Ten slices crosswise on the wrist might throw up a flag for suicidal behavior, but a closer look may reveal an individual trying to soothe himself the only way he knows how.

In corrections facilities custody staff may see this behavior as simply suicidal and treat it with a trip to the emergency room. Experts in self-injurious behavior (SIB), however, say that there is a distinction between cutting to soothe or attract attention and cutting to end your life.

“One of the important things to understand and establish is people choose to focus on suicidal behavior, but if you look at the research, there's a variety of behavior,” said Henry Schmidt, Clinical Director of the Washington State Juvenile Rehabilitation Administration, who runs several programs for offenders exhibiting SIB.

Corrections officials who strive to keep people on their watch alive often utilize the emergency room or an isolation cell to keep an offender safe. But underlying self injurious behavior is often something other than a suicide attempt. Manipulation, showing power, trying to find comfort, punishing oneself, or hearing voices may be explanations for SIB.

“From a correctional or residential setting, we have a great responsibility for keeping people alive and there's a real tendency to try to figure out who is truly suicidal and who is manipulative. I find that to be an unhelpful pursuit [because] what we know is that those who do SIB have a high risk of suicide.  If you look at the reasons why people try to kill themselves, there's a lot of ambivalence,” said Schmidt.

While there are concrete figures each year for the number of suicide “completes,” there are no real statistics about how many “attempts” there were or how many of those resulted from SIB. The correlation between SIB and suicidal behavior may be closer that people realize.

According to David Thomas, Chairman of the Department of Correctional Medicine at Nova Southeastern University in Florida and former medical director for the Florida Department of Corrections, attempts or gestures such as taking an overdose of medication, not-deep-enough lacerations or tying something around the neck may accidentally lead to a suicide.

But how these gestures are treated in the correctional setting varies.

“Clearly the goal is to err on the side of caution. We spend a lot of time with one-on-one observation of inmates, but these are labor intensive and expensive modalities,” said Thomas.

These kinds of interventions can be especially difficult to employ if there are doubts on the part of custody staff about the authenticity of a suicide attempt. Thomas explains that inmates who self injure for manipulative purposes can cast a shadow on other types of self-injurious behavior.

“There's always a tension between mental health, medical and security and various other assets of a correctional environment. Sometimes it is expressed in someone who has been repeatedly self-injurious. We know some gang members arrange to injure themselves because they would be transferred to a mental health facility and they can get together there – where they can plot gang activities,” Thomas said.

A deeper understanding of the types if SIB may help corrections officials see the differences more clearly.

Defining SIB

According to Elizabeth Jeglic, Assistant Professor in Psychology at John Jay College of Criminal Justice, there are four different functions of SIB.

Some offenders are suicidal, and SIB is a suicide attempt or a way to punish themselves. Others are schizophrenic or psychotic and have delusions that tell them to harm themselves. Another group has borderline personality disorder and uses cutting as a way to soothe.

“Some people disassociate. It's kind of a soothing experience and that's why it's hard to get them to stop,” said Jeglic.

Finally there are manipulators, who cut in order to have power or control over some aspect of their incarceration. Jeglic added that correctional staff can sometimes fall victim to this manipulation when they automatically transfer an offender to the emergency room, sending the signal that this is how these gestures will be managed.

“We saw prisoners coming back three and four times [for self injurious behavior] and coming back for the same reason. What we encourage is they [are not] reinforced,” said Jeglic.

She said good suicide assessment tools and an in-depth review of an individual's history can help reveal what is behind the self injurious behavior.

“The best thing to do is chart review and talking to the offender. Those who are not suicidal won't have really good explanations,” she said.

Robert Trestman, Director for the Center for Correctional Mental Health Services Research at University of Connecticut Health Services, has conducted several research projects involving inmates in Connecticut who use self-injurious behavior.

