Supporting Imprisoned Women who Self-Harm: Exploring Prison Staff Strategies

Abstract

The aim of this qualitative research study was to explore the experiences of prison staff working with

imprisoned women who self-harm in English prisons. In this small-scale study, fourteen prison staff in three

English prisons were interviewed to examine the strategies currently used by them to support imprisoned

women who self-harm. Thematic analysis (Braun and Clarke, 2006) was used to identify three key themes:

‘Developing a relationship’; ‘Self-help strategies’ and ‘Relational interventions’. Many staff expressed some

dissatisfaction in the techniques available to support the women, and felt their utility can be restricted by

the prison regime.

This study suggests there is currently a deficit in the provision of training and support for prison

staff, who are expected to fulfil a dual role as both custodian and carer of imprisoned women. Further

research into prison staff’s perception of the training currently available could highlight gaps between

current theory and practice in the management of self-harm and thus indicate content for future training

programmes. Research exploring the impact of working with imprisoned women who self-harm is

suggested to identify strategies for supporting staff. It must be acknowledged that this is a small-scale

qualitative study and the findings are from only three prisons and may not apply to staff in other settings.

Currently few studies have focused on the perspective of prison staff. This study is one of very few

which focuses on the techniques and resources available to support the women, from the perspective of

the prison staff.

1

Introduction

It is estimated that around 20% – 24% of imprisoned women in England and Wales self-harm each year,

compared with 5% - 6% of male prisoners (Hawton et al., 2014). Imprisoned women are more likely to

harm themselves repeatedly at around 8 times per year; whereas imprisoned men self-harm around twice

per year on average (Hawton et al., 2014).

In 2003, imprisoned women accounted for 46% of recorded self-harm incidents in English and

Welsh prisons, but only 6% of the prison population (Borrill et al., 2005). During the period 2010 – 2013,

the number of self-harm incidents committed by women in custody dropped briefly by 50% (Ministry of

Justice [MoJ], 2015). This trend reversed during 2014 however when 1,104 women self-harmed in custody,

an increase of 6% compared to 2013. Altogether, for the period 2004 – 2014, imprisoned women

accounted for 27% of self-harm incidents, whist making up only 5% of the total prison population (MoJ,

2015). Research also shows that the methods imprisoned women use to self-harm are more lethal than

those used in the community (Towl et al, 2000). Ward and Bailey (2011) found a relationship between

incidence rates and potential lethality and from 2008-2009 they found an average of 3.5 incidents of self-

harm per woman being reported in their prison study with 33 per cent of those incidents being related to

women tying a ligature around her neck. Lastly, a case control study of all prisoners in England and Wales

undertaken by Hawton and colleagues in 2013 found that of 139,195 self-harm incidents recorded in

26,510 individual prisoners between 2004 and 2009 repetition of self-harm was common, particularly in

women and teenage girls, in whom a subgroup of 102 prisoners accounted for 17 307 episodes. Thus, a

few imprisoned women therefore accounted for many episodes.

There is a widely acknowledged correlation between self-harm and subsequent self-inflicted

deaths (SIDs) in custody (Senior and Shaw, 2008). In 1990, Dooley identified 50% of prisoner SIDs as

occurring in individuals with a history of self-harming; Fazel et al. also found this in a later systematic

review (2008). Hawton et al. (2014) subsequently reviewed all reported self-harm incidents in all English

and Welsh prisons during the period 2004-2009, finding that over half of prisoner SIDs occurred in

prisoners who had self-harmed in the preceding month. The prevention and treatment of self-harm is

2

therefore a key aspect of suicide prevention in prisons (Hawton et al., 2014; Walker and Towl, 2016). An

outline of the current key strategies for managing and treating self-harm in English and Welsh prisons

follows.

Healthcare

In 2001, a cross-organisational approach was introduced, leading the Prison Service and the NHS to work

collaboratively to develop and deliver prison healthcare (Department of Health [DoH], 2001). This aimed to

raise the quality of prison mental health care to meet the standards outlined in the National Service

Framework (DoH, 1999) for mental health care generally. Achieving this ‘equivalence principle' involved

creating a Prison In-Reach service to support prisoners with mental health needs on prison wings in the

estate. Prison in-reach mental health services aim to reduce the number of prisoners being transferred to

hospital for their mental health care, and ensure more effective liaison if transfer was necessary (DoH,

1999; Senior and Shaw, 2008). In addition, this led to improved screening for mental health problems, and

better drug treatment (Senior and Shaw, 2008). To date there is little information about how this change in

how mental health care in prisons is being delivered is influencing incidents of self-harm and SIDs (Walker,

2015; Walker and Towl, 2016). However, work undertaken by Ward and colleagues has shown some cost

savings and reduction in severity and incidence of self-harm (Ward and Bailey, 2011; Ward, 2014).

Assessment, Care in Custody and Teamwork (ACCT)

During the years 2005 – 2006, the National Offender Management Service (NOMS) rolled out a new SID

and self-harm prevention strategy which had an overarching aim to reduce distress and improve the

quality of life for prisoners. The NOMS strategy recommended that staff should be provided with the

necessary training to support prisoners effectively in this area. One component for achieving this was the

Assessment, Care in Custody and Teamwork (ACCT) system, which provides a framework to record and

manage the risk of self-harm and / or suicide for individual prisoners (HM Prison Service, 2005; PPO,

2014a).

