural views are the challenges encountered by the prison staff in relation to the entire prison system. These are the issues disclosed by participants in the studies reviewed: resource constraints; prison/institutional environment; collaborative and flexible training to cope with the job; and project funding, focus, roll-out, and evaluation. Resource constraints affect the management of self-harmers, and any program needs proper and sufficient funding in order to be well executed.

A lack of time and resource…Again, logistical nightmare. As it is always in the prison service. It's dealing in crisis management. (Perry et al., 2019, p. 6)

Because she's done this you won’t be able to that or three jobs for somebody else, so its time constraints, time consuming and yes, I suppose a little bit resentful and that sounds awful, and I probably wouldn’t say it to anybody else but that's sometimes how you feel. (Short et al., 2009, p. 417)

Additionally, the overcrowded and understaffed prison/institutional environment is perceived to be another obstacle, since prison staff are conflicted regarding whether to perform their custody roles or their care roles.

You can’t have a prison officer being a mental health nurse as it's a conflict of interest because one minute you have to sit down and counsel them and the next minute they might throw a punch at you and you’ve got to put them in locks and put them behind their doors. (Short et al., 2009, p. 416)

‘We can safeguard them and stop them from dying because that's what we are trained for…but we’re just not trained as counselors to sit there and listen to their past and their problems. (Short et al., 2009, p. 417)

Therefore, collaborative and flexible training to cope with the job is seen as a solution to reconcile the difficulties and facilitate system operations, with self-harmers not being ignored and prison staff not being neglected.

We are simply not equipped for dealing with self-injurious behaviors in inmates. We need a place for the ‘cutters’. A place that is not in this facility…that will have the resources to address the behavior, with more intensive therapy. People who engage in this behavior should be totally separated from the main prison population. Keep them in a program instead of moving them around from unit to unit. (Smith et al., 2018, p. 12)

I think more awareness around what self-harm is, why people self-harm, how we (prison staff) can manage it, ways of coping and ways to help participant…How staff can off load if they need to if they’re feeling frustrated or it's (witnessing self-harm) upset them. (Walker, et al., 2017, p. 820)

Lastly, programs also need support for the dissemination of information for stakeholders to obtain success and evaluate if the goals were met. Prison staff perceived that programs must also be focused and coherent, with reflections on understanding the relative importance of the project.

Bringing together some tools that don’t need to come directly from mental health is good and to raise understanding of what these tools can do for people. (Biddle et al., 2018, p. 9)

We should really have planned for the evaluation part of it. What we were going to look at, how we were going to evaluate it and that should have been embedded first. (Biddle et al., 2018, p. 9)

Discussion

The primary intent of this narrative synthesis is to integrate qualitative research studies on the engagement of prisoners in self-harming behavior. The aim is to highligh the perspectives of both correctional setting self-harmers and their caregivers to better understand the behavior in terms of its nature, functions, and management from investigations of the last 15 years.

Fifteen eligible articles were reviewed that enabled the integration of the two views on self-harming behavior in the penal setting. The analysis yielded key insights on the various causes, functions, and consequences of this behavior from self harmers and frontline responder viewpoints. As shown by the Yin-Yang model of self-harming behavior, a duality of perspectives from inmates and prison management staff was found to be complementary, interconnected, and interdependent; each view plays a vital role in elucidating definitions, descriptions, and management of the behavior in carceral environments.

NSSI or self-harming is a complex, deviant behavior that is prevalent in the forensic setting. Self-harm is more complicated than it is perceived and calls attention when language is unable to translate feelings. Current findings confirm that self-harming is not only complex, but it is also a challenging behavior for both self-harmers and caregivers. It is indeed a prevalent and dangerous occurrence (Kaba et al., 2014) within correctional settings. Although the behavior is said to be without suicidal intent (International Society for the Study of Self-injury, 2018), repetitive self-harm is an important risk factor for suicide (Fazel et al., 2013; Hawton et al., 2014)and poses danger to the individual and distress to prison staff and officials.

In the inmates’ view on self-harming behavior, findings from the eligible articles highlighted their perspectives on the significance of their past traumatic events which became precipitating factors of the urge to self-mutilate in prison, on the importance of living harmoniously inside the facility, on the functions of self-harming behavior in the prison population, and regarding the barriers for the effective management of these acts.

