Preventing Deliberate Self Harm in Prison: Review of Methods

Systematic review of the efficacy of methods of preventing deliberate self harm in prison

In delving into an examination of a ‘Systematic review of the efficacy of methods of preventing deliberate self-harm’ it is important to understand that the scope of the examination takes in a broad range of considerations, views and methodologies that are aligned with the main subject matter. Thus, having a clear understanding of what self-harm is represents a necessary facet in order to be able to determine the context within the scope of this examination. Hawton (1) states that “deliberate self-harm” entails “intentional self-positioning or self injury, irrespective of the apparent purpose of the act”. The most common forms, and or actions usually entail self-poisoning, overdosing on drugs, and the cutting of oneself (2). The preceding, self-harm, in a prison environment represents “a significant problem” that “requires the coordinated input of a number of agencies”, which includes “acute medical and psychiatric care (3)”.

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The subject of deliberate self-harm represents a broad subject area that includes alcohol abuse, deliberate self-injury by means of cutting, and other techniques. It also entails drug use, starvation, and other means via which individuals seek to harm, and or damage themselves. Harrison and Sharman (4) advise that self-injury represents a manner in expressing deep distress as represented by the cutting, burning, or other injury to oneself. They continue that frequently individuals do not know, or understand why they inflict harm upon themselves, and add that it is frequently a means to communicate what one cannot put into either words or thoughts (4). Harrison and Sharman (4) indicate that self-harm can be described “as expressing an inner scream”, which after the harm has been inflicted, then individuals are frequently able to cope with life, for a period of time. The preceding is expressed by many studies and articles that self-harm and self-injury represents a broad set of acts that can, and does emanate from one not looking after their own needs from either an emotional and or physical standpoint (4). The infliction if self-injury can include cutting oneself, scratching, burning, hitting oneself, swallowing, and or putting harmful things inside one’s body, as well as the use of drugs to hide, and or mask distress, for escapism, and or relief (4). Self-harm also can include becoming involved in as well as staying in a relationship that is abusive, taking unneeded and unnecessary risks, eating disorders such as anorexia and bulimia, and as mentioned drugs, along with alcohol abuse (4). The preceding are manifestations of excess that almost all individuals exhibit in some limited form or another as also represented by overeating. Overwork is an illustration of the foregoing whereby one attempts and or tries to lose themselves in an activity as opposed to being alone with their thoughts, and or feelings (4).

The foregoing explanation of self-harm, and self-injury spans a broad range of descriptions, and has been utilized to draw attention to the depth of methods that a systematic review of the subject matter entails. In equating a ‘systematic review of the efficacy of methods for preventing deliberate self-harm in prison, it is critical to understand the terms utilized in the preceding title, focusing first on ‘efficacy’ as the core word defining the context. The Merriam-Webster online dictionary (5) defines ‘efficacy’ as “the power to produce an effect”. This definition is mirrored by Houghton Mifflin (6) that states it, efficacy, is the “power or capacity to produce a desired effect; effectiveness”. The foregoing represents a significant contribution to the understanding of the range this examination will cover in terms of its systematic review. The core of the problem represent identification, treatment, and follow up, which is referred to as interventions at varying stages in the process of uncovering and dealing with individuals exhibiting the traits, and or recorded histories of self-harm.

The primary objectives concerning intervention is to identify, and manage self-injurious behaviour, enacting where possible improvement in the individual’s mental state, behaviour patterns, and functioning over the short, medium and long term. The preceding is manifested by less than six weeks, six weeks to six months, and more than six months respectively. The typical manner in which the foregoing is handled in a prison environment is via:

the utilization of conventional as well as newer antipsychotic drugs,
use of non-pharmacological interventions as represented by dialectical behaviour therapy, and
the removal of identified individuals to safe cells whereby they can be placed under close observation.

The secondary objectives represent the determination of the invention(s) that might have a beneficial effect. Such also entails understanding the diagnosis of treatable illnesses as evidenced by:

severe depression episodes that include psychotic symptoms, as well as
post-schizophrenic depression, and
the diagnosis of individuals suffering from emotionally unstable disorders of the personality that are borderline

This examination shall delve into the understanding of self-harm, and self-injury as it relates to individuals that are incarcerated, along with treatments, evaluation of intervention methodologies, common treatments, strategies in treatment and the efficacy of the methods utilized in prevention of the condition of deliberate self-harm. Jackson and Waters (7) inform us that there is no singular method that provides the necessary scope to answer the broad array of questions concerning “… public health, health promotion problems and interventions”. They point to Pettigrew and Roberts (8) who advise that when the problem is known, then the types of studies to answer, and hone in on the problem can be deduced. The preceding thus sets the parameters for this examination concerning a ‘systematic review of the efficacy of methods of preventing deliberates self-harm in prison’.