3

An ACCT documents the prisoners unique ‘risk signature’ or precipitants to self-harm (HM Prison

Service, 2005; PPO, 2014a). Crucially, it should facilitate the development of a multi-disciplinary Care and

Management Plan (CAREMAP), in which the prisoner’s needs are identified and action to support them is

agreed (NOMS, 2011; PPO, 2014a). This should be done by engaging the prisoner in developing and

reviewing their plan in a timely manner, setting relevant achievable goals to help the prisoner manage their

risks, and identifying specific resources in support of this (NOMS, 2011; PPO, 2014a).

The introduction of the ACCT in the mid-2000s has been credited with contributing to the decline in

prison suicide, however, despite this self-harm and SIDs have continued to occur in prisons (PPO, 2014a).

The Prisons and Probation Ombudsman (2014a) reviewed a sample of 60 out of 280 SIDs in English and

Welsh prisons during 2008 – 2012 and found that only 30 of the ACCTs were implemented correctly. In

many cases, responsibility for completing the actions agreed in the CAREMAP were not assigned to a

specific individual; or were inappropriately assigned to the prisoner (PPO, 2014a). A quarter of the ACCTs

sampled did not correctly identify or update the prisoner’s risk signature, meaning that opportunities to

intervene may have been missed (PPO, 2014a). 19 of the cases sampled were judged not to have received

adequate mental healthcare provision, at the appropriate point, and equal to what they would have

received in the community (DoH, 2001; PPO, 2014a). Further difficulties with the ACCT has been voiced by

imprisoned women and research by Ward and Bailey (2013) has found that although some women in

prison found the ACCT helpful others found it intrusive. There was a lack of staff understanding about self-

harm noted by the women and they stated this was then reflected in the care they received in prison. The

effectiveness of the ACCT is therefore limited by the skills and training of staff using it; staff are often

unclear as to who is responsible for maintaining it, and CAREMAP goals are undermined if the process and

responsibility for achieving them is not explicit (PPO, 2014a). Furthermore, the recent budget-reduction

policies, including ‘Benchmarking’ and ‘New Ways of Working’ put forward by the current Conservative

government has further inhibited ACCT training for prison staff.

4

Harm-minimisation and distraction

Harm-minimisation and distraction techniques are increasingly being used to manage self-harm (Pengelly

et al., 2008). Harm-minimisation is used to reduce the dangers of self-harming (Harrison and Sharman,

2005; Pengelly et al., 2008) and examples include causing pain by squeezing ice, pinching, or snapping an

elastic band against a sensitive area of the body, instead of cutting (Pengelly et al., 2008). Distraction

techniques aim to create a diversion from the cycle of emotions and stressors that can lead to self-harm,

by engaging in activities such as crafts, exercise or gardening (Harrison and Sharman, 2005).

There is a poor evidence base for the effectiveness of harm-minimisation (Royal College of

Psychiatrists [RCP], 2004; Pengelly et al., 2008); and concerns about the ethics and legality of advocating

any form of self-harm (RCP, 2004; Pengelly et al., 2008). For prisoners, access to the means of harm-

minimisation is problematic, as prisons restrict the availability of items such as blades or ice (NOMS, 2012)

but distraction packs containing puzzles and art materials have been supplied to imprisoned women on

ACCTs to support them to avoid self-harming (NOMS, 2010).

Prison staff’s perception of their role in managing and treating self-harm

There is increasing pressure on prison staff to maintain a good relationship with prisoners in order to

reduce or prevent self-harm occurring (Her Majesty’s Prison Service, 2005; 2007; Moses, 2013), whilst

maintaining discipline and security (Towl and Forbes, 2002; Short et al., 2009; Marzano et al., 2013; Moses

2013). The Prison Officers Association (POA) states that prison officers must simultaneously fulfil the

conflicting roles of welfare officer, agony aunt, listener, guard and enforcer to be successful in their job

(Moses, 2013). Many prison staff, including prison healthcare staff (Marzano et al., 2013), report feeling

insufficiently trained to manage prisoners who self-harm, and thus powerless to support them (Towl and

Forbes, 2002; Short et al., 2009; Moses, 2013; Walker, 2015; Walker and Towl, 2016).

Many prison staff categorise self-harm according to the motives of the prisoner (Liebling, 1992;

Dear et al., 2000; Short et al., 2009; Kenning et al., 2010). Those prisoners whose self-harm is perceived to

be an attempt to influence the environment, gain attention from others, or otherwise profit from the

5

behaviour (Short et al., 2009; Kenning et al., 2010) has been linked to staff beliefs that supportive

interventions could serve only to perpetuate the behaviour (Dear et al., 2000). On the other hand, self-

harm that relates to attempted suicide (Dear et al., 2000) or to mental illness (Short et al., 2009; Kenning et

al., 2010) is more commonly perceived as being more worthy of staff intervention and support. Despite

this, many prison officers feel ill-equipped to manage self-harm in this context, perceiving it to be the

responsibility of healthcare staff (Marzano et al., 2013).

Aims and objectives of this research

The aim of this study was to use qualitative methods (Braun and Clarke, 2006; Flick, 2009; Guest et al.,

2012) to explore prison staff’s experiences of working with imprisoned women who self-harm, to identify

the strategies used by prison staff to support imprisoned women who self-harm, and the strengths and

limitations of these strategies.

The present study

The qualitative study was nested in a randomised control trial, which used mixed-methods, in three

women’s prisons in England that used Psychodynamic Interpersonal Therapy (PIT) as a treatment

intervention for women in prison who self-harm (Abel et al, 2015). As part of a wider study reported

elsewhere semi-structured interviews were conducted with 14 prison staff from three prisons in England.