Many inmates experience dysfunctional and chaotic family life, where the incidents of abuse and neglect date back to childhood. As adults, these disturbing memories are incorporated into their lives inside custody. The traumatic experiences of imprisonment coupled with problems of overcrowding, insufficient resources, loss of sense of humanity, and feelings of powerlessness and hopelessness trigger stress, making it more difficult to adapt to prison life. Consistent with previous literature, the motivations to engage in self-injurious behavior are engendered by pre-existing histories of trauma (Reyes et al., 2019), which inmates have little chance to “process.” Therefore, negative emotions are left unsettled, and conflict with the law worsens the feelings.

Living harmoniously inside the facility became a fundamental concern, with the issue of genuine care overlooked. Implied in the findings are a distrust of the system, the troubling prison environment, and the unhelpful staff responses to their self-harming behavior. Linked to their traumatic experiences, persons deprived of liberty are unable to trust other inmates and staff inside the facility. This was expressed by generalized negative beliefs of suspicion and lack of faith and confidence that someone would be there to adddress their needs and welfare. In addition, they reported challenges in adjusting and coping with the prison environment. Individuals who self-injure believed that the lack of social support and artificial comradeship between and among inmates and staff contributed to the build-up of negative emotions. Unhelpful staff responses to the self-harming behavior seemed like adding “fuel to the fire” of existing difficulties in dealing with childhood trauma, coping deficits, and unsettling environment. When staff became cynical and resentful to them, it cultivated frustration, anger, and depression that, in turn, intensified the need to self-harm.

Injuring oneself serves important purposes for these incarcerated men. Similar to some studies, affect regulation and environment manipulation (Power et al., 2016); coping mechanism (Smith & Power, 2015) as well as self-punishment (Arcelus et al., 2016); and separation from social supports (Wakai et al., 2014) contribute to high rates of self-injury among inprisoned people. Linking past problems to present difficulties in prison, the act of self-harming functions as a relief, relaxation, and tension-reduction of the overwhelming emotions that causes psychological distress.

Moreover, the key findings classified under staff views posit how the prison management staff perceive what self-harming behavior is, its secondary results or indirect facility-wide consequences, and the prevailing obstacles experienced in the management of self-harm in terms of both dispositional and structural views.

The incongruence of how prison staff perceive self-injuring acts compared to what it means to the self-harmers underscores the conflict regarding the management of the behavior. For the self-harmers, these are annihilating negative emotions which they seem unable to properly communicate. Whereas, for prison management staff, the behavior is perceived as acts of manipulation, attention-seeking, and avoidance. For them, these inmates just want to get more than what other inmates receive in terms of attention, resources, and basic needs. They also viewed their hurting themselves as tactics to avoid tasks, to be assigned to other chores, or to be re-located to another prison cell. Unless both views are taken into careful consideration, there will be an inablity to resolve conflicts stemming from the engagement in self-mutilating behavior. Yet, both the self-harmers and the prison staff construe self-injuring acts as a coping strategy to survive a life inside custody. Similar to the Yin-Yang Philosophy of interconnectedness and interdependence, two parties may perceive one thing differently. However, with closer investigation, the consistencies and relationships of the interpretations can give rise to a more efficient understanding and management of this behavior in prisons.

The findings also elucidated the indirect consequences of self-harming behavior. Self-harmers, especially the prolific ones, deplete facility limited resources; the cost of hospitalization adds to the difficulties of extending finances to support the necessities of the entire facility. In a similar vein, a self-harming incident disrupts the institution's daily operational routines, including those of non-self-harmers. Prison staff are impacted as they must both supervise the execution of their daily tasks and that of other inmates while attending to the incident of self-harm. These added job burdens leave prison staff feeling resentment, with subverted power relations among self-harmers, especially ones seen as non-genuine attention-seekers and system manipulators. As a result, this caregiver antipathy adversely influences the self harmers’ help-seeking behavior, interfereing with their willingness to engage treatment and, consequently, making their supervision more challenging.

