Self-Injurious Behavior in Prison

Abstract

The practice of self-injurious behaviors (SIBs) within corrections disproportionately consumes resources and negatively impacts staff. To date, the majority of empirical studies on the topic have relied upon quantitative methodologies that fail to include the perspective of the actual offender who is engaging in self-injury, thus reinforcing mischaracterizations and confusion. In response, this manuscript features a case study of an offender currently housed in a maximum security prison who routinely engages in self-injury. Findings are presented along the tripartite themes of family background, suicidality, and SIB. Policy implications include supporting a systematic reorientation toward therapeutic responses in lieu of the current punitive responses that may in fact be iatrogenic.

Keywords

self-injurious behaviors case study prison offender mental illness

Introduction

The issue of self-injurious behaviors (SIBs) occurring in prisons continues to be puzzling and costly. A recent national survey on SIBs in U.S. prisons by Smith and Kaminski (2011) identified prevalence rates of 2.4% for self-injury and 0.7% for serious self-injury; this equated to 98% of respondents stating that their prison housed one or more inmates who practiced SIB at the time of the survey. This disconcerting behavior has negative effects on fiscal budgets, institutional function, and often produces tributary problems for staff. For example, DeHart, Smith, and Kaminski (2009) surveyed mental health staff working in a prison system and found consensus that education and training were needed to provide efficacious management of SIB. Likewise, Usher, Power, and Wilton (2010) identify the presence of SIB within a correctional environment as a significant predictor of stress, one that adds significant frustration, distress, anger, and anxiety to the staff role. It is important to mention that while SIB may manifest in various ways, the behavior itself is actually quite distinguishable. To this end, Armando Favazza (1989) is credited with establishing a standard definition of SIB as, “the deliberate destruction or alteration of body tissue without conscious suicidal intent” (p. 137). Favazza adds that “serious self-injury” (p. 137) is more extreme and involves the targeting of the face, neck, eyes, genitals, and even complete amputations or self-emboweling.

Brickman (2004) describes the evolution of research that addresses SIBs as being sporadic and often perpetuating myths. She adds that, in recent years, there has been an overall growth in academic- and policy-related interest on SIBs that is much needed. A review of these empirical studies finds several broad categories that include: (a) risk factor epidemiology designed to identify exogenous factors (e.g., demographics, psychological variables) that contribute to SIBs, (b) contrasts between the manifestation of SIBs and suicidal processes, and (c) comparisons between offenders who engage in SIBs with other incarcerated offenders who do not engage in SIBs. A reflection of these approaches reveals an overemphasis on quantitative methodologies, coupled with a disinclination to include the perspective of the offender who self-injures. This lack of research is problematic as SIB remains a difficult behavior for many prison administrators and staff to understand, principally because it violates the biological imperative toward self-protection (Favazza, 1998). As Borrill et al. (2003) articulate, “it is acknowledged that in practice the individual may have complex and ambivalent motives” (p. 230). Even in studies of offenders who routinely self-injure and who seem to have no intention of committing suicide, there is significant clinician and researcher confusion. For example, Dear, Thomson, and Hills (2000) examined a subset of offenders who routinely engaged in SIBs and wrote “although these prisoners were seeking to improve their circumstances, they seemed prepare to die in the process. This appears difficult to explain” (p. 172).

Devoid of methodological approaches that attempt to explain SIB from the perspective of the offender, there is frequently an acceptance by staff to assert their own assumptions (DeHart et al., 2009). Prison staff and administrators may misperceive SIBs as a product of free-choice, manipulation, or attention-seeking functions, with some staff even perceiving the behavior as a personal threat used to assert institutional control (Smith, 2014). Inevitably, such beliefs lead to punitive (non-therapeutic) institutional responses that produce an additional cycle of more severe and frequent acts of self-injury (see Lanes, 2011; Smith, 2014).

Literature Review

The psychiatrist Karl Menninger (1935, 1938) was one of the most influential researchers to investigate SIBs. Menninger’s (1938) work titled Man Against Himself is replete with case studies that detail self-mutilation. Menninger details the SIB exhibited by a 20-year-old male who experienced chronic mental illness (see the appendix: Karl Menninger’s Case Study). Menninger (1938) generalizes the themes within this specific case (and others in the book) as sharing the following commonalities: SIB is a general tendency rather than a clinical diagnosis, SIB manifests in graphic and varied forms, SIB is distinct from suicidal impulses, SIB may contain a sexual or rejected love component, and the targeting of a particular body part in SIB always contains meaning. Menninger (1938) adds that the act of self-injury is confusing because it is “apparently senseless or is justified by such irrational and illogical explanations” (p. 261).