Trestman agrees that SIB poses a real challenge for custody staff as well as medical and metal health staff because when inmates use it as a manipulation tool, it can de-sensitize staff to a true SIB or suicidal incident by another inmate or a future one by a previous manipulator.

In the case of those with borderline personality disorder, they very well may feel a relief from injuring themselves in one incident, but they may also be suicidal in another.

“Many people with borderline personality disorder [BPD] have learned that if they harm themselves by cutting or burning, they feel a sense of emotional relief. They are not doing it to kill themselves. [But] tomorrow they may try to kill themselves,” said Trestman.

For inmates who are manipulative, they can be very creative and use SIB in ways that seem authentic to BPD, but still they are attempting to manipulate of the officers or the system.

“I've seen someone who because of punishment in a restrictive housing unit, they were not allowed to watch a football game on TV and they became enraged. They bang their heads until they are unconscious or insert objects into body orifices, stab themselves. A lot can be said for specific secondary gain to feel powerful,” said Trestman. “Any one of these situations can lead to a cascade of events in an attempt to manage those behaviors.”

As recently as a decade ago, Trestman said, inmates who exhibited self-injurious behavior were written up or ticketed for it by correctional staff. Trestman said the ticket would be for destruction of state property – with the inmate being the property.

“As more people with profound mental illness have been incarcerated, it has become more complex. So, it requires a more thoughtful evaluation and intervention,” said Trestman. “And in many ways, things have gotten worse, not better, because of special management units. When people are in that kind of environment, they may do things to manipulate the situation.”

Trestman suggests that correctional agencies and facilities consider protocol and practices that specifically address SIB.

Managing SIB

When considering how to handle SIB, Trestman suggests first understanding the underlying cause and what is driving the problem.

This includes a diagnostic assessment as well as looking for triggering events, such as a “Dear John letter” or some other event.

Once the diagnostic assessment shows that autism, borderline personality disorder, psychosis or manipulation is behind the behavior, then staff can determine what the intervention should be.

What is difficult for corrections staff is that the diagnosis is rarely a textbook one.

“In prison or jail settings diagnoses are rarely clear cut. It is unusual to see a clear cut case of anything, usually the issues are complex, so staff must focus on functional impairment and outcome,” said Trestman.

Trestman said management of SIB is equally complex.

Those with autism, for example, may or may not be able to manage their behaviors and may or may not have the capacity to participate in treatment. This means the behavior may need to be managed by medicine or housing environments.

Those with borderline personality disorder  – and there is a growing number in prisons and jails – are impulsive and emotionally unstable and need tools to help them function better in the corrections environment, Trestman said.

Some corrections agencies have been testing a community treatment approach that has had positive results with SIB offenders in particular.

Dialectical Behavior Therapy

Dialectical Behavior Therapy [DBT] is a treatment and therapy developed by Marsha Linehan from the University of Washington that is typically used for those diagnosed with borderline personality disorder. Related to psychotherapy, the treatment is related to cognitive behavior therapy currently used in many correctional settings. DBT works with individuals to accept who they are and simultaneously works with them to change in ways that are empowering.

The four modules that are embedded in the therapy and that are taught to each participant include mindfulness skills -- attention to the present moment, distress tolerance skills and strategies, emotion regulation skills – how to identify and describe emotions -- and interpersonal effectiveness skills, which teach assertiveness and other skills to deal with conflict.

In the community, the use of DBT, according to Trestman, has meant a 30 percent reduction of hospital stays and self-injurious behavior.

In Connecticut prisons, this therapy has been used in 16-week pilot programs for offenders who participate in SIB and officials have found it has also had positive results.

“Doesn't it make sense to teach people how to cope with their impulsivity and their problems in their interpersonal relatedness, rather than letting them spiral down?” said Trestman. “It had become one of the nation's and the world's psychotherapy standards for treatment of borderline personality disorder.”

With funding from a National Institute of Justice grant, Trestman and his team created a DBT program geared for offenders. They re-wrote the materials to a fifth grade reading level, inserted icons into the material so the concepts would be easier to understand and used words that are related to the prison environment.