Methods

Participants

A purposive sample (Mays and Pope, 1995) was selected for qualitative data collection. Purposive sampling

is a form of non-probability sampling undertaken when strict levels of statistical reliability and validity are

not required because of the exploratory nature of the research (Kidder, 1981). Thirty prison staff, 10 from

each prison, were approached and 14 prison staff were recruited (4 men, 10 women) 7 from one prison, 4

from prison site two and 3 from the last prison. Of the 14 participants 10 were prison officers, 1 was a

6

prison governor and 3 were healthcare staff. All the prison sites were closed category for female adults and

participants were employed across the three prison sites. No further participant information is provided in

order to protect their anonymity.

Interviews

The interviews with the prison staff lasted up to 60 minutes and were digitally recorded with participant’s

consent. All interviews were conducted face to face and in a private room within the prison between

January 2014 and January 2015. Prison staff interviews followed a semi-structured interview schedule and

they were informed by previous work in the field (Ward and Bailey, 2011). Staff were invited to discuss

their experiences of responding to self-harming and suicidal women offenders, their views on staff support

and perceived training needs. Written consent was obtained before interview. Experienced qualitative

interviewers from within the research team undertook interviews.

Analysis

All interviews were transcribed verbatim, anonymised to protect the identity of research participants, and

were individually checked for accuracy by a third member of the research team. Analysis used the

systematic method of thematic analysis proposed by Braun and Clarke (2006). With this analytic strategy,

data exploration and theory-construction are combined and theoretical developments are made in a

‘bottom up’ manner to be anchored to the data (Braun and Clarke 2006). Each transcript was analysed by

looking for patterns in the data and noting themes or analytical categories. This process continued until no

new themes were found – ‘data saturation’. Themes were then clustered together, noting overlaps and

goodness of fit, to form categories, which are reported in the results section of this paper.

 

Ethical considerations

Participants had an information sheet that contained an assurance of anonymity, information regarding

the study, the possibility to withdraw and the voluntariness of participation. Written informed consent

7

was obtained prior to interview and the findings presented in a way that no one could be recognised.

Ethical approval for the study was obtained from the Health Research Authority (12/EE/0179), the National

Offender Management Service (NOMS: 76-12), the University ethics committee where the authors were

based and each Prison site.

Results

Following the application of the thematic analysis to the interview transcriptions, three overarching

themes emerged: ‘Developing a relationship’, ‘Self-help strategies’ and ‘Procedural interventions’ (Table 1).

Quotes are included to illuminate the context and meaning of the themes.

Developing a relationship

All staff expressed the opinion that their relationship with the women was of paramount importance in

supporting them in relation to their self-harm (HM Prison Service, 2005, 2007; Moses, 2013). The

development of a supportive, professional relationship was seen as the backdrop against which more

targeted interventions could occur.

Being honest and consistent

Staff identified honesty and consistency as key to developing a good relationship with the imprisoned

women (Mangnall and Yurkovich, 2010). This was in the context of the integrity of staff’s interpersonal

exchanges with the women at a one to one level, rather than as a staff group or as a representative of the

prison system. Staff felt that being perceived by the women as an untrustworthy or unreliable person

created barriers, preventing a positive relationship from developing.

I think having somebody consistently… that will try not to let you down… I think sometimes they

[imprisoned women] just need to have that “go to” person (R3).

8

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 (R4).

And being honest with them [imprisoned women] and being straight down the line… they

[imprisoned women] respect you for that. If they think that you’ve ever lied to them or done them

over, then that creates a massive barrier (R8).

One staff member commented on the importance of the consistency of the staff as a team, as opposed to

the individual relationships between a staff member and a prisoner.

Your staff have to back you up, because if you do something one day, when they [other staff] say,

“oh, we're doing it like this, then we're doing it like this, then we're doing it like this,” you've got no

continuity, because once you’ve given it’s hard to take back (R8).

Knowing the women

Knowing the imprisoned women well helped staff to recognise their individual ‘risk signatures’ (HM Prison

Service, 2005). These are the unique warning signs that the imprisoned woman’s risk of self-harm is at an

increased level (HM Prison Service, 2005). Awareness of this enabled staff to intervene at an earlier

opportunity, and potentially reduce the severity of the consequences of self-harm for the woman (National

Confidential Inquiry into Suicide and Homicide by People with Mental Illness, 2011; PPO, 2014a, 2014b):

I knew her that well, I'd invested so much energy into her I could tell by the look on her face, her

mood that day, that she was going to self-harm, and I was so persistent I went back and to, to her

door…I kept going back and I thought “she’s not right, she’s not right,” … I said “I’m coming in.”

And… she’d cut from here to her elbow (R1).

9

She used to put a hat on if she could hear the voices and then you knew she was probably going to

self-harm at that point (R8).

You can usually tell a lot of the ladies when you work with them for a bit, the triggers. So there was

one, if I checked on her and she was under the bed with the covers over her head, I knew nine

times out of ten she had a ligature around her neck (R9).

The consequences of incomplete information about the women’s history; or poor awareness of risk

signatures, could be significant.

It's up to them [imprisoned women] to disclose certain things, and they don’t always want to

disclose it, I had one who… was fine, there was no information or signs that she was going to self-

harm, nothing. She… went back to her cell, she wasn’t put on an ACCT, self-harmed, hung herself

and died. (R8).