While Menninger provides a remarkable starting point for SIB case studies, there have since been a number of relevant case studies that focus on the correctional milieu. We will now discuss some salient themes found in these noteworthy studies.

SIB Case Studies (Incarcerated Settings)

A review of the empirical literature finds only a few examples of case studies within corrections (Bach-Y-Rita, 1974; Cohen, 2003; Cooper, 1971; Harding, 1994; Jeglic, Vanderhoff, & Donovick, 2005; Parker, 1991). Here, one finds themes specific to correctional populations. For example, many of the early experiences presented, in these incarcerated case studies, feature profoundly disturbing familial patterns. This included the presence of sadism, deprivation and random violence, parental mental illness that was severe enough to require hospitalization, and extensive criminality and/or deviance within the family. Sexual abuse often included multiple family perpetrators and even occurred in the open. By adolescence, these offenders reported experiencing outbursts of anger, very few close relationships or social bonds, and early symptoms of chronic mental health (Bach-Y-Rita, 1974).

Not surprisingly, many of these case studies also revealed the presence of more extreme, frequent, and severe SIBs when compared with non-incarcerated groups; with the offender often arriving for their prison sentence already physically scarred from a history of SIB (Cohen, 2003; Cooper, 1971). Moreover, this research revealed that once incarcerated, the surveillance and control by correctional staff required that the offender utilize whatever makeshift or improvised SIB tools that they could identify, store, and quickly access (e.g., scrap metal, broken glass, acquisition of tools from another inmate; see Cooper, 1971; Smith, 2014). The SIB act itself was customarily conducted in a private setting, usually a cell (Cooper, 1971).

In terms of policy, these case study analyses all suggest that the correctional system was simply unable or unwilling to adequately deal with SIB-prone offenders. In other words, prisons appear to be counter-productive to effective therapy and desistance from SIBs. Although many of these offenders arrived at the prison already self-defined as habitual “cutters,” they soon displayed explosive expressions of violence toward staff and themselves, increasingly experienced symptoms related to a chronic mental illness, and were perceived by staff as being non-compliant with regard to institutional rules. For example, Cooper (1971) states that self-injurious offenders “are of real concern to the prison authorities who do not know how to handle them” (p. 185). Bach-Y-Rita (1974) finds that many SIB offenders filter into mental health units within a prison due to their “unmanageable violent behavior” (p. 1018) and Cohen (2003) simply terms these offenders as “management’s worst nightmares” (p. 45).¹

This is perhaps most striking in the case study of Gary David (Parker, 1991). David, an Australian inmate, was institutionalized in orphanages from an early age and progressed from crimes such as burglary and robbery to homicide, the crime that ultimately resulted in his incarceration. His subsequent acts of SIB were numerous and severe,² resulting in brief stays at a psychiatric hospital “to give prison officers a break” (Parker, 1991, p. 371). David was diagnosed with antisocial personality disorder, and, in contrast to other SIB-based case studies, he fully articulated a decidedly manipulative motive. In David’s own words, “If I didn’t like a particular situation or I thought there was something unjust, I used my body as a hostage” (Parker, 1991, p. 371).

The most remarkable aspect of the Garry David case study occurred at his time of impending release. Here, there was an attempt at reforming existing mental health laws in direct response to David, specifically to include consideration of his personality disorder and aggressive history. The nexus of this case culminated in the media exploitation of David’s severe and bizarre history of SIBs, challenges to Supreme Court rulings regarding the constitutionality of preventive detention, accusations of political interference, and the questioning of the mental health assessments made by psychologists and psychiatrists (Parker, 1991).³ It is fascinating that one offender who routinely conducted an expressive behavior that denotes being personally overwhelmed (i.e., SIB) did, in fact, overwhelm an entire correctional system mainly by exploiting SIBs and violence (see Parker, 1991).

