Self-injury encompasses behaviors that result in deliberate harm or injury to oneself. This comprises a number of behaviors including nonsuicidal self-injury (NSSI), suicidal self-injury, and suicide attempts resulting in death. This article focuses on and distinguishes between two forms of self-injury: suicidal and nonsuicidal.
NSSI includes self-directed behaviors that are deliberately inflicted and that result in injury or harm. These behaviors must be outside the realm of socially sanctioned forms of self-injury, which have a creative or expressive purpose such as piercings and tattoos. They must also be distinguished from suicidal self-injury in which one engages with specific intent to end one’s life. The key difference between these two forms of self-injury is intent; NSSI occurs without specific intent to die, whereas in suicidal self-injury, this intent is present.
Self-injury, both suicidal and nonsuicidal, is common in correctional settings (nearly all U.S. state prisons report housing at least one offender who engages in self-injury) and, compared to the general population, is consistently found to be more prevalent among correctional populations. Such behaviors have important implications for offenders, the correctional rehabilitation environment, and institutional staff. This article focuses on prevalence and description of the phenomena, risk factors, motivations and theoretical explanations, implications, and treatment.
Prevalence of Suicidal Self-Injury and NSSI in Correctional Settings
Prevalence rate estimates of self-injury among offenders vary because specific intent to die (or lack thereof) is not always recorded or established. Lifetime prevalence of NSSI among offenders is estimated to be up to 48%, and rates among offenders with mental disorders are even higher, with rates of NSSI up to 60%. It is estimated that between 2% and 18% of male offenders, and 5–24% of female offenders, will engage in some form of self-injury during their incarceration.
Prevalence rates of suicide attempts in offender populations are reported to range from 15% to 22%. These estimates are considerably higher than the general adult population, where 4% are estimated to have ever engaged in NSSI and nearly 5% report ever attempting suicide.
Suicidal self-injury and NSSI can also be differentiated in their methods and their lethality. The most common methods of suicide attempt in Western nations are hanging and ingestion of toxic substances, with the exception of the United States where use of firearms is predominant. In contrast, cutting is the most common form of NSSI, usually performed on parts of the body associated with low lethality such as forearms. Other common forms of NSSI include burning, scratching, head banging, and ligatures. The most common forms of NSSI in correctional settings are cutting, scratching, head banging, opening old wounds (also known as interference with wound healing), and inserting objects.
Gender Considerations
It is often assumed that NSSI is more common in women, yet epidemiological studies in the general population do not find differing rates of the behavior among genders. The same is true of borderline personality disorder (BPD), for which self-injury is a diagnostic criteria. That is, although BPD is generally thought of as being more common in women, and indeed is more likely to be diagnosed in women, when random samples of both genders are assessed for BPD, no gender differences are found. There are a number of reasons why these perceived gender differences may exist. For example, women may be more likely to disclose their self-injury, or health professionals may be more likely to directly inquire about self-injury with women. Alternatively, men may find it easier to provide plausible alternative explanations for their injuries given that men more commonly engage in activities or employment where injury is likely (e.g., construction) or to be involved in physical altercations.
In correctional settings, as with the general population, although women offenders have been the subject of more empirical research than have men, it is now commonly thought that self-injury is prevalent in male offenders as well. Gender differences have been noted in methods of self-injury, however, with women being more likely to cut themselves and men being more likely to hit or burn themselves.
Risk Factors
NSSI and suicide attempts are correlated. Of individuals in the general population who engage in NSSI, one half to three quarters have also attempted suicide at least once, and 50% of individuals who attempt suicide have a history of NSSI. NSSI is one of the strongest predictors of suicide attempts and completed suicides. Among offenders, those who die by suicide are more likely to have a history of NSSI than other members of the offender population, and male offenders who engage in self-injury have higher levels of suicidal ideation than those who do not have such a history. NSSI is also a strong predictor of suicide both while incarcerated and after release.
Limited research has attempted to differentiate between these two behaviors in correctional settings, as it is often difficult to distinguish between self-injury that is motivated by an intent to die and self-injury that is not, and most correctional institutions respond to the behaviors in the same manner, regardless of intent. However, offenders who have made suicide attempts have been found to have different clinical presentations and histories than those who engaged in NSSI, so precise investigation and distinction is warranted.
Research has begun to focus on specific risk factors for NSSI in offender populations. BPD, trauma history (particularly sexual abuse), anxiety and depression, post-traumatic stress disorder, substance use, eating disorders, and aggression/impulsivity all have been noted as correlates of NSSI. Risk factors for self-injury with suicidal intent differ slightly, with depression (particularly hopelessness) being one of the most important risk factors for suicide attempts. Older age is also more strongly associated with suicidal self-injury than NSSI.
It is extremely likely that offenders who engage in NSSI while incarcerated have a history of doing so prior to entering a correctional setting. The majority of offenders who have engaged in self-injury (suicidal or otherwise) report initiating the behavior in adolescence, prior to any form of incarceration. This finding is also consistent with the average age of initiation of self-injury, which is generally during adolescence. As such, it is highly plausible that risk factors for criminal behavior, substance use, or other antisocial behaviors will overlap with risk factors for self-injury, making the likelihood of self-injury in incarcerated populations that much greater.
