AFP L6

suicide & self- harm

suicide gesture

an apparent attempt at SS by someone wishing to attract attention, gain sympathy, or achieve some goal other than self-destruction

Non-suicidal self-injury (NSSI): (DSM5 – APA, 2013)

intentional self-injury (destruction of external body tissue) in which a person has no intent to die

solely involving intentional, immediate damage to the surface of the body – not over-dose, poisoning - & not socially sanctioned (eg tattooing, piercing)

suicide rates in prison

•Male prisoners x5 more likely than men in general public to die by suicide

•Young offenders x18 more likely to die by SS than adolescents in community

Single most common cause of death in a prison setting.

Kreitman (1977): desire to die group

Small Group

•Male

•Severe mental illness

•Violent death

(i.e., hanging or shooting)

Kreitman (1977): cry for help group

•Female

•Situational (not MI)

    (i.e., relationship breakdown & substance misuser)

•Non-lethal

•Often high freq

Function of deliberate self-injury (Klonsky, 2007)

Affect-regulation

Anti-dissociation

Anti-suicide

Interpersonal boundaries

Interpersonal-influence

Self-punishment

Sensation-seeking

Affect Regulation Functions of Self-injury

•Self-injury as regulation of autonomic arousal & -ve affect

•Injury regulates physiological ‘agitation’ and psychological tension

–act of mutilation produces feelings of calm and relief

•Regained control of emotional state

•Reinforcement of avoidance

Environmental/Functional Model of Self-injury: (Simpson & Porter, 1981)

(extension of affect regulation model)

•Based on social learning theory/modelling

•Idea that adolescents learn through their dysfunctional families that injury and care are associated, and attempt to self-care through self-injury

•Self-injury then reinforced by internal affect and/or external social factors

A Functional Study of Self-injury (Nock & Prinstein, 2004)→ order of strongest factors

A-NR (strongest)

A-PR

S-NR

S-PR (weakest)

Suicide as a Process

•No assoc betw medical seriousness of attempt and strength of intent to die

•Can’t differentiate between levels of lethality in prisons by specific motives: usually a mixture of motives

–No serious (“genuine”) vs. non-serious (“manipulation”) suicidal processes

–Only:

•Interrupted processes (SH/SSA)

•Ongoing processes

•Completed processes (SS)

Interpersonal-Psychological Theory (IPT) of Suicidal Behaviour (Joiner, 2005)

•Perceived burdensomeness to others – “my death is worth more than my life”

•Low belongingness/social alienation

•Acquired ability to enact lethal self-injury – overcome self-preservation through repeated exposure to painful/fearsome experiences – previous SSAs, previous NSSI, roles as physician, front-line soldier

•Interaction - All 3 elements must be present

IPT in prisons

•Prisons can create:

–shame/guilt → burdensomeness

–exclusion/isolation → thwarted belongingness

–exposure to violence → acquired capability

•Measures of thwarted belonginess & perceived burdensomeness in male prisoners→ stronger suicidal ideation (controlling for depression & hopelessness)

Attachment Theory & Suicidal Behaviours: (McKeown et al., 2017)

•Insecure attachment styles from early childhood relationships lead to maladaptive coping responses to interpersonal stress as an adult, resulting in hopelessness-related attempted suicide and SH behaviours

•Insecure attachment styles are over-represented among offender pops

stable/ chronic risk factors vs acute factors/ triggers

stable/ chronic: quite stable and only change slowly

acute factors/ triggers: change rapidly, so their influence on the level of risk may be short-lived – often these are life events/changing circumstances.

Risk Factors - Women in Prison

•History of continuing abuse – sexual (1/3 vs. 1/10 males), physical (Domestic Violence: 50% vs. 25% males)

•MH – 26% received treatment for MHP in year before custody (vs. 16% males)

•Substance abuse – 70% entering prison require detox (vs. 50% males)

•Suicide – 46% of women prisoners have attempted suicide in past (vs. 21% males)

Protective factors (CDC, 2022)

decrease the probability of -ve outcome in presence of elevated risk.

–Effective coping and problem-solving skills

–Social support & feeling connected to others

–Obligations to children, other family, friends, etc.

–Cultural, religious, or moral objections to SS

After the Corston Report on Women in Prison: What Have We Learned? INQUEST report highlighted serious flaws in the learning process following recent deaths in custody

what patterns still exist?

–Histories of signif disadv and complex needs

–Poor medical care and limited access to therapeutic services in prison

–Unsafe prison env and cells that are unable to stop SS despite having known MHP and histories of SH

•Serious concerns about high rates of SH and vulnerability across the women’s prison estate

•SH among women in prison has increased in last 10 years→ now 8.5x higher than in men’s prisons