In addition to emphasizing the challenges that offenders who self-injure create for correctional jurisdictions and administrators, these cases studies also highlight the challenges of providing staff with adequate education and training. Correctional staff are primarily trained on matters of security rather than therapy. When encountering a SIB-prone offender, there is frequently a battle for control, which often leads to a disastrous cycle in which punitive strategies such as isolation only encourage more acts of SIB (Smith, 2014). Bach-Y-Rita (1974) states that prison administration, and staff, often “shuns these patients and, for lack of better terms, labels them psychopaths, schizophrenic personalities, or just plain manipulators. They arouse considerable anxiety, fear, and hostility in the staff and usually get little treatment” (p. 1018). This state of affairs is consistently reported in SIB case study research within corrections, and also documented in different international contexts and time periods. Certainly, more research is needed to develop efficacious strategies that can reduce rates of SIB occuring in prison.

To address this gap, this article details a case study of one offender who has used SIB habitually through his life course. This offender is currently housed in a maximum security prison. The nuances of self-injurious behavior are explained in terms of its etiology, manifestation, and decision making that now represents a serious threat to the morbidity and mortality of this individual. An extreme example was selected for purposes of articulating SIB over an extended period of time, and while graphic in content, it is estimated that the correctional system in which this individual resides currently has approximately 60 to 70 other offenders who engage in SIBs at this level of frequency and severity.

Method

Participant and Case Study Design

The individual in this case study was a participant in a larger research study that used the following criteria for recruitment. Participants were (a) known to mental health staff as being recidivistic SIB practitioners while incarcerated, (b) SIB was practiced with such frequency and severity that it produced physical scars, (c) the participant was currently engaged in ongoing therapeutic counseling within the prison, and (d) they were deemed by mental health staff and the interview team to understand the Institutional Review Board (IRB) protocols. This original study employed a purposive sampling technique designed to include recidivistic SIB practitioners who were housed in a high security prison at the time of the study (Singleton & Straits, 2005). The participant in this case study presented himself with noticeable acumen for explaining SIB processes and a case study methodology was created. The acronym Mr. S was subsequently used to identify this participant.

Mr. S was 30 years of age at the time of the interview and had been incarcerated for approximately 10 years. His criminal history involves numerous felonies, including violent offenses with a firearm, with a cumulative sentence of 12 years in prison. Mr. S also had previous sentences that resulted in contact with jails and the police. Although his current psychiatric diagnosis was bipolar disorder, he stated that since the age of 16 he had received “confusing and mixed diagnoses, like every new person had a new diagnosis for me.” According to Mr. S, previous diagnoses included posttraumatic stress disorder (PTSD), depression, anxiety, PTSD with psychotic episodes, and alcohol abuse. Mr. S displayed substantial intelligence, reflective insight, and was adept at articulating emotions, which was a notable contrast to many other SIB-prone offenders who often have trouble communicating emotions or are even completely alexithymic (see Klonsky & Muehlenkamp, 2007).

Mr. S is a long-term SIB practitioner who is well known to prison officials due to his current and historical SIB, which can definitely be classed as “frequent and severe.” With this in mind a case study design was deemed appropriate. Yin (2013) states that a single case design is eminently justifiable when “the case represents an extreme case or an unusual case, deviating from theoretical norms or even everyday occurrences” (p. 52). Yin (2013) adds that extreme cases “may reveal insights about normal processes. In this manner, the value of a case study can be connected to a large number of people, well beyond those suffering from the original clinical syndrome” (p. 52). As such, although statistical generalizations are impossible, this approach aims to develop analytical or conceptual generalizations (Yin, 2004).

In recognizing the vulnerable status (e.g., inmate, mental illness, SIB/suicide history) of Mr. S, several steps were taken. The IRB application was reviewed and approved by both the University of South Carolina and the correctional system in which Mr. S was housed. A consent document (including IRB caveats) was read by the researcher to Mr. S and his permission was obtained. In addition, the interview was conducted immediately prior to an individual therapy session with a certified psychiatrist to ensure that any troubling issues could be addressed by a trained professional. Finally, names and specific details were altered or withheld to further protect confidentiality.

Procedure and Data Analysis

One interview was conducted with Mr. S that lasted 3 hr in length. This interview began with several questions that were obtained from Favazza’s “Self-Harm Behavior Survey” (e.g., “Were you ever sexually/physically abused?”; “How often do your currently self-injure yourself?”; “What was your reaction after you first harmed yourself, for example, scared, suicidal, relieved?”; and so on; see Favazza, 1988). These questions were introduced as prompts for a more open-ended discussion in which the respondent was encouraged to construct reality and think about situations (Yin, 2004). Due to the fact that Favazza’s prompts were designed for non-incarcerated samples, additional questions regarding personal relationships with staff and other inmates, violence, criminality, and perceptions of incarceration were added. Consistent with prison requirements, the interview was handwritten and typed up immediately afterward. Data collection and analysis were developed together in an iterative process, thus following a grounded theory approach (Corbin & Strauss, 2007; Glaser & Strauss, 1967). This inductive approach produced rich data within the incarcerated context. Coding produced the following tripartite themes: family background, suicidality, and the primary topic of SIB.