With intentions of addressing these issues of prison staff challenges and frustration in the execution of their jobs, the development of a strategic plan was emphasized in the reviewed studies—one that is basically built on trusting relationships, self-help strategies, and procedural interventions. Prison staff recognized the need for open and empathetic communication and professional relationships to bridge the gap created by differences in staff-inmate views. Ideally, a collaborative safety plan where prisoner engagement is encouraged is aimed to lessen, if not eliminate the occurrences of injury. As perceived strategically, having relational-based care is paramount to the effective management of the behavior. Considering the “heavy load” of prison staff work, it is emphasized that self-help strategies be part of training for those with close contace with self-harmers. Additionally, utilizing immediate psychological debriefing for those who witness the injury will protect these frontline responders from exhaustion and emotional trauma.

Besides relational-based mediation, procedural interventions were also encouraged. These include the review of in-place protocols that might need revision and tailor-fitting to the unique needs of self-harming inmates. Importantly, there is also the need for training specifically focused on self-harming behavior, apart from suicide prevention. These findings run parallel to other studies that found most prison staff felt unsupported and lacking in appropriate training (Ramluggun, 2013); prison protocols (Mangnall & Yurkovich, 2010), and interpersonal and behavioral strategies (Sousa et al., 2019) as frontline responders to self-injuring prisoners. Indeed, the research literature has documented a dearth of programs designed specifically to assist prison staff assigned to deal with self-harmers. Further, the existing protocols are assessed to be ill-suited to support caregivers in the management of the behavior inside the facility.

The dispositional view revealed the prison staff challenges related to their outlook about the behavior. Participants recognized both the need for a more positive and caring attitude toward the self-harmers and the implications of the labels attached to them. Negative responses, reactions, attitude and practices about NSSI are common in prison. They affect both staff and inmates, wth the problem perceived as an irritating disturbance in the facility very much influencing the way it is managed. Besides these dispositional challenges, structural difficulties account for carceral environment and program conflict related to the behavior. Participants expressed the need for a specific place for “cutters” that was separate from the general prison population, so that the behavior could be appropriately addressed. However, due to lack of resources, staffing, and funding, self-harmers were transferred from one cell to another for medical attention,without receiving proper psychological interventions. Furthermore, the studies highlighted the need for suitable programs that are not punitive in nature. Again, the ideal is a collaborative safety plan that not only supports self-harmers, but also reconciles the conflicting dual roles of the prison staff as both security and care providers. In the light of these findings, programs that do not solely rely on existing suicide protocols are also envisioned. The need to increase awareness and ability to distinguish suicidal acts from NSSI must be given priority.

Clearly, the understanding of these views could serve as a framework in designing more relevant and meaningful programs geared toward the mental health awareness and psychological well-being of incarcerated self-harmers. The inmates will benefit from more structured and detailed mental health programs that address their needs, incorporating their views as reflected in this study's results. Equally important is the inclusion of adequate, continuous, and systematic training for frontline prison staff to equip them to manage their dual roles of security and care.

Notably, there are limitations to the current research which future studies may consider. Included papers ulitlized to synthesize the inmates’ views differed on the specific experiences of a particular prison population. Some studies obtained their findings from self-harmers with comorbid mental health conditions, some from repetitive self-harmers undiagnosed of mental health problems, while other investigation differed related to the gender of their participants. Correspondingly, the focus of the eligible studies used to integrate the staff views came from the responses of varied prison staff responders—some were from the medical field, others from the security department, and some were prison officials. Future research may delve into an emphasis of the needs and experiences of a more specific group of self-harmers and their caregivers, with emphasis on job roles, gender, and ethnicity.

Conclusion

In view of the analysis of the included studies, findings of this current research reiterate the need for a comprehensive understanding of the complex behavior of self-injuring, its nature, causes, functions and consequences, not just for the self-harmers, but also for the frontline prison staff responders. As implied from the views of both the inmates and the staff, mental health protocols and programs must be directed towards support, treatment, and psychoeducation of prisoners. When inmates experience overpowering emotions while incarcerated, they should be directed to the appropriate well-trained mental health professionals. There are low levels of psychiatric training and numbers of registered mental health professionals across correctional systems. This lack of required skills and confidence to manage mental health issues inside prison facilities need to be addressed (Forrester, et al., 2018). The act of self-injuring is a complex behavior that requires specific interventions which can only be delivered by trained mental health professionals. Importantly, some of these interventions should include but not be limited to cognitive behavioral therapy, dialectical behavioral therapy, and/or reality therapy.