Staff feeling vulnerable

Some staff recognised that having a good relationship with the women could make them vulnerable to

feeling rejected, should the woman continue to self-harm. Other studies (Pannell et al., 2003; Kenning et

al., 2010; Marzano et al., 2012) have suggested this can lead to prison staff reprimanding the prisoner for

their behaviour:

[Staff] would get a little bit of a bond with one of the prisoners… and then the prisoner would self-

harm… And then the staff would get upset… You’ve then had staff come in who’ll… ignore them or

be grumpy with them because of the self-harming a day ago, and I just think you can’t do that (R3).

10

I’ve seen people take it personally when a client that they feel they have a relationship with would

self-harm, that the staff takes it personally, and actually it’s nothing to do with them, it’s the

individual [imprisoned women] (R1).

One staff member reflected on the personal impact of conflict with an individual with whom they usually

have a good relationship; but did not comment on the consequences for their relationship with the

prisoner or how they coped with the difficult emotions this seemed to raise.

Trying to negotiate with [imprisoned women] when they don’t want to negotiate, they just want to kill themselves, you're completely the enemy yet normally you get on with them… you start to think a lot about how they're feeling and why they're feeling it… you kind of get drawn down to it … you start to feel quite dark about a lot of things (R7).

Staff feeling vulnerable

Some staff recognised that having a good relationship with the women could make them vulnerable to

feeling rejected, should the woman continue to self-harm. Other studies (Pannell et al., 2003; Kenning et

al., 2010; Marzano et al., 2012) have suggested this can lead to prison staff reprimanding the prisoner for

their behaviour:

[Staff] would get a little bit of a bond with one of the prisoners… and then the prisoner would self-

harm… And then the staff would get upset… You’ve then had staff come in who’ll… ignore them or

be grumpy with them because of the self-harming a day ago, and I just think you can’t do that (R3).

I’ve seen people take it personally when a client that they feel they have a relationship with would

self-harm, that the staff takes it personally, and actually it’s nothing to do with them, it’s the

individual [imprisoned women] (R1).

11

Self-help strategies

Some staff described the use of self-help or practical strategies and approaches to support imprisoned

women who self-harm. These activities aim to reduce the likelihood for negative and painful feelings to

dominate and motivate self-harming behaviour. By undertaking alternative actions, it aims to allow

individuals to manage their feelings (Douglas and Marriott, 2012).

Harm-minimisation techniques

Several staff spoke about using harm-minimisation techniques, to reduce the physical dangers of the

imprisoned women’s self-harm (Harrison and Sharman, 2005; Pengelly et al., 2008; Ward, 2014). For

example, imprisoned women wanting to experience pain, snapping an elastic band against the skin can

provide a safe alternative to cutting (Pengelly et al., 2008; Ward, 2014). Some of this work has been

criticised for having a poor evidence base and for the potential to be interpreted as advocating self-harm

(RCP, 2004; Pengelly et al., 2008):

Things like the elastic band technique; that was one (R8).

I would never say to a woman “stop doing it, don’t self-harm”. That’s their means and to me, it’s

about let’s reduce the times [of self-harm], the lethality [of self-harm], let’s look at options… It

happens, get your head round it, let’s try and encourage a reduction in it [self-harm] but let’s get

people to do it safely and look at alternatives (R4).

Distraction techniques

Many staff identified distraction techniques, as the primary means by which they addressed the women’s

self-harm in prison (Pengelly et al., 2008; NOMS, 2010). Some literature (NOMS, 2010) has suggested that

12

distraction packs can cause imprisoned women to try to be placed on an ACCT to obtain a distraction pack;

however, this was not reported in this study:

They [imprisoned women] started off with just basic puzzles and colouring. The word got out then

so we had queues of people coming for them… The [activities] where you sit and actually make

something and produce something at the end of it is for people in crisis that really aren’t coping

(R4).

Staff would come in and help them [imprisoned women] do their hair or beauty stuff… then there’d

be days when I’d come in and I’d take them [imprisoned women] out and play football with them or

take them out and ball games with them or take them up to the gym… and there was some staff

who would sit and do art with them [imprisoned women] (R5).

Some staff felt that distraction techniques were limited in terms of effectiveness for helping the women

manage their self-harm; and suggested that time spent with the women, making them feel valued and

supported, was more useful.

I think what’s really helpful is external services coming in and listening to what our ladies have to

say… people, objective, coming in, I think that is huge… they’ll be there and that time is especially

for them [imprisoned women], and I think the importance of protected time with quality

professionals is worth it’s weight in gold (R9).

The reasons for this belief were not made explicit, but previous studies (Borrill et al., 2005; Kenning, 2010;

Walker and Towl, 2016) have shown that imprisoned women who self-harm do so for reasons including

difficulty articulating strong emotions or seeking support. It is therefore possible that facilitating the

women to express themselves, and to communicate that they have been heard, could have a positive

impact on the women’s experience of distress and subsequent self-harm. Additionally, Mangnall and

13

Yurkovich (2010) found that women who self-harm value being able to talk to professionals about their

self-harm, without fear of judgement:

I think we can give people things but actually addressing the problem and supporting them

[imprisoned women] is more important than saying “ok, we’ll give you some colouring… I think it’s

more about actually just making them [imprisoned women] feel supported and listened to and that

they’re important (R7).

Procedural interventions

Procedural interventions were prescribed by the prison regulations (HM Prison Service, 2005, 2007; NOMS,

2011) in order to prevent, reduce or manage the women’s self-harm. All staff referred to the ACCT in this

context, though with mixed views as to the appropriateness and effectiveness.