Findings

Family History

Mr. S experienced an extremely turbulent childhood in a rural setting. At an early age, he was processed by the foster care system and placed in a home that could house up to 28 children at a given time. Three of these children were biological children of the foster parents. During childhood and continuing since that time, Mr. S has identified the foster parents as “mom and dad.” Sexual abuse was rampant in the household, with the earliest recalled event occurring when Mr. S was approximately 5 years of age. One of the older female children would engage Mr. S in sexual acts that were often bizarre and degrading. At approximately age 6 or 7, an older male child also attempted to perform sexual acts on Mr. S while he was taking a shower. His account of the incident and family reaction follows:

I knew that it was wrong and ran into the living room. My daddy and momma were there with my uncle and aunt. I was naked and wet and I told them what happened. Daddy punched me and said I was lying and that was his only real son—not me. He picked me up by the feet and took me to the bathroom and started dunking my head saying I was a liar and shouting to take back the lie. My head was getting pounded into the porcelain and I was swallowing toilet water. Finally, my uncle grabbed my dad and said, “He is too young to make that up, stop it.” He grabbed my dad and my dad dropped me into the toilet upside down. I still remember that it felt, like it was going to break my neck cause my head was stuck in the bottom of the toilet and my body all twisted up when he let me go. It taught me to be a liar, taught me to say the best thing not the truth.

Sexual abuse victimization continued to be experienced by Mr. S until the age of 15. During childhood and early adolescence, the sister of Mr. S was the chief perpetrator and when the parents left the house she would create sadistic punishments that involved making him stand with arms wide open for long periods of time, hitting him with a belt or switch, and engaging in different forms of sexual abuse. At other times, Mr. S described her as being very “possessive” of him and keeping him close to her at all times, “like a doll.” On one occasion, Mr. S hid under the house for 8 hr until the police were called to locate him. Mr. S demonstrated resilience by attempting to report the abuse to his foster parents, but these efforts were always met with physical abuse that included sadism. Although this included many disturbing recollections, the most noteworthy was this event that took place when Mr. S was about age 7:

It got worse after that (reporting abuse). Dad would be more abusive, more violent. It was bad. One time, I was little, he put me in one of those burlap sacks. Do you know those things? Well he stuffed me in that. He got this yellow nylon rope and put it through the top of the sack and ran it over this beam so I was hanging in the sack in mid-air. The pressure on my shoulder and side was unbelievable. All your body weight puts pressure on one part, man it hurts. I could see out a little and as the bag spun in the air I would see the things in barn go back and forth, like the fridge. Dad would get a broom or something in barn and smack the sack over and over.

Mr. S experienced repeated physical and sexual abuse until the age of 15, at which time he was required to fulfill chores and manual labor on the farm before and after school, which lead to a significant turning point. Being tired, he fell asleep in study hall and was sent to the principal’s office. This event signified an opposition to perceptions of injustice as shown here:

The teacher seemed vicious or mean to me. I had dealt with so much bullshit at home. I was barely holding it all together, holding it all in for so long. I just snapped and dealing with authority figures I shouted “fuck you” to the teacher. My dad and mom had written a special note so I was the only person that I knew of in the school who would get a paddle. So the Principal pulls out the wooden slab and tells me to take the punishment in his office. I think to myself—“No way, this ain’t happening, this [abuse] is over. I have been chocked, sexually abused, beaten, broken nose, no more.” So I just walked out of school and got expelled.

The response to the school expulsion was another beating by his foster father, but Mr. S states he refused to strike back “out of respect.” Instead, his foster father found the biological grandmother of Mr. S and “dumped him” at her house. Mr. S remembered great optimism as his grandmother reconnected him with his biological mother who he described as “my idol.” Within the first week of their unification, his mom told Mr. S that he was “stressed out” and she proceeded to provide him with marijuana, beer, and Xanax pills. This drug use progressed into shoplifting, and the need for more money to support an emerging drug habit. At age 15, Mr. S once again experienced hopelessness and began to interact with the criminal justice system:

My real (biological) mom would hit me with a screwdriver. She got me smoking crack. I needed Xanax and booze everyday just to function. So a friend gave me this shotgun which I kept under my door for like one day. It had only been hours and my mom found the gun. She thought I was going to kill her so she called the police. I got my DJJ⁴ probation violated for “possession of a shotgun” and for being drunk and beating on mailboxes.