Lastly, since prison management staff act as first responders who have the most contact with self-harming prisoners, it is equally important to craft programs and training geared towards capacity building, psychological and emotional wellness, and investments in practical resources that lessen the hurdles faced in the supervision of self-harming incarcerated people. Similarly, the addition of mental health professionals to prison support staff is highly recommended, as they will act as the psychological de-briefers to those who came in contact with the self-injuring prisoners (Table 1)

Table 1.

Included Papers in the Narrative Synthesis.

Author, date & country	Selection	Article	Main findings/Conclusion
1. Griffins et al., 2019 United Kingdom	Professional and peer support preferences of women who self-harm	n = 30 women in custody who self-harm n = 65 support group	- Women prefer to access support for their self-harm from professionals over peer support. - Professionals and peers play a vital role to fully support women who self-harm.
2. Perry et al., 2019 United Kingdom	Perspective on training initiative to reduce self-harm	n = 19 prison staff n = 18 prisoners n = 6 field researchers	- A collaborative and flexible support training is needed. - Prison environment and personal circumstances affect prisoner engagement. - Staff attitudes, prison environment and resource constraints hindered the implementation of the skills by prison staff.
3. Biddle et al., 2018 United Kingdom	Implementation and evaluation of a project to prevent suicide and self-harm	n = 3 frontline practitioners	- Interventions about suicide and self-harm in prisons are needed. - A clear project focus, realistic budgets, timeframes; delivery across multiple sites; the need for specialist evaluation input; awareness and engagement with prison staff; delivery by practitioners who are familiar with prisons; and a ‘champion role’ are issues needed to be addressed when focusing on prison suicide and self-harm.
4. Gutridge et al., 2018 United Kingdom	Attitudes towards self-harm and the use of medical skin camouflage	n = 10 women prisoners	- Women in prison seem to feel ashamed and self-conscious about their scars. - The relationships of women in prisons are affected by the presence of scars. - Medical skin camouflage can potentially affect the well-being and sociability of women in prison.
5. John-Evans et al., 2018 United Kingdom	Functions of NSSI	Male prisoners with mental health difficulties	- Affect regulation, affective change and coping are the functions of NSSI to prisoners with mental health difficulties. - The mediators of NSSI are medications and social support. - Interventions aiming emotion identification, regulation and expression, as well as coping strategies in prison are highly important.
6. Smith et al., 2018 United States of America	Perceptions on self-harming behavior	n = 20 administrative prison staff n = 21 therapeutic prison staff	- Prison staff see self-harming acts as manipulative behaviors. - Self-harming behavior of prisoners is complex, challenging and severe.
7. Walker et al., 2017 United Kingdom	Responses to self-harming behavior	n = 14 prison staff	- Presenting an impression of coping, rejecting support and becoming desensitized are the strategies employed by the prison staff in coping emotionally with self-harmers.
8. Marzano et al., 2016 United Kingdom	Needs and motivations of incarcerated self-harmers	n = 20 adult male prisoners	- Adult male prisoners describe self-harming behavior as a desperate but meaningful coping strategy; a means of releasing tension, sadness and frustration, and of being heard in an unresponsive system. - A greater demand for awareness of the complex needs of men in prisons and the issue of self-harm separated from suicide is pointed out.
9. Walker et al., 2016 United Kingdom	Experiences of prison staff working with imprisoned women who self-harm	n = 30 prison staff	- Developing a relationship, self-help strategies and relational interventions are identified as strategies used by staff to support imprisoned women self-harmers. - A deficit in the provision of training and support for staff is realized. - Prison staff perform dual roles as both custodian and carer of women who self-harm.
10. Marzano et al., 2015 United Kingdom	Responses to repetitive non-suicidal self-harm	n = 15 custodial officers n = 15 healthcare staff	- Dealing with self-harming behavior in prison is challenging and frustrating. - Negative reactions to self-harm are not inevitable, levels of prisoner care suffer when staff becomes cynical and angry. - The need of practical resources and/or skills to deal with self-harmers are implied.
11. Bennett & Dyson, 2014 United Kingdom	Barriers that prevent the implementation of policies to reduce deliberate self-harm in prisons	n = 12 studies on deliberate self-harm in prison	- The barriers and levers identified were knowledge, attitudes, emotion, skills, environmental factors and inmates resisting treatment. - There is a need for training to understand self-harm, improve prevention skills, positively influence attitudes, address coping skills of both the self-harmers and prison staff and address environmental factors contributing to the engagement in the act.
12. Marzano et al., 2012 United Kingdom	Responses to self-harming behaviors	n = 20 adult male self-harming prisoners	- Prisoners’ experiences of staff's responses to them and their self-harm were generally negative. - The need for appropriate training, support and supervision for staff in contact with self-harmers in prison is suggested.
13. Kenning et al., 2010 United Kingdom	Views on self-harm	n = 15 prisoners n = 15 prison staff	- Prison staff viewed self-harm as manipulation and attention-seeking - Women prisoners, prison governors and healthcare staff viewed self-harm as affect regulation and self-punishment. - To improve staff-prisoner relationships, more training and support for officers is needed for safer service provision.
14. Short et al., 2009 United Kingdom	Attitudes of prison staff to self-harm in women prisoners	n = 8 prison officers n = 5 healthcare staff	- Prison staff categorized self-harmers as “genuine or non-genuine.” - “Non-genuine” self-harmers were viewed as “rational manipulators” to achieve specific purpose. - Staff expressed feelings of resentment towards self-harmers and feelings of untrained and unsupported in their role, pressured due to time constraints and low staffing levels.
15. Howerton et al., 2007 United Kingdom	Understanding help seeking behavior of self-harming offenders	n = 35 male offenders	- The major barrier to help seeking behavior of male offenders is distrust. - Health professionals are recommended to undergo awareness training to foster trust among the self-harming population in prison.