The ACCT process

Many staff felt the effectiveness of the ACCT process was limited by the time taken to complete it; and that

this ultimately could prevent staff carrying out the interventions the ACCT process was designed to

facilitate.

You’re writing in them [ACCTs] all the time or if they’re [imprisoned women] off the unit you’re

chasing round trying to take the ACCTs everywhere. You haven’t got time to sit down and have the

time with the women, and then they get frustrated. So that’s a massive problem, staff not having

time for prisoners (R8).

If you've three or four women all on 15 minute obs [due to being on ACCTs], by the time you get to

the bottom of them you're back to the start again. So generally night shift staff haven’t got time but

14

that's the time you're saying [to the imprisoned women] “Right, you're all locked in, speak to your

staff,” but you haven't got that resource. So nights are quite difficult sometimes (R3).

A lot of senior officers who are managers of the ACCTs on wings, [have] absolutely no idea, and

they're the ones that are managing the risk of the self-harm and they don't know anything about

[self-harm]... you could have that woman [prisoner] in that review for half an hour but then you

spend another hour with a member of staff talking about why (R3).

Furthermore, some staff felt that the ACCT was too rigid and could not be adapted for the individual needs

of the women, for example, to maintain their privacy:

Managing ACCTs… was often a very rushed process… It’s just a process, it’s not about the individual

[imprisoned woman] and it’s not matched purely to the individual [imprisoned woman]. It could

potentially but it’s just the time (R7).

[Self-harm is] not handled in a discreet way by the prison service, self-harm, it’s like “here’s an

ACCT, here is a bright orange folder,”… The world and his wife is involved in that, in the ACCT, the

ACCT review, I think, so I think that would put people off saying that they self-harm, and I think it’s

a very personal thing for a lot of women and they wish for it to remain a personal and private thing

(R9).

If you come in for murdering a family member you’re automatically put on an ACCT. So that takes

away the discretion, in a way (R8).

One member of staff reflected that the inflexibility of the ACCT could in fact be detrimental to their

professional relationships with the prisoners. This appears to be due to some imprisoned women’s

15

perception of the ACCT process of information gathering as being too intrusive, particularly if that

individual sees their self-harm as an effective coping mechanism:

A lot of [imprisoned women] have said “Don't put me on an ACCT book… I’ve got no intention to kill

myself. I just make lots of small scratches because the pain helps me focus on myself and get the

emotion out.”… They don’t want to particularly sit and talk to you about what their issues are… But

I’m not allowed to close that ACCT while they're actively self-harming to my knowledge. So they

then go from seeing me as a supportive role to being completely the opposite. “I’m not going to

talk to you Miss because you’ll put me on an ACCT” (R12).

One staff member spoke about the difficulties of implementing the CAREMAP element of the ACCT in

terms of support from the wider team and accessing resources. This is concerning, as failure to implement

the CAREMAP and lack of clarity around who is responsible for this have been shown to be factors in SIDs

in custody (PPO, 2014a):

The other people who work in the prison and the other areas of the prison put obstacles in place

for things to happen because it requires something from them. So if you need a resource off them

and they don’t have that resource they’re then resistant to what it is you’re trying to plan (R7).

Only one staff member identified the ACCT as helpful both in terms of protecting the women and in terms

of ensuring the defensibility of staff’s decision-making. Properly completed ACCTs have been shown to

play a role in preventing self-harm and SIDs in custody (PPO, 2014a; 2014b):

It’s about protecting yourself, because the ACCT document is ultimately to keep the prisoner safe

but you need to work to ensure that you’re filling it in completely and that you’ve gone through all

the actions and the CAREMAP… because, God forbid, something then does happen you have to

defend yourself in a coroner’s court (R5).

16

Improving practice

The majority of staff reflected that they benefited most from informal learning, such as observing peers or

experiential learning on the job:

I think you become equipped by learning and watching and seeing other staff [in prison] do certain

things. There’s been times when I’ve been in incidents with other staff and I’ve watched other

people speaking and doing and I thought “I’m going to keep that because that was definitely one to

learn from”; and you go back to learning from your prisoners as well (R2).

Most of it [training] is probably trial and error and support from people who are around you,

really… Staff, the prison officers, and… the mental health team (R5).

I got to know the mental health nurses personally and I would ask questions after questions after

questions, not about a particular individual but about what they [mental health nurses] do and how

did you [mental health nurses] come to that assertion? Can you [mental health nurses] explain this

to me? (R11).

Some staff gave examples of training available to them:

Everybody that comes to the prison has to have Mental Health Awareness… Once everybody’s done

that we then offer separate sessions on “would you like a session on self-harm?”… People are then

interested and they’ll ask you “is that why so and so is like that?”… I know there’s a waiting list for

people who want to come on it (R4).

We do an introduction to safer custody package, which basically tells you about the litigation and

the rules of governance of why we do the safer custody ACCT document, which is the self-harm

book, and then you talk through that raised awareness of mental health issues, what to consider,

what to look for (R12).

17

I’ve been on a SWIC [Sex Workers in Custody] course; I've been on the WASP [Women Awareness

Staff Programme] course. [WASP is] not necessarily focused towards ACCTs training, just about

women in prison, dealing with women in prison (R10).

Several staff called for more formal training and supervision specifically relating to self-harm and

personality disorder. Staff appeared not only to want to improve the support available to the women, but

also to develop their own resilience and understanding when managing or witnessing self-harm. Staff have

called for this across the Prison Service (Justice Committee, 2009; NOMS, 2010).