This episode was followed by two experiences of complete abandonment that devastated Mr. S. Initially, Mr. S returned home only to find his biological mother and her boyfriend had simply left town, “I did not know where they went, no forwarding information. I was in a trailer by myself way out on the prairie. I had no job, no family, nothing.” Following this, Mr. S located his biological father and while hopeful of a life change, this reunion only lasted one day as shown here:

My real (biological) dad took me in and I thought I was great. I went out that night with friends to party and came home like one hour late. My real dad was (physically) huge and I didn’t know him. He stopped me at the door and asked why I was late. He told me to go to my room. I thought he was going to beat me, that’s what happened when I was younger with my adopted dad. I was 15 and said “no more.” I told him I was not going into my room. He said, “Then I don’t have a son” and he told me to leave. I have since let him know that he is a grandparent but have not heard anything from him in response. I wish he knew that my (foster) dad would send me to my room and beat me. It was not about him.

At age 17, Mr. S had one child with his girlfriend who was in college and also working at a gentlemen’s club. Mr. S began to experience mental health symptoms at this time, described as such, “While I’m with her I was having trouble sleeping, bad dreams every night. Trying to rest but I can’t. It’s like there are lots and lots of little compartments in my head, and concentration becomes very hard.” Mr. S then drove out of state to locate his biological mother. This decision ultimately led to a string of crimes that resulted in his long-term incarceration. Mr. S states,

Mom was smoking crack, then she would drive me around and we would steal from places where she used to work. She would know where the safes were, what the combinations were, where the cameras were and how to turn them off, what windows to break and all that stuff. We were like a little team, breaking into stores, gas stations, mom would draw me a map, and I would break and enter. I started getting more and more high all the time. I took so many drugs that if I didn’t get high I was convinced that I would die. Most people don’t stop until it’s too late. Without drugs, I would instantly think about suicide and try it. I was so high for years and years. I had to learn that getting high does not solve or avoid problems. Those problems are still waiting for you to come back sober and deal with, but there are too many problems around. There were periods of months where I would just keep myself high and drugs in my body non-stop. A lot of this was because I would have flashbacks to my childhood. I would go to sleep, wake up with flashbacks, and I would be in the fetal position in the corner and not know how I got there. I would wake up anywhere, different times of night, sleep, dreams, flashbacks. I would wake up choking someone and there would be no-one there. It got more intense. I would be sweating and crying. Much more intense. I started getting feelings and hearing I never had before. Like my sense were on “super-alert,” like I had super-hearing and could hear everything. Eventually I did [crime redacted] and violation of probation, it was 28 charges, all felonies.

Suicide

Mr. S recalled three distinct suicide attempts at age 13 (due to sexual abuse), age 17 (in response to his girlfriend’s impending departure and repressed emotions), and age 18 (when his biological mother left without notice). All of these attempts included highly lethal methods with the motivation clearly recalled as being death. For example, during the suicide attempt at age 18, Mr. S sat in his trailer for 2 days following the abandonment by his biological mother. As the power was turned off, food ran out, and the rent was due, he recalled a feeling that he “had to do something.” He remembered the event with remarkable clarity and gallows humor:

I got this dead feeling. I was raised religious so I kept thinking about the quote “ashes to ashes, dust to dust.” I ate 17 Xanax’s (pills) and drank a King Cobra. You know that “snake piss.” I felt it hit me and I staggered back to the farthest room from the exit. I just sat there and set the curtains on fire and lit a cigarette. I was nodding of and the fire was getting hot. I thought, “Well, I guess I don’t have to worry about falling asleep with a lit cigarette and starting a house fire.” I put the cigarette out and nodded off. I guess the neighbors saw the flames and smoke and pulled me out of the fire. I don’t remember and I never got burnt. I mean my skin was all really red but there was no burns or blisters. But I did get charged a second degree arson felony charge for the fire. My blood pressure after the fire was 56/48 so I did almost die.