Footnotes

Author Note

Julie Ann R. Clemente-Faustino, Department of Psychology College of Social Sciences and Philosophy, Bulacan State University, Guinhawa, City of Malolos, Bulacan, Philippines.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Authors Biographies

Julie Ann R. Clemente-Faustino, RPm, PhD, is a clinical psychologist at the Graduate School of the University of San Tomas, and an assistant professor in the psychology department of Bulacan State University, Malolos City, Bulacan, Philippines.

Allan B. de Guzman, PhD, is an Australian Awards Fellow in Curriculum Leadership, a professor at The Graduate School of the University of Santo Tomas, and a prolific writer who has extensively published more than a hundred articles in various ISI-listed journals.

References

Andrews

, et al. (2017). Relationships between the frequency and severity of NSSI. Early Interventionin Psychiatry. https://doi.org/10.1111/eip.12461

Arcelus

, et al. (2016). Risk factorsfor NSSI among transyouth. Journal of Sexual.

Arthurs

Tan

(2017). Personality traits, early maladaptive schemas, and severity of nonsuicidal self-injury. International Honor Society in Psychology, 22(3), 182–252. https://doi.org/10.24839/2325-7342.JN22.3.181

Bennett

Dyson

(2014). DSH Among adults in prisons. Mental Health Practice, 18(1), 14–20. https://doi.org/ 10.7748/mhp.18.1.14.e931

Biddle

, et al. (2018). Reflections on a project to prevent suicide and self-harm among prisoners. Health & Justice, 6, 22. https://doi.org/10.1186/s40352-018-0080-7

Briner

Denyer

(2012). Systematic review & evidence synthesis. In Rousseau

(Ed.), Oxford Handbook of evidence-based management (pp. 112–129). Oxford University Press.

Chammah

Meagher

(2015). Why jails have more suicides than prisons. Marshall Project. https://www.themarshallproject.org/2015/08/04/why-jails-have-more-suicidesthanprisons#.HwjmGkACA

Chen

Chun

(2019). Association between emotion dysregulation. International Journal of Environmental Research & Public Health, 16, 3361. https://doi.org/10.3390/ijerph16183361

Dixon-Gordon

, et al. (2012). NSSIwithinoffender populations. International Journal of Forensic Mental Health, 11(1), 33–50. https://doi.org/10.1080/14999013.2012.667513

10.