Their [prison officer’s] frustrations are they don’t get it [self-harm], and I think if you help and guide

them and help them get it, or at least help them understand why that is, it becomes less anxiety

provoking for them and for the women then as well (R3).

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 staff… How staff can offload if they need to if they’re

feeling frustrated or it’s [witnessing self-harm] upset them (R4).

I think [staff] need supervision, which I’ve been told they don’t get. I think the… Knowledge and

Understanding Framework for Personality Disorder, I think they [prison staff] should all have that,

even just the kind of awareness phase of it, because a lot of them [prison staff] inevitably have a

negative stance with regards to personality disorder because all they see is the negative side (R6).

Discussion

Three strategies used by staff to support imprisoned women who self-harm were identified. The main one

of these as recognised by the prison staff was the importance of developing an honest and consistent

professional relationship with the imprisoned women who self-harm (HM Prison Service, 2005; 2007). Staff

perceived this as key to reducing the imprisoned women’s self-harm by enabling staff to recognise the

women’s individual risk signatures (HM Prison Service; 2005 PPO, 2014a). Staff recognised their

vulnerability to feeling rejected by the imprisoned woman if she continued to self-harm despite their

efforts of support, and were aware of the potential for this to negatively impact on their relationship

(Pannell et al., 2003; Kenning et al., 2010; Marzano et al., 2012).

18

Staff used practical self-help strategies and approaches to help and support the imprisoned women

in an attempt to reduce and manage their self-harm. These included harm-minimisation techniques, which

is the substitution of a dangerous method of self-harm such as cutting, for a safer, though equally painful

one, such as snapping an elastic band against a sensitive area of the body (Pengelly et al., 2008; Ward,

2014). Distraction techniques were also used by staff to reduce the imprisoned women’s self-harm, and

included facilitating activities such as crafts or exercise as an alternative to self-harming (Pengelly et al.,

2008). Some staff felt that although these interventions have some value, listening to the women and

making them feel valued and supported was the most beneficial intervention (Mangnall and Yurkovich,

2010).

Procedural interventions were the prison directives identified by staff as formal methods to support

the imprisoned women who self-harmed. All staff referred to the ACCT (HM Prison Service, 2005; PPO,

2014a) as the primary means by which they did this. Staff felt that the ACCT was limited in its effectiveness,

owing to the time taken to complete the ACCT reviews, difficulty obtaining the resources needed to fulfil

the ACCT, and the ACCT’s inflexibility in adapting to the different individual needs of the imprisoned

women, such as for discretion in relation to their self-harm. Only one staff member identified the ACCT as a

potential means of professional protection for defending decision-making (PPO, 2014a, 2014b).

Lastly, many staff appeared to value experiential learning over the formal training currently

available to them. Several staff felt that additional training specifically in self-harm and personality disorder

would help to improve their understanding of these issues and their ability to support the imprisoned

women affected by them.

Conclusion

This study has highlighted that for staff dealing with imprisoned women who self-harm was challenging

and that there remains a need for specific, effective and on-going training in this area. Our findings suggest

that a positive and trustworthy prisoner-staff relationship is of prime importance (Kenning et al., 2010) and

although staff may feel vulnerable at times and this may mean they reposed negatively to imprisoned

19

women who repetitively self-harm this is not inevitable (Marzano et al., 2012). Prison staff reactions to

self-harm appear to be influenced by a range of factors for example their personal experience of this issue

and the feasibility of repeatedly dealing with this issue within an environment where there are are poor

facilities, overcrowding and a lack of resources (Marzano et al., 2015). The findings from this current study

reiterate the need to better support staff dealing with prisoners who self-harm (Marzano and Adler, 2007;

Marzano et al., 2012) but particularly imprisoned women who self-harm (Walker and Towl, 2016). As

implied by the participants in this study, with more training, this will help to improve staff reactions and

understanding of these issues and greatly improve their ability to support imprisoned women who self-

harm.

Strengths and limitations of this research

The qualitative design of this research used an inductive approach (Yin, 2015), which allowed themes to be

drawn from the data (Braun and Clarke, 2006). The themes presented here are supported by evidence

from the data itself (Braun and Clarke, 2006; Guest et al., 2012). The techniques of thematic analysis

(Braun and Clarke, 2006) enabled the unique perceptions of individual participants to be recognised, which

could have been rejected as anomalous using other methods (Bird, 1998; Braun and Clarke, 2006; Flick,

2009). Additionally, although purposive sampling was used to ensure that a range of professional roles

within the prisons was represented (Kenning et al., 2010; Guest et al., 2012) it must be acknowledged that

only 14 staff were recruited across the three English prison sites. We therefore recognise that the sample

in this study is not representative as it has a very small sample size and it will limit the potential for the

findings to be generalised to other English women’s prisons.

Implications for practice

Many staff expressed some dissatisfaction in the techniques available to support the women, such as

distraction (Pengelly et al., 2008); the accessibility of which can be restricted due to the prison regime

(NOMS, 2012). Some staff felt the ACCT was too inflexible to be of genuine benefit to the imprisoned

20

women; and that for the ACCT to fulfil it’s potential for protecting the imprisoned women; staff require

more time and resources to fully implement the CAREMAP actions therein (NOMS, 2011; PPO, 2014a).

Furthermore, it is important that prison staff receive formal training in the management of self-harm

amongst imprisoned women so that their confidence can improve in using the current available strategies.