Garner (9) advises that in general, “people who deliberately hurt themselves do so because they feel that they need to, and that the act itself makes them feel better for a while, and more able to cope”. She adds that “People report overwhelming feelings of misery, emotional distress and hopelessness which lead them to the apparent solution of inflicting pain on their bodies”, and thus harming themselves. For a great many individuals, the preceding, self-harm, represents the solution, but however, it is in the reality a facet of the problem that is unresolved within themselves (9).

Harrsion (10) advises that in the “strictest terms” Deliberate Self-Harm represents the general terminology describing activities that are self-damaging. The foregoing includes activities such as alcohol abuse along with bulimia to add to the other manifestations thus far mentioned. He also advises that Self-Injury makes more specific reference to the activities entailing the utilization of cutting, positioning, bruising, burning, and over-dosing with the intent of suicide as well as other activities directed at self-injury (10). In the preponderance of instances, it has been observed that the infliction of self-injury often means self-protection as opposed to self-destruction, representing a “way of copping … when things get really bad (11).” Bywaters and Rolfe (11) continue that “People deal with things in different ways and, unfortunately or not, this is my way”. The preceding is an important understanding in the issue, which is highly complex.

The phenomenon, deliberate self-harm, represents a subject that has, and is entailing “extensive sociological, epidemiological, psychological, biological and clinical study” along with research as well as speculation as to its causes, reasons and roots (12). Jackson (13) published a set of guidelines which added to the ‘Handbook’ that provide “a working framework to conduct a systematic review of health promotion or public health intervention” to be utilized in conjunction with other source materials in the conducting of reviews concerning health interventions. There are two types of ‘reviews’ referred to by Jackson (13), which consist of:

“traditional literature reviews/narrative reviews”, and
“systematic reviews (with or without) meta-analysis”

The first, “traditional literature reviews/narrative reviews” is generally conducted as well as interpreted by experts in the field utilizing “informal, unsystematic and subjective methods … which is often summarised subjectively and narratively” (13). Jackson (13) explains that such processes representing “searching, quality appraisal and data synthesis are not usually described and as such, they are prone to bias”. The advantage of the preceding is the participation by said experts “who may have a thorough knowledge of the research field”, however it is also pointed out that the disadvantage is represented by the fact that these individuals and or authors “may have preconceived notions or biases and may overestimate the value of some studies” (13).

In conducting a ‘systematic review’ of an individual with the condition of self-harm and self-injury, Jackson (13) defines the process as one that is “a review that is “very much driven”, in today’s terms, “by the evidence-based medicine movement”. She continues that a systematic review is thus defined as “a review of the evidence on a clearly formulated question that uses systematic and explicit methods to identify, select and critically appraise relevant primary research” (13). She adds that said systematic review is utilized to “extract and analyse data from the studies that are included in the review”(13). A meta-analysis represents when two or more studies are combined statistically “to produce a single estimate of the effect of the health care intervention under consideration” (13). Jackson (13) cautions us that the preceding, a meta-analysis, represents simply the statistical combination concerning the result from the studies utilized, and that as such the final estimate concerning the effect might not necessarily represent the result found in the systematic review as done via the literature. Accordingly, the preceding should thus “not be considered as a type of review” (13).

The following represents a comparison of the varied types of reviews:

Table 1 – Different Types of Reviews, A Comparison (13)








Narrative Review

Describes as well as

appraises prior work,

but does not describe

the specific methods

by which the reviewed

studies were identified,

selected and evaluated.



critiques of

prior work,

and the current

gaps that may

exist in knowledge

The preceding is

often utilized as a

rationale for new


To gather and update

on the types of

interventions available to

include in a review.

The writers assumptions and

agenda are often unknown.

Biases that occur in selecting

and assessing the literature are


Cannot be replicated.

Systematic Review

The scope of the review is identified

in advance (eg review question

and sub-questions and/or sub-

group analysis to be undertaken)

Comprehensive search to find

all relevant studies.

Use of explicit criteria to include /

exclude studies.

Application of established

standards to critically appraise study quality.

Explicit methods of extracting and

Synthesising study findings.

Identifies, appraises

and synthesises all

available research that

is relevant to a particular

review question.

Collates all that is known

on a given topic and identifies

the basis of that knowledge.

Comprehensive report

using explicit processes

so that rationale,

assumptions and methods

are open to scrutiny by external parties.

Can be replicated / updated

Systematic reviews with

narrowly defined review

questions provide

specific answers to specific questions.

Alternative questions that

have not been answered

usually need to be reconstructed by the reader.

The Department of Health, under its “Delivering the Future” guidelines concerning self-harm (14) state that in many instances, acts of self-harm are not connected with attempts to commit an act of suicide. It states that such may represent instead an attempt to either influence, and or secure aid and help from others as well as a means to obtain relief from what is an unpleasant, and or overwhelming emotional state and or situation (14).