SIB

Mr. S reported being a long-term practitioner of SIB, with a peak cutting period occurring between ages 11 to 17. Mr. S distinctly recalled the first time he encountered SIB and its instant psychological and physiological effects. Interestingly, he initially discovered the emotional regulation that SIB could provide by accident. He states:

The first big time I remember is when my parents were out of the house. Even though I was going through a lot of stuff [abuse] I was very protective of all the little kids they had in the house. So this little girl had been running and broke the glass on the stereo cabinet. The girl was going to get in big trouble and I knew I had better just take the blame and protect her. So first I cleaned up all the broken glass. I put it in a plastic shopping bag and took it outside to throw away. Some pieces of glass fell out the bag and cut my hand. I felt it right away. I was like WHOA!!! So I took another piece of glass and rubbed into my skin. Just enough to rip the skin. I got beat for the broken cabinet. The little girl was so scared. She didn’t mean it; she was just running around the house. It was weird they had statues and stuff all over the house with 28 kids, and kids break stuff. Anyway I took the beating and then started more cutting. I would pinch my thighs; I started burning things on my thighs or would just use an iron on my skin. I would make sure not to melt the skin just put the iron close and burn. I would lay paperclips on the iron and use the paperclips to burn myself. This (SIB) stayed the same for years.

The need for privacy during SIB as a form of ritual was evident in the following two accounts by Mr. S. The initial pattern with SIB occurred during childhood:

Remember we were way out in the country and so we had to burn our own trash. We had to separate all the trash, like paper, and cans, and then way away from the house was where we took and burnt the trash. So I would go there with a little trash and sit in this one ditch where no-one could see me. That was my spot. I would take a can lid and make little marks on my arm. We were always in the briar patches and out on the farm so bruises and scratches were never questioned. I always had an excuse and they didn’t care anyway.

The second pattern illustrates the need for SIB-privacy during incarceration as an adult:

I have almost died from cutting a few times. I tried to hide it from them (prison staff) for a while. I would get a Styrofoam cup off my food tray and keep it in my cell. I would cut myself in the cell and when the cup got filled I would tip it down the toilet and flush, but doing this I kept losing too much blood. I have been to hospital 4 times or so for doing this too much.

During incarceration, Mr. S would routinely engage in serious SIB, often in direct response to recollections of his abusive and traumatic childhood. He also self-injured when he received bad news (e.g., his foster mother having terminal cancer) or when his abusive sister contacted him to apologize for her actions. It also occurred in relation to a generalized building of stress and the repression of emotions. When asked by the author about his current state of emotions, that is, feelings of happiness, sadness, dread, anxiety, and hope, Mr. S needed some time to process the question.⁵ He then simply responded, “I think I feel all those things at the same time.” Mr. S explained this emotional impasse as such:

I move things around in my mind. I do this in life too, I reorganize my locker all the time, take everything out and reorganize, move furniture around the room. Same with feelings, I am always moving around my feelings.

In addition to addressing emotional repression, there were significant physiological benefits produced by SIB. This was articulated by Mr. S as follows:

In here (prison) I try to do lots of recreation, to move around a lot. Any activity helps, football, handball, just moving. See here we are in a small space with lots of people. It gets stale, and then I may get a buildup of stress. I get stuck in my room, and my mind goes a thousand miles a minute, I can’t sleep, I can’t eat, I can’t focus on shit. I start with scratches, and then I manage the blood. It feels so good, I know I have to make the decision to stop, but it is good so I want it to last. I feel the relaxation, and my body gets cool, my hands less active, and my mind slows way down. I hold my arm to stop the bleeding and sometimes it is bad, like blood may be flowing under the cell door. I have never passed out, but I know when I have gone too far.

In terms of institutional responses, Mr. S highlighted punitive isolation as carrying high risk of accidental death via SIB. Isolation reaffirmed feelings of hopelessness, abandonment, and heightened the symptoms of chronic mental illness. Mr. S recalled one such event:

When I got to prison I was on lock-up. They put me in isolation because I tried to escape. My cutting always starts in my dreams. I fall asleep and wake up with me in the bag (burlap sack from earlier account). It feels so real, like I am back there, in the bag. My eyes are looking out of the bag, spinning. I see the tools in the shed, spinning slowly, and the big fridge. It is so real and I wake up covered in sweat. I want to take a shower, and when I tried to sleep again I try to be objective and think how this was a dream and not real. So when I get stressed it starts in my body, it is like a building up inside. My heart starts beating quickly. I get anxiety and it is like panic, and stress. Once you cut, if you hit a vein, lots of blood comes out. Not enough to die, but I will feel my heart rate decrease, my breathing goes back to normal, it is like I wanted. The stress is gone. It works.