It must be noted that Ward and Bailey (2011) take this a step further by arguing that women and prison

staff should work together to develop training for prison staff in relation to the management of self-harm.

At the time of writing NOMS is undertaking a review of the effectiveness of ACCT in the adult (over 18)

prison estate in England and Wales (NOMS, 2015). This review is focusing on what improvements need to

be made to the operation of the current system and the NOMS national policy and one of the key

emerging findings is that there needs to be improvements to staff awareness and training in this area

(NOMS, 2015).

Implications for future research

As it stands, there is little existing research into the psychological function of self-harm in imprisoned

women (Borill et al., 2005; Mangnall and Yurkovich, 2010; Walker, 2015). Increased insight into this, and

into safer alternatives to self-harm, would be of benefit both to the imprisoned women and to the ability

of prison staff to support them (RCP, 2004; Borrill et al., 2005; Pengelly et al., 2008). Further insight into

prison staff’s perceptions of the training available to them in the management of self-harm may illuminate

gaps between current theory and practice. A greater understanding of the impact of working with

imprisoned women who self-harm on the prison staff would also be useful in identify strategies to support

the staff.

Funders

This paper presents independent research funded by the National Institute for Health Research (NIHR)

under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-0610-22176).

The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the

21

Department of Health.

Research ethics

The study required ethical approval from five organisations. Firstly, the Health Research Authority

(12/EE/0179), secondly the National Offender Management Service (NOMS: 76-12), the University where

the authors were based and each Prison site. All services included also provided individual, site-specific

approval for the study.

Acknowledgments The authors would like to thank all the prison staff who participated in the research and

the Prison Service for allowing us to conduct the research.

Conflicts of interest

The authors declare no conflict of interest.

References

Abel, K., Shaw, J., Walker, T. et al. (2015), “Women offenders repeat self-harm intervention pilot II

(WORSHIP II)”, National Institute for Health Research for Patient Benefit (RfPB) Programme.

Bird, A. (1998), Philosophy of Science, Routledge, Oxon.

Borrill, J., Snow, L., Medlicott, D. et al. (2005), “Learning from ‘near misses’: interviews with women who

survived an incident of severe self-harm in prison”, The Howard Journal, 44(1), pp.57-69.

Braun, V. and Clarke, V. (2006), “Using thematic analysis in psychology”, Qualitative Research in

Psychology, 3, pp.71-101.

22

Dear, G.E., Thomson, D.M. and Hills, A. M. (2000), “Self-harm in prisons: manipulators can also be suicide

attempters”, Criminal Justice and Behaviour, 27(2), pp.160-175.

Department of Health (1999), “National Service Framework for Mental Health: Modern Standards and

Service Models”, Department of Health, London.

Department of Health (2001), “Changing the outlook – a strategy for developing and modernising mental

health services in prisons”, Department of Health, London.

Department of Health (2010), See, Think, Act: Your Guide to Relational Security, Department of Health,

London.

Dooley, E. (1990), “Non-natural deaths in prison”, British Journal of Criminology, 30(2), pp.229-234.

Douglas, N and Marriott, S. (2012) SAFE & SECURE. Working constructively with people who self-injure – a

guide for staff working in secure mental health units. Department of Health Self-Harm Expert Reference

Group, London.

Fazel, S., Cartwirght, J., Norman-Nott, A. et al. (2008), “Suicide in prisoners: a systematic review of risk

factors”, Journal of Clinical Psychiatry, 69, pp.1721-1731.

Flick, U. (2009), An Introduction to Qualitative Research, 4th edn. Sage Publications, London.

Guest, G., McQueen, K.M. and Namey, E.E. (2012), Applied Thematic Analysis, Sage Publications, London.

23

Harrison, D. and Sharman, J. (2005), “Understanding self-harm”, available at:

http://www.mind.org.uk/information-support/types-of-mental-health-problems/self-harm/about-self-

harm/#.VeZNIUL4vlJ (accessed 1st September 2015).

Hawton, K., Linsell, L., Adeniji, T. et al. (2013) “Self-harm in prisons in England and Wales: an

epidemiological study of prevalence, risk factors, clustering, and subsequent suicide”, The Lancet, 383,

pp.1147-1154.

Her Majesty’s Prison Service (2005), “Prison Service Order 18/2005: introducing the ACCT (assessment, care

in custody and teamwork) – The replacement for the F2052SH (risk of self-harm”), HMSO, London.

Her Majesty’s Prison Service (2007), “Prison Service Order 2700: suicide prevention and self-harm

management”, HMSO, London.

Jaffe, M. (2012), “The Listener Scheme in prisons: final research findings”, available at:

http://www.samaritans.org/sites/default/files/kcfinder/files/research/Peer%20Support%20in%20Prison

%20Communities.pdf (accessed 30th July 2015).

Kenning, C., Cooper, J., Short, V. et al. (2010), “Prison staff and women prisoner’s views on self-harm; their

implications for service delivery and development: a qualitative study”, Criminal Behaviour and Mental

Health, 20, pp.274-284.

Kidder, L.H. (1981). Qualitative research and quasi-experimental frameworks. In: Brewer M.B., Collins B.E.,

eds. Scientific Inquiry and the Social Sciences. San Francisco, CA: Jossey-Bass.

Liebling, A. (1992), Suicides in Prison, Routledge, London.

24

Magee, H. and Foster, J. (2011), “Peer support in prison healthcare: an investigation into the Listener

Scheme in one adult male prison”, available at:

http://gala.gre.ac.uk/7767/1/helenDraft_Listener_report_27_091_doc-finalversion2.pdf (accessed 30th

July 2015).

