Deliberate Self-Harm
By Gregory Sokolov, MD
Posted on August 31, 2009 –
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| Deliberate Self Harm |
Deliberately Self-Harming Inmates: Assessment and Management Issues:
Gregory Sokolov MD
According to the American Psychiatric Association (APA) Practice Guidelines on the Assessment and Treatment of Patients with Suicidal Behaviors, Compendium 2006, ¡§deliberate self-harm¡¨ is defined as the ¡§willful self-inflicting of painful, destructive, or injurious acts without the intent to die.¡¨ The lack of the intent to die is the key distinction between deliberate self harm (DSH) from a suicide attempt. Other terms commonly used to describe DSH include self-injurious behavior (SIB), para-suicide; suicidal gesture, manipulation or malingering of suicide. Examples of DSH include, but are not limited to: burning, cutting, opening wounds, hair pulling, head banging, inserting objects into body or under skin. More severe forms of DSH may include self-mutilation of genitals, limbs, and self-evisceration. In addition, self-asphyxiation where the noose material was loosely tied around one¡¦s neck has also been associated with DSH. Specific mental disorders or illnesses associated with DSH are listed in Table 1:
(Table 1):
„X Borderline Personality Disorder
„X Autism
„X Factitious Disorder
„X Post-traumatic stress disorder
„X Obsessive compulsive disorder
„X Eating disorders
„X Impulse control disorders
„X Substance disorders
Estimates of DSH in correctional settings vary. In one study, 52.9% of inmates admitted to two medium-security hospital units in the United Kingdom engaged in self-injurious behaviors (Gray et al. 2003). Other studies have reported a 2-4% rate in two New York State prison populations with self-injurious behaviors (Toch, 1975), and 15% of prisoners receiving psychiatric treatment in California had self-injurious behaviors (Young, Justice & Edberg, 2006).
Although the APA Practice Guidelines report that ¡§[DSH] is related to but distinct from attempted suicide,¡¨ a history of DSH may place inmates at a greater risk for suicide. In one study (Haycock, 1989), a review was conducted of sixty-two inmates (both prison and jail) that were admitted to a state hospital because they had made a suicidal threat or engaged in an act of self-injury. The group that had made a ¡§life-threatening attempt¡¨ (vs. the ¡§non-life threatening attempt¡¨ group): a.) was older, b.) more likely to have prior histories of potentially lethal attempts, c.) more likely to have been intoxicated or withdrawing from drugs or alcohol at time of attempt and d.) more likely to have been experiencing recent ¡§family turmoil¡¨ (defined as death of a loved one; recent divorce or separation; loss of custody of children; violent fights within the family including intra-familial murder; or criminal charges lodged by family members).
When assessing an inmate¡¦s self injurious behavior with respect to intent to die and risk for future suicide, the clinician should address the above risk factors and also consider other risk factors including recent legal or custodial stressors, the presence of a suicide note, collateral information from custody, attorney, family suggesting changes in inmate¡¦s behaviors or ¡§giving up¡¨ behaviors, i.e. giving away personal belongings, etc. In addition, the clinician should review inmate¡¦s prior history (if available) to determine if the current behavior is consistent with any prior episodes of DSH. The clinician should clearly document the risk factors for and against suicide (intent to die) including any possible ¡§protective¡¨ factors associated with ¡§future thinking¡¨ (discussion of legal appeal, plans for after jail release, obtaining employment or benefits after release, etc). The clinician should also determine an associated risk level for suicide (high, medium, or low). In addition, the clinician should avoid labeling terms that could be construed as being negative or pejorative, such as manipulative, not truly suicidal, or attention-seeking.
Once an assessment has been performed, the clinician must determine an appropriate treatment or management plan associated with the risk level for suicide, i.e. whether the inmate requires acute psychiatric hospitalization or closer observation status, or whether the inmate is able to return to the prior housing environment with other different interventions to include more frequent mental health follow-up or instituting a ¡§behavioral management plan¡¨ with custody (that might include possible temporary use of safety garments, limited access to commissary items which can be used in self-injurious acts, etc.).
In addition to adequately treating any underlying psychiatric disorders associated with DSH with psychotropic medications, a correctional mental health program should also consider the use of dialectical behavioral therapy (DBT), since many inmates with a history of DSH meet criteria for the diagnosis of borderline personality disorder. DBT has been shown to be an effective treatment in a forensic population due to the increased incidence of personality disorders, the targeted treatment of specific behaviors including aggressive and life-threatening behaviors, to help prevent staff burnout with inmates who engage in DSH and accreditation bodies support empiric treatments (McCann, et al 2000).
Dr. Sokolov is the Medical Director of Sacramento County Jail Psychiatric Services and Associate Clinical Professor of Psychiatry at the UC Davis Department of Psychiatry and Biobehavioral Sciences. REFERENCES: Gray, N. Hill, C., McGleish A., Timmons, D., MacCulloch, M., & Snowden, R. (2003). Prediction of violence and self-harm in mentally disordered offenders: A prospective study of the efficacy of HCR-20, PCL-R, and psychiatric symptomatology. Journal of Clinical Psychology, 71, 443-451. Haycock, J. (1989). Manipulation and suicide attempts in jails and prisons. Psychiatric Quarterly, 60, 85-98. McCann, R. A., Ball, E.M., & Ivanoff, A. (2000). DBT with a forensic inpatient population: The CMHIP forensic model. Cognitive and Behavioral Practice, 7, 447-456. Toch, H. Men in Crisis: Human Breakdowns in Prison. Chicago: Aldine, 1975 Young, M.H., Justice, J.V., & Erdberg, P. (2006). Risk of harm: Inmates who harm themselves while in prison psychiatric treatment. Journal of Forensic Sciences, 51, 152-156.