With regard to desistance from SIB, Mr. S reported few resources. As evident in his accounts, the act of SIB never held a death-impulse although he admitted that his cutting was severe enough that he could possibly end his life by accident. Mr. S was a recognized prison tattoo artist and found that tattooing himself could assuage an impending SIB event. He described pain from tattooing as a “feel good pinch” and found value in tattooing to hide scars on his body and other “cutters.”⁶ Several members of his family who had abused him or who had not protected Mr. S had since apologized in person or with letters. However, his response was “thanks, but big help this does now” and these apologies had no effect on decreasing SIBs. Following one severe SIB event, Mr. S engaged in a routine that offered some desistance:

Mr. S:

I know this sounds stupid. I put pictures (photos of family and his child) on top of the Bible and flip to a new one every day. It is a little ritual I do, with the Bible under it. I pray the people in the pictures are safe. I remind myself that I got people out there who had nothing to do with it (abuse). After I almost died cutting I decided to do this picture thing.

Author:

That sounds like a success. So how would you describe your own strengths?

Mr. S:

I never thought about it. I guess I never give up. I don’t wanna lie down. Really deep down I don’t wanna die. Sometimes, I think I went through all that stuff to help other people.

Discussion and Conclusion

This study presents the case study of a highly recidivistic SIB practitioner currently residing in a high level security prison in the United States. Although generalizations cannot be made from one case, this particular case was determined to be worthy of profiling as it effectively illustrates several themes that are commonly found among offenders who self-injure: extremely abusive family environments, histories of substance abuse, violence and trauma, affect regulation achieved through SIB, an initiation of SIB prior to incarceration, a desire to self-injure privately (and therefore not for attention), and a co-occurrence, although differentiation, between SIB and suicide attempts.

A reflection of Mr. S’s life experiences and SIB practices reveals several key similarities to the empirical literature. In fact, it is quite remarkable how similar many of these themes are, regardless of when the empirical piece was written or the type of SIB manifestation, suggesting that the behavior itself maintains distinct characteristics. In this case study, one is presented with evidence of childhood experiences that extend far beyond dysfunctional, to include acts of complete abandonment, sadism, and bizarre sexual abuse. Solomon and Heide (1999) define such pervasive and violent child abuse as Type III trauma, signified by early victimization onset, lasting a long time, and including multiple perpetrators. Offenders like Mr. S often cope with Type III abuse via emotional numbing, suppression of rage, and with “anger acted out on the self in the form of self-hate and self-mutilation” (Solomon & Heide, 1999, p. 207). Furthermore, the exposure to Type III trauma during childhood remains entrenched throughout the life course, often emerging in the form of intensely disturbing dreams that trigger self-injury (Smith, 2014).

In the case of Mr. S, the behavior of SIB was discovered by accident but proved to be an immense and overriding means of coping. Mr. S began to utilize SIB during childhood and early adolescence during a time of extreme abuse and trauma, and SIB was then practiced routinely over time. This finding is consistent with quantitative studies that indicate many SIB offenders enter the correctional milieu already practicing the behavior. For example, Haines, Williams, and Brain (1995) found that in their sample that 79% of offenders had engaged in SIB prior to any form of incarceration. This included a mean of 48 self-reported SIB events per respondent. Similarly, Power, Brown, and Usher (2013b) found that 93% of federally sentenced women in their study with a history of SIB had initiated this behavior prior to being admitted to a federal correctional institution. This prevalence of SIB prior to incarceration suggests that prisons with offenders who engage in recidivistic SIBs are largely inheriting the problematic behavior, and that these offenders are highly reliant on this entrenched and alternative form of coping. Although not creating this pathological behavior, the correctional institutions are left trying to effectively manage it.

