Addressing Self injury and Suicide: the perspective of prisoners in Ireland of the risk, contributory and protective factors and barriers to support.

Abstract

Background: Self-harm and suicide present a major issue in the prison population (Harris et al., 2015, Hawton et al., 2014 & 2016). International rates of suicide and lifetime self-harm are higher in prisoners than the general population (Hawton et al., 2016, Fazel et al., 2017). There is a five to six fold increase of risk of death by suicide for men in custody and a 15 to 18 fold inflation of risk of death by suicide for women in custody when compared to the general population (Towl and Crighton, 2017).
Since 2017, there has been a multi-agency effort in Irish prisons to improve the monitoring of the incidence and profile of self-harm, which has led to a better understanding of the characteristics and profile of prisoners who engage in self injury (McTernan et al., 2023). However, it remains unclear why some individuals in prison harm themselves, why some individuals do not harm themselves, and why some desist and others persist with their self harm (Forrestor et al, 2014). There is increasing evidence that demonstrates potential benefits of prevention measures used to reduce self-harm and suicide (e.g. Howard & Pope 2019, Walker et al., 2022). There are no qualitative studies that have collected and shared individuals’ experiences of self harm and/or suicide in prisons in Ireland.
Objectives: This PhD aimed to explore, from the perspective of people in custody, what factors contribute to self-harm and suicide, what works to prevent it, and what supports desistance. This was done through the lens of the developmental trauma model (Lewis, 1990), the tripartite schema (Smith et al., 2019) and the Power Threat Meaning Framework (Johnstone & Boyle, 2018a). This aimed to inform effective ways for prison managers and staff to respond to incidents of self-harm and provide appropriate, helpful care.
Method: This PhD used a qualitative approach. 15 men in custody with a history of self harm and/or attempted suicide were interviewed across eight prisons in Ireland. Data was collected about the profile of self harm and/or attempted suicide, including their history of self-harm across prison and community settings, sample demographics, and psychometric measures. Men were selected from three groups including i) those who have engaged in repeat self-harm, ii) those who have attempted suicide and iii) those who have engaged in both self-harm and suicidal behaviour (many of whom had desisted from self-harm and suicide). Thematic Analysis (TA) was used to generate a detailed description of their perspectives of what factors contribute towards their self-harm and/or attempted suicide (including individual risk factors, the risk environment and contributory factors) and factors that may promote desistance from self-harm and suicide and interventions.
Results: In this PhD, six themes were identified as relevant to self-harm and suicide in prisons, including 1. Nature of harm, 2. Risk Factors, 3. Link to Violence, 4. Factors contributing to self-harm and suicide, 5. Barriers to Support and 6. Protective Factors and Interventions. Key findings showed that the nature of harm involved acts of self-harm, suicide and both suicide and self-harm in prisons in Ireland, from which intentionality could not be inferred. Risk factors identified by participants as relevant to their self-harm and suicide included a history of substance use, being on remand, previous history of custodial sentence(s), lack of visits, neurodiversity and the presence of Adverse Childhood Experiences (ACEs)’s. These are all, however, typical prisoner population characteristics (McDermott & Willmott, 2018). Contributory factors identified by participants included substance use, stress and anxiety, arising in the context of recent committal to prison, mental health difficulties (e.g. emotion regulation difficulties & Axis 1 disorders ), feelings of loneliness, isolation, hopelessness and despair, adjustment issues, neurodiversity, loss of relationships through bereavement or loss, and relational difficulties with staff and other prisoners. Five key factors were identified that underlie the level of risk posed by the environment included lack of structured activity, staffing shortages /overcrowding, large prisons, prison culture that does not support showing vulnerability, and lack of procedural justice. Factors that may increase risk of harm include the use of a Special Observation Cell and lack of trauma informed practice. Barriers to support identified included mistrust, lack of available support, shame, punitive response and prison culture. Lastly, protective factors that promoted desistance from self-harm and suicide attempts or strategies that prevent or reduce risk of harm to self included recovery from substance use, family connections, involvement in structured activities and psychological therapies, taking personal responsibility, intervention focusing on prevention (not crisis management), continuity of medical care (including effective communication about clinical decisions), trusting relationships with staff in which they feel they are treated as individuals, and that their rehabilitation matters, and a culture that makes it safe for them to reveal their vulnerabilities and to seek support. This study offers both unique contributions and integrated learning. This includes an understanding of the aetiology of self harm and suicide, the role of repetition, and the relationships between self harm and suicide. It also identified intertwined cycles of adversity, trauma and self harm and/or attempted suicide and the unique contributions and shared insights of prisoners.
Conclusions: These findings are contextualised within the strengths (e.g. innovative methodology combining both self-harm and suicide, first qualitative study in Irish prisons, new data exploring prisoner experiences and perspectives) and limitations (e.g. male sample only which included those who have desisted, self reported data, poor response rate to psychometrics). Potential implications and future directions are considered for policy (e.g. benefits of trauma informed prisons, a recovery based model for mental health and substance use and a focus on prevention) and practice (e.g. enhanced family contact, greater access to structured activities and psychological therapies, specialist units and supports for specifics cohorts, and promoting a culture that instills hope, embraces vulnerability, treats people with respect, courtesy and as individuals, making sure they feel that they matter and that we care about their rehabilitation), theory (e.g. aetology of self harm and suicide as similar entities, role of procedural justice), and research (e.g. importance of adaptive methodologies) within Ireland & other jurisdictions.