Ekanem

O.J.

(2020). Effectiveness of NSSI Interventions among incarceratedwomen in correctional… University of Saskatchewan, Canada. http://hdl.handle.net/10388/12785

11.

Fazel

, et al. (2013). Suicide in prisoners with BPD and other psychiatric disorders. Bipolar Disorders, 15, 491–495. https://doi.org/10.1016/S2215-0366(16)30142-0

12.

Fazel

, et al. (2016). Mental health of prisoners: A review of prevalence. Lancet Psychiatry, 3(9), 871–881. https://doi.org/10.1016/S2215-0366(16)30142-0

13.

Forrester

, et al. (2018). Mental illness and the provision of mental health services in prisons. British Medical Bulletin, 127, 101–109. https://doi.org/10.1093/bmb/ldy027

14.

Green

, et al. (2018). Association between masculinity and NSSI. American Journal of Men’s Health, 12(1), 30–40. https://doi.org/10.1177%2F1557988315624508

15.

Griffins

, et al. (2019). Professional and peer support preferences for women who SH in custody. Journal of Criminal Psychology, 9(3), 109–121. https://doi.org/10.1108/JCP-12-2018-0049

16.

Gutridge

, et al. (2019). Exploratory study of women prisoners’ attitudes towards their self- harm. Journal of Forensic Psychiatry and Psychology, 30(1), 167–184. https://doi.org/10.1080/14789949.2018.1530285

17.

Hawton

, et al. (2014). Self-harm in prisons in England and Wales: An epidemiological study. Lancet, 383, 1147–1154. https://doi.org/10.1016/S0140-6736(13)62118-2

18.

Hooley

Franklin

(2018). Why do people hurt themselves? Clinical Psychological Science, 6(3), 428–451. https://doi.org/10.1177%2F2167702617745641

19.

Howerton

, et al. (2007). Understanding help-seeking behaviour among Male offenders. BMJ, 334, 303. https://doi.org/10.1136/bmj.39059.594444

20.

International Society for the Study of Self-injury (2018). What is self-injury? Retrieved from: https//itriples.org/about-self-injury/what-is-self-injury

21.

John-Evans

, et al. (2018). Functions of NSSI in prisoners with mental healthdiagnoses. Mental Health Practice. https://doi.org/10.7748/mhp.2018.e1282

22.

Kaba

, et al. (2014). Solitary confinement and risk of self harm among jail inmates. American Journal of Public Health, 104(3), 442–447. https://doi.org/10.2105/AJPH.2013.301742

23.

Kenning

, et al. (2010). Prison staff and women prisoner’s views on self-harm. Criminal Behavior and Mental Health, 20, 274–284. https://doi.org/10.1002/cbm.777

24.

Leamy

, et al. (2011). Conceptual framework for personal recovery in mental health. British Journal of Psychiatry, 199(6), 445–452. https://doi.org/10.1192/bjp.bp.110.083733

25.

Liljedahl

Westling

(2014). Unified Theoretical Framework of Self-harming Behavior. Presented at 3rd International Conference on BPDand Allied Disorders.

26.

Mangnall

Yurkovich

(2010). Grounded theory exploration of DSH. Journal of Forensic Nursing, 6(2), 88–95. https://doi.org/10.1111/j.1939-3938.2010.01072.x

27.

Mann

, et al. (2019). Review of the literature on self-injurious thoughts and behaviors. Clinical Child Psychology, 24(2), 304–321. https://doi.org/10.1177%2F1359104518812724

28.

Marzano

, et al. (2012). Impact of prison staff responses on self-harmingbehaviors. British Journal of Clinical Psychology, 51(1), 4–18. https://doi.org/10.1111/j.2044-8260.2010.02007.x

29.

Marzano

, et al. (2015). Responding to repetitive, non-suicidal self-harm in an English male prison. Legal & Criminological Psychology, 20, 241–254. https://doi.org/10.1111/lcrp.12025

30.