Motivations and Theoretical Models
Historically, self-injury was viewed in correctional settings as a form of manipulation or as an attention-seeking behavior. Current research, however, suggests a more complex range of motivations for the behavior. NSSI has been theorized as serving a multitude of functions including affect regulation (i.e., emotional release), anti-dissociation, anti-suicide, interpersonal influence, self-punishment, and sensation seeking. While there is much evidence to suggest that NSSI serves multiple purposes, affect regulation has received the most empirical support in offender and nonoffender populations alike. Even when multiple motivations for the behavior are reported, emotional regulation is most frequently cited as a primary motivator. This finding is consistent in forensic populations. In correctional settings, affect regulation is the most commonly reported motivation for NSSI in both male and female offender population. Self-injury, in this case, serves as a coping mechanism that allows an offender to relieve distress and regulate emotional arousal. This is further supported by findings that negative emotions are the most commonly reported emotions prior to engaging in self-injury.
Self-punishment and self-directed anger have also received considerable attention as motivators for self-injury, as this function is commonly cited as a secondary motivation for self-injury. This function has been hypothesized as a manifestation of being raised in an invalidating environment, particularly among individuals with BPD, which is expressed as self-derogation or self-invalidation through self-injury, and often conceptualized as a stereotypically female motivation. Consistent with this theory, anger is frequently cited as a precipitating emotion to NSSI among offender populations.
Despite the convergence of evidence that self-injury serves primarily as a means of affect regulation, social influence and coercion as motivations have also been documented in correctional settings. Reasons commonly cited include communication of distress or a desire to obtain external rewards (e.g., movement in or out of segregation, relocation to a psychiatric or medical unit). The social influence function is more common in offender populations than in the general (nonincarcerated) population, with such motivations often explicitly reported, particularly among male offenders.
Theoretical functional models of self-injury have been proposed in an attempt to account for primary motivators for the behavior. In particular, the Four Function Model, developed by Matthew K. Nock and Mitchell J. Prinstein, is notable because as of 2018, it is the only functional model of NSSI that has been validated with an offender population. Four Function Model is a functional approach to classification where functions of NSSI are categorized dichotomously: Behavioral reinforcements are either positive (addition of favorable stimuli) or negative (removal of aversive stimuli) and either automatic (intrapersonal) or social (interpersonal). For example, automatic negative reinforcement would occur when an individual uses NSSI to reduce negative emotions. Automatic positive reinforcement would occur when NSSI is used to create a desirable psychological/physiological state (e.g., dissociation, numbness). Desire to escape responsibilities and desire to obtain attention or material goods are examples of social negative reinforcement and social positive reinforcement, respectively. Research validating this model in correctional settings found support for all four functions, with automatic negative reinforcement being most strongly endorsed, followed by automatic positive reinforcement suggesting once again that emotional regulation is the primary function of NSSI.
Impact on the Correctional Environment
Working with offenders who self-injure can be extremely stressful for correction staff. The rates of burnout are elevated among staff working with any populations who engage in self-injury, and the correctional environment adds additional sources of stress. Staff who routinely engage with individuals who self-injure report significant anxiety, frustration, fear, anger, feelings of helplessness and inadequacy, and lower levels of job satisfaction. Most staff report lack of knowledge and understanding of the behavior as well as lack of explicit training on how to effectively work with offenders who self-injure. Self-injury also presents significant costs to correctional institutions in terms of transfers from general prisons to specialized treatment centers and forensic hospitals. Appropriate treatment and prevention strategies are important for mitigating these impacts on the correctional system.
Intervention and Treatment
Institutional response to self-injury has often defaulted to the use of physical restraints or therapeutic seclusion (i.e., isolation, segregation). Research has found that these approaches have limited effectiveness and may in fact increase the frequency of NSSI and suicidal ideation. As a result, such approaches may place further burden on the correctional system, as segregation or hospitalization requires additional monitoring and intensive supervision. Evidence-based therapeutic responses are therefore recommended instead.
Dialectical behavior therapy (DBT) is a well-established treatment for NSSI and has received attention within the correctional literature. DBT was originally developed by Marsha Linehan to treat BPD and is frequently used to treat chronic self-injury, including NSSI and suicide attempts. DBT has been adapted for correctional setting in a number of jurisdictions across North America, the United Kingdom, and Australia and typically targets coping, self-monitoring, emotion regulation, distress tolerance, and interpersonal skills. DBT is a highly structured and intensive form of treatment that requires significant resources and training to implement. Other promising, less intensive interventions include problem-solving therapy, manual-assisted cognitive behavioral therapy, and START NOW, which is an intervention based on cognitive behavioral therapy and motivational interviewing that takes into account the realities of the correctional environment and is being implemented and evaluated in the United States.
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