Mangnall, J. and Yurkovich, E. (2010), “A grounded theory exploration of deliberate self-harm in

incarcerated women”, Journal of Forensic Nursing, 6, pp.88-95.

Marzano, L., Ciclitira, K. and Adler, J. (2012), “The impact of prison staff responses on self-harming

behaviours: prisoners’ perspectives”, British Journal of Clinical Psychology, 51(1) pp.4-18.

Marzano, L., Adler, J. and Ciclitira, K. (2013), “Responding to repetitive, non-suicidal self-injury in an English

male prison: staff experiences, reactions and concerns”, Legal and Criminological Psychology, 12, pp.1-14.

Mays, N. and Pope, C. (1995). Qualitative research: Rigor and qualitative research. British Medical Journal

311: 109-112.

Ministry of Justice (2015) “Safety in custody statistics England and Wales, deaths in prison custody to

March 2015, assaults and self-harm to December 2014, update to April 30 th 2015”, Ministry of Justice,

London.

Moses, C. (2013), “The role of a prison officer”, available at: http://www.poauk.org.uk/index.php?the-role-

of-a-prison-officer (accessed 31st August 2015).

25

National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (2011), “Annual

report 2011: England, Northern Ireland, Scotland and Wales. July 2011”, University of Manchester,

Manchester.

National Offender Management Service (NOMS) (2010). Safer custody news editorial: safer custody and

offender policy April 2010, [Online]. Available at: http://iapdeathsincustody.independent.gov.uk/wp-

content/uploads/2010/06/Safer-Custody-News-April-2010.pdf

(Accessed 1st September 2015).

National Offender Management Service (NOMS) (2011) “Prison service instruction 64/2011: management

of prisoners at risk of harm to self, to others and from others (safer custody)”. NOMS, London.

National Offender Management Service (NOMS) (2012) “Conveyance and possession of prohibited items

and other related offences”. NOMS, London.

National Offender Management Service (NOMS) (2015) “Health and Justice Summit: Safer Custody – ACCT

and Suicide Prevention. NOMS, London.

Pannell, J., Howells, K. and Day, A. (2003), “Prison officers’ beliefs regarding self-harm in prisoners: an

empirical investigation”, International Journal of Forensic Psychology, 1, pp.103-110.

Pengelly, N., Ford, B., Blenkiron, P. et al. (2008), “Harm-minimisation after repeated self-harm:

development of a trust handbook”, British Journal of Psychiatry Bulletin, 32(2), available at:

http://pb.rcpsych.org/content/32/2/60 (accessed 1st September 2015).

26

Prisons and Probation Ombudsman (PPO) (2014a), “Learning from PPO investigations: self-inflicted deaths

of prisoners on ACCT”, Home Office, London.

Prisons and Probation Ombudsman (PPO) (2014b), “Learning from PPO investigations: risk factors in self-

inflicted deaths in prisons”, Home Office, London.

Royal College of Psychiatrists (2004), “Assessment following self-harm in adults (Council Report CR122)”,

Royal College of Psychiatrists, London.

Samaritans, (2015a), “How we can help you”, available at:

http://www.samaritans.org/how-we-can-help-you (accessed 30th July 2015).

Samaritans, (2015b), “The Listener Scheme”, available at:

http://www.samaritans.org/your-community/our-work-prisons/listener-scheme (accessed 30th July 2015).

Senior, J. and Shaw, J. (2008), “Mental healthcare in prisons”, in K. Soothill, P. Rogers, P. and M. Dolan, M.

(eds.), Handbook of Forensic Mental Health, Willan Publishing, Cullompton, pp.175-195.

Short, V., Cooper, J., Shaw, J. et al. (2009), “Custody vs care: attitudes of prison staff to self-harm in women

prisoners—a qualitative study”, Journal of Forensic Psychiatry and Psychology, 20(3), pp.408-426.

South, J., Bagnall, A.M., Hulme, C. et al. (2014), “A systematic review of the effectiveness and cost-

effectiveness of peer-based interventions to maintain and improve offender health in prison settings,

Health Service Delivery Research, 2(35), 290”, available at:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4404270/ (accessed 30th July 2015).

27

Towl, G. and Forbes, D. (2002), “Working with suicidal prisoners”, in G. Towl, L. Snow and M. McHugh

(eds.), Suicide in Prison, Blackwell, Oxford, pp.93-101.

Walker, T. (2015), “Self-injury and suicide in prisoners”, in G. Towl and D. Crighton (eds.) Forensic

Psychology. Wiley-Blackwell, London, eScholarID:261696.

Walker , T. and Towl, G. (2016) Preventing self-injury and suicide in women’s prisons. London: Waterside

Press.

Ward, J. and Bailey, D. (2011) At arms length: the development of a self-injury training package for prison

staff through service user involvement. The Journal of Mental Health Training, Education and Practice, Vol.

6 Iss 4, pp. 175-185.

Ward, J. and Bailey, D. (2013) A participatory action research methodology in the management of self-

harm in prison. Journal of Mental Health, 22: 4, 306-316.

Ward, J (2014) Women's Imprisonment, Self-Harm and Emancipatory Research: Developing a Framework

for Transformative Research in a Women's Prison, Durham theses, Durham University. Available at Durham

E-Theses Online: http://etheses.dur.ac.uk/9506/

Yin, R.K. (2015). Qualitative research from start to finish. 2nd edn. New York: Guilford Press.

28