Marzano

, et al. (2016). Non-suicidal SH amongst incarcerated men. Journal of Criminal Psychology, 6(4), 157–172. https://doi.org/10.1108/JCP-04-2016-0017

31.

Masana

, et al. (2020). Unraveling NSSI: Understanding behavioral dynamics of Filipino adolescents at risk of DSH. North American Journal of Psychology, 22(2), 331–354.

32.

Moher

, et al. (2009). Preferred reporting items for systematic reviews and meta- analyses. PLoSMedicine, 6(7), e1000097. https://doi.org/10.1371/journal.pmed.1000097

33.

Oxley

, et al. (2017). Punch injury self-harm in young people. Clinical Child Psychology and Psychiatry, 22(2), 318–325. https://doi.org/10.1177%2F1359104516664121

34.

Perry

, et al. (2019). Implementation of a problem-solving training initiative to reduce self- harm in prisons. Health and Justice, 7, 14. https://doi.org/10.1186/s40352-019-0094-9

35.

Plener

, et al. (2015). Longitudinal course of NSSI and DSH. BPD and Emotion Dysregulation, 2(2), https://doi.org/10.1186/s40479-014-0024-3

36.

Popay

, et al. (2006). Guidance on the Conduct of Narrative Synthesis in Systematic Reviews. Product from the ESRCMethodsProgramme (ref H33250019). Version 1. Lancaster: NSSR.

37.

Power

, et al. (2016). Examining Nock and Prinstein’s4 function model. Personality Disorders: Theory, Research&Treatment, 7(3), 309–314. https://doi.org/10.1037/per0000177

38.

Ramluggun

(2013). Critical exploration of the management of self-harm. Journal of Forensic Nursing, 9(1), 23–34. https://www.https://doi.org/10.1097/JFN.0b013e31827a5984

39.

Reid

Listwan

(2018). Managing the threat of violence: Coping strategies. Journal of Interpersonal Violence, 3(8), 1306–1326. https://doi.org/10.1177%2F0886260515615143

40.

Reyes

, et al. (2019). Adverse childhood experiences and NSSI as mediated by pathological personality traits. Suicidology Online, 10, 9. Corpus ID: 204778259.

41.

Shelton

, et al. (2017). Effective interventions to self-harming behaviors and suicide. Journal for Evidence-Based Practice in Correctional Health, 1(2), 3. https://opencommons.uconn.edu/jepch/vol1/iss2/3

42.

Short

, et al. (2009). Custody vs. Care: Attitudes of prison staff to SH. Journal of Forensic Psychiatry & Psychology, 20(3), 408–426. https://doi.org/10.1080/14789940802377114

43.

Smith

, et al. (2019). Working with prisoners who self- harm: A qualitative study. Criminology Behavioral Mental Health, 29, 7–17. https://doi.org/10.1002.cbm.2103

44.

Smith

Power

(2015). Applying the dual-taxonomy of offending to self- injury. Victims and Offenders, 10(2), 179–213. https://doi.org/10.1080/15564886.2014.913539

45.

Sousa

, et al. (2019). Prison officers’ attitudes towards self-harm in prisoners. International Journal of Law and Psychiatry, 66, https://doi.org/10.1016/j.ijlp.2019.101490

46.

Wakai

, et al. (2014). Women in prison: Self-injurious behavior, risk factors, psychological function and gender-specific interventions. The Prison Journal, 94(3), 347–364. https://doi.org/10.1177%2F0032885514537602

47.

Walker

, et al. (2016). Supporting imprisoned women who SH: Exploring prison staff strategies. Journal of Criminal Psychology, 6(4), 173–186. https://doi.org/10.1108/JCP-02-2016-0007

48.

Walker

, et al. (2017). Coping with the job: Prison staff responding to SH. Journal of Forensic Psychiatry and Psychology, 28(6), 811–824. https://doi.org/10.1080/14789949.2017.1331369

49.

Winicov

(2019). Systematic review of behavioural health interventions for suicidal and self-harming individuals in prisons and jails. Heliyon, 5(9), https://doi.org/10.1016/j.heliyon.2019.e02379