Offenders are referred to the program through a formal consent process and are chosen based on their length of stay in their environment.

There are some slight differences in the program from what is used in the community.

DBT usually calls for individualized treatment following the initial program, but Trestman is trying out other scenarios in the corrections setting to see if it is truly needed among the inmate population. Once offenders finish the 16-week treatment program, they are sent to either a psycho-education group with case management or to an individualized reinforcement program, where the DBT skills they have learned are practiced.

“We are hoping that because in the prison setting there is a restricted setting with more structure in place, it would limit the kind of range of behaviors that people would have. It might not be as difficult for them to learn,” Trestman said.

Using the four components of DBT, the program has treated about 50 adults and, by doing so, has won the support of the wardens in the facilities.

“The anecdotal evidence has been substantial. We are teaching people how to interact. When you sit down with inmates who are behaving this way, they do not know how to get what they want. When you cut away the window trappings, that's what it's all about,” Trestman said. “It's about giving people tools to deal with anxiety and anger in a structured way.”

In working with offenders in a 23-hour a day lock down setting, Trestman's team helped them to target their specific problems and give them DBT tools to practice for situations when SIB would be the next step.

For example, using the mindfulness module, an inmate would be asked to remember a positive part of their day, find ways to enjoy their life such as enjoying a shower when they get it, and [with interpersonal skills] focus on how to ask for things they need, Trestman said.

“We're trying to help people develop the skills to ask a CO, ‘When you cuff me, can you not put the cuffs on so tightly.' Rather than provoking the CO who indeed puts them on too tightly or where they would act so aggressively that they would need a SERT team to get them out of the cell,” said Trestman.

He added that in one treatment group for inmates in the lock-down setting, the team worked with an inmate who had stabbed a nurse in the neck when she tried to give him anti-psychotic medicine. By the completion of the DBT program, he had apologized to the nurse, was willing to take medications orally and was able to step down to a lower security level.

Researchers and clinicians in Washington State have had similar success with DBT programs for offenders.

According to Schmidt, DBT is being implemented in all residential setting for juveniles.

“When you look at who it was set up to treat – problems with self-cognitive dysregulation and interpersonal dysregulation – it really matched a lot of the deficits that youth, and I would argue most of people in correctional settings, have,” said Schmidt. “It is a non-judgmental validating approach. These folks act these ways for reasons [and] we really want to be in a position to help them improve.”

Schmidt said Washington's program follows the therapy as it was originally designed. He believes that adaptations are not necessary for corrections or juvenile detention – and may miss some important elements of DBT.

Schmidt said one important element that should not be skipped is the support groups among the therapists – which help ensure that each therapist continues to follow the DBT model. Another, he said, is the individual sessions for participants, which also help keep the patient motivated.

Starting a DBT program, however, takes support from the agency and commitment on the part of clinicians. DBT training is usually done in teams of four and follow-up training is required. This may raise an issue for corrections agencies about sufficient staffing levels for a program like this.

This is something that Trestman hopes to address as he tries different adaptations of DBT in the correctional environment.

But despite the work that it takes to launch a DBT program, those who have used it are convinced it is worth the effort in order to address what has become a growing problem in correctional environments.

“The real issue is facing custody and the medical and mental health folks who are working with these folks – they say, ‘Now what do I do?' when faced with [these situations]. In many ways it's easier to deal with suicidality protocols and procedures. In general they are in place and people can follow them. It's harder with SIB,” said Trestman.

And this may make the recent research around self injurious behavior and DBT all the more valuable.

Resources:

Information on Linehan and DBT:
http://faculty.washington.edu/linehan/index2.html

Correctional Service of Canada, Prevention, Management And Response To Suicide And Self-Injuries
http://www.csc-scc.gc.ca/text/plcy/cdshtm/843-cde_e.shtml