Similar to previous literature, this case study reveals an absence of adequate resources and education that can be used by institutional staff to respond to offender SIBs. Often, there is an assumption of manipulation by others; however, this seems to stand in contrast to the accounts of Mr. S who practiced the behavior prior to incarceration, did not report conducting SIB in response to any staff member or inmate, continually hid acts of SIB and scars rather than display them, and was far more troubled and triggered by an abusive history than any prisonization effects. As Bach-Y-Rita (1974) notes, “the role played by self-mutilation was occasionally manipulative, but it had a greater meaning than this” (p. 1018). Studies generally suggest that while individuals, including offenders, do engage in SIB for instrumental reasons, it is rarely the primary (and never the most common) reason (see Power, Brown, & Usher, 2013a). Rather, the SIB reported in the literature (Bach-Y-Rita, 1974; Emerson, 1913; Grunebaum & Klerman, 1967) and the accounts of Mr. S were a response to feelings of impending dread and as such the offender needed to “do something.” SIB as a coping mechanism produced very clear psychological and physiological benefits, and while directed toward living, this was practiced with such frequency and severity that it carried risk of accidental death.

When SIB manifested in the prison milieu, the institutional response was often punitive and included strategies of isolation that mimicked earlier childhood experiences of abandonment and hopelessness. The accounts supplied by Mr. S reinforced this sense of hopelessness with a pattern of “one step forward” in optimism, followed by life events that seem to push him “seven steps backward” and ultimately left him emotionally overwhelmed. Isolation merely provides boredom and reaffirmed this sense of hopelessness. Isolation also stimulated the presence of symptoms of chronic mental illness. As such, it is hardly surprising that punitive institutional responses only promoted greater and more severe acts of SIB. Unfortunately, a recent study by Lanes (2011) revealed that offenders who engaged in three or more documented acts of SIB while in prison were twice as likely as their non-SIB counterparts to be housed in long-term administrative segregation. This strategy features 23 hours a day in a solo cell, infrequent showers, use of leg-irons, cuffs and other restraints when leaving the cell, distance from other inmates and parts of the prison, revocation of family visitation rights, and reduced contact with much need programs and therapies. Lanes (2011) states that this high-risk status reduces the SIB-prone offender to limited access to “custody, legal, health care, and mental health visits and yard time in an outside cage or cubicle about the size of the prisoner’s cell” (p. 1037). These findings reinforce a systematic response to a dysfunctional coping mechanism that currently offers little utility.

In its place, this study reinforces the need for a therapeutic response to SIBs, with the realistic goal of reducing (not necessarily stopping) rates of SIBs occurring in prison. As Solomon and Heide (1999) point out, an individual who has sustained Type III trauma will still present the therapy staff with complexity and demands. However, a therapeutic approach is much more likely to decrease costs, lessen the burden on staff, and improve the lives of these troubled offenders when compared with current punitive responses that may in fact be iatrogenic. As Bach-Y-Rita (1974) summarizes,

I can only speculate as to why patients who show such overwhelming pathology end up in punitive maximum security prisons rather than being isolated from society in a protective way. They are undoubtedly dangerous, but the danger extends to themselves as well as society. (p. 1018)

Although the themes were clearly articulated, an acknowledgment of weaknesses is warranted. Using a case study methodology, no statistical generalization to other populations or settings is possible; rather, the emphasis is placed on the thematic discourse. In addition, the highly subjective nature of these accounts does not include alternative viewpoints from family, friends, and victims. Although validation of historical and personal details is difficult, an assessment of institutional records did verify a history of SIB events and one escape attempt (as mentioned above). Nonetheless, this case study offers an effective illustration of the life history of an offender who engaged in serious, recidivistic SIB and provides valuable insight into the development and maintenance of this behavior.

Footnotes

Appendix: Karl Menninger’s Case Study

Karl Menninger’s case study (1938) reads,

A boy of twenty returned from the war to find that a girl to whom he had been engaged had married another man. This was the precipitating factor in the development of an acute schizophrenic illness with delusions, hallucinations, and queer posturing, after which a few relapses became chronic and necessitated continuous hospitalization. From the standpoint of care, he was an exceedingly difficult patient in the hospital because of his persistent efforts to injure himself. He would, for example, tie string tightly about his toes with the evident purpose of producing gangrene. He would slip up behind the heavy doors of the hospital as they were being closed after a physician or nurse and put his fingers into the cracks so as to have them crushed. Upon several occasions, he snatched pins from the front of a nurse’s uniform and attempted to jab them into his eyes. He would seize and separate the fingers of one hand and by using his leg and his other hand attempt to pull them apart so violently as to tear the webs between them. With his thumb and finger nail, he would pinch chunks out of his ear lobes. He frequently dived or plunged from his bed onto the floor, head first, as if attempting to crush his skull. Once he was found nearly asphyxiated as a result of having forced several large stalks of celery deep into his throat. (p. 262)

Declaration of Conflicting Interests

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

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Notes

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