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A National Survey of Self-Injurious Behavior in American Prisons. Psychiatric Services

by Kenneth L. Appelbaum, Judith A. Savageau, Robert L. Trestman, Jeffrey L. Metzner, & Jacques Baillargeon (2011).  62(3): 285-290.

Discussion, and even research, on self-injurious behavior among men and women prisoners may be more common in Canada, the United Kingdom, and perhaps elsewhere than in the United States, where attention to this serious matter seems muted. This article from a team of researchers at the University of Massachusetts Medical School, the University of Connecticut Health Center, and the University of Texas Medical Branch in Galveston is therefore appropriate and long overdue.

Self-injurious behavior, the authors note, can lead to death, but death is not the intent. Such behavior is not suicidal. Rather, it includes cutting, burning, hitting, head banging, ingesting or inserting foreign objects, and self-amputation or enucleation, but not tattooing, piercing, or autoerotic acts. Cutting is the most common form of self-injury, and it is more likely to occur with women or young people, particularly those confined in punitive or restrictive housing units.

For this study, the first national survey of self-injurious behavior among adult prisoners, Appelbaum et al. emailed information to state correctional mental health care services directors on a 30-item online questionnaire that covered definitions and frequency of self-injurious behavior, tracked data, the impact of operations and resources, diagnoses, management, and the roles of custodial and mental health staff. The survey was pilot-tested and sent to correctional mental health directors in the 51 state and federal prison systems. Data were collected between November 2009 and March 2010 from 39 (77%) jurisdictions. Respondents included the federal Bureau of Prisons, plus 12 western states, 10 southern states, 8 midwestern states, and 8 northeastern states. Six states refused to participate, and 6 states simply failed to participate. Only 22 states (56%) reported that they kept data on self-injurious behavior, and this is more likely to tally the gender of the prisoners or the housing unit where the behavior occurred than the sanctions imposed as a result of the behavior.

Thirty-two percent (12) of the reporting jurisdictions have policy statements on self-injury. Three-quarters of the remaining systems distinguish between self-injurious and suicidal behavior; nearly all of those jurisdictions without policy directives allow mental health clinicians, medical clinicians, and even custodial staff to determine the self-injurious nature of specific behavior. Some evidence emerged that self-injurious behavior correlated with system capacity; jurisdictions that distinguished self-injury and suicidal behavior did not show much difference in comparative levels of such behavior.

Self-injurious behavior occurs regularly among the state and federal prison systems. Appelbaum et al. report that 29 systems reported self injurious behavior once a week, 17 several times a week, 2 once a day, and 5 more than once a day. Most of these systems report needing outside of the prison medical services less than 10% of the time; one system reported needing such care 50% of the time. Still, such behavior was general perceived as being disruptive of institutional operations, including the consumption of mental health care services. Both custodial and mental health care staff typically handles such behavior, which is usually viewed as a rule infraction. Custody and mental health staff members are usually "somewhat" or "mostly" collaborative around self-injury events, and the degree of collaboration does not seem to align with who has primary responsibility for such behavior.

Important findings include:

  • Consistently used definitions are not available on the nature of self-injurious behavior, especially those that distinguish between suicidal and non-suicidal behavior;
  • Relatively small numbers of inmates account for frequent self-injurious behavior;
  • Self-injurious behavior is notably present in segregation and other lockdown units, although it is not clear whether such behavior is caused by aggressive behavior, mental illness, or the conditions of these facilities;
  • Management practices attending to self-injurious behavior are inconsistent; and
  • Corrections staff frequently view self-injurious behavior as manipulative, but even if so it is rarely addressed within the context of treatment. 

Treatment options are not routinely available in high-security settings, but things are changing in this regard, although not necessarily with success. As the authors note, "these programs often fail because they are designed and run by custodial staff with inadequate involvement of mental health staff. Custody rules, regulations, and practices can also make it difficult to provide effective positive reinforcements, such as suspension of disciplinary lockdown time, increased out-of-cell time, congregate recreation time, or loaner TVs. More recently, some systems have begun to establish behavioral management unit that address these shortcomings. Similar programs, as well as innovative therapeutic communities in which violent inmates with personality disorders participate in frequent community meetings and play an active role in group decision-making, have met with success in other countries, although one or two years of treatment may be needed before significant improvements occur."

For further information, contact Kenneth L. Appelbaum, M.D., Center for Health Policy and research, University of Massachusetts Medical School, 333South St., 13E779, Shrewsbury, MA 01545, (email) kenneth.appelbaum@umassmed.edu.




Posted Thu, Aug 4 2011 4:53 PM by Tracey Vessels

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