Chapter 2 – Clinical Guidelines and Interventions

As advised by Jackson and Waters (7), there is no singular method that provides the scope of information, and or definitions to answer the broad array of questions concerning interventions. As indicated by Pettigrew and Roberts (8), the foregoing requires a determination of what the problem is as a means to select the types of studies and information needed to hone in on the problem so that answers can be deduced. Therefore, in order to reach a determination, and or closer approximation of the potential type, or types of intervention needed, a “preliminary scooping search” (7) represents a means aids in gaining familiarity with the type(s) in interventions. This entails utilizing the questions that are asked, and answered in the interview session as the basis for the preceding. Jackson and Waters (7) in referring to Popay et al (15), as well as Dixson-Woods and Fitzpatrick (16) argue “… qualitative research should have a role in systematic reviews”. Spenser et al (17), as cited in Jackson and Waters (7), advises that the purpose of qualitative research is to provide a deeper understanding of the experience that individuals have, along with their experience factors, histories and importantly, their perspectives within their individual settings, and circumstances in an attempt to glean why people behave in the manner they do. The preceding represents the attempt to understand behavioural patterns, and social actions.

In a study conducted in the United States representing a small group of just 21 adults that were receiving aid for deliberate self-harm, it was found that the most promising intervention methodology entailed ‘problem solving therapy’ (18). The preceding found that the most promising type of intervention entailed short-term problem solving therapy, that was cognitively oriented psychotherapy. The foregoing, as represented in five studies versus that standard aftercare indicated a trend that showed decreasing self-harm, with the treatment time varying among all five participants (18). In another set of interventions conducted that entailed twenty adults in each study group indicated a reduction concerning the repetition of self-harm incidents (18). The methodology utilized represented what is termed ‘dialectical behaviour therapy (DBT), which is a treatment program that is comprehensive, and was developed to see to individuals with severe dysfunctional problems. It also was designed to uncover those who exhibit borderline personality disorder along with recent incidents of deliberate self-harm (18). In addition, the study revealed that the “administration of antipsychotic flupenthixol” was shown to significantly reduce the percentage of repeated incidents of deliberate self-harm among individuals that had a prior history of at least two previous suicide attempts as opposed to testing the preceding on another trial group whereby a placebo was used (18). Hogg and Burke (19) advise that self-harm represents more in the attempt to relieve distress and or tension than anything else.

Clinical Guidelines

Nationally, in the United Kingdom, there are ‘clinical practice guidelines’ as represented by what are termed systematically developed statements developed to assist clinicians, and patients in making decisions concerning the appropriate treatment as represented by differing specific conditions (14). And while the aspects of conditions, circumstances, and related criteria differ in a prison environment, it is important to understand that there are national clinical practice guidelines in place that have some applicability. The preceding guidelines have been devised from available research, and evidence that utilized both predetermined as well as systematic methodologies for the identification, and evaluation of evidence concerning the varied specific conditions (14). In those instances whereby sufficient evidence is either lacking, or not compiled in meaningful numbers, and or conclusions, the guidelines incorporate recommendations as well as statements that have been based upon a consensus as arrived at by the development group responsible for the guidelines (14).

The National Institute for Clinical Excellence (20) approach the subject of intervention by stating that the management of self-harm calls for the utilisation of both primary as well as secondary care services in order to provide a complete assessment of the individual’s mental health as well as social needs, along with factors that precipitated the situation, and the factors of risk entailing future and further self-harm incidents. This approach is also supported by Green and Sinclair (21) who add that the appropriate treatment methodologies should be sensitive in terms of the differences that exist between patients exhibiting self-harm characteristics, therefore interventions must be mindful as well as acknowledge the diverse needs as represented by differing circumstances. Thomas and Faulkner (22) add that what is termed as “user led” evidence is increasingly being recognized in both policy making as well as research, and that perspectives of self-harm treatment following incidents should be investigated thoroughly to correlated findings to further establish care pattern guidelines based upon similar lines of historical facets. Such, however has not been the case, as present evidence relies strongly upon patient studies based upon preventing, and managing self-harm based on a medical perspective. The National Institute for Clinical Excellence (20) in its NICE guidelines, recommend that such a study should be implemented whereby qualitative methodology is applied in a rigorous fashion to examine user experiences, and results.

The utilization, and importance of clinical guidelines has been devised as a means via which to improve the outcomes along with processes for the treatment, and intervention of individuals demonstrating a tendency, and or actual history of self-harm and self-injury. It is important to understand that the reasons, and causes for self-harm as well as self-injury are not entirely understood, and that each case and instance represents its own unique set of causes, histories, backgrounds, and rationales. As such, the Department of Health in developing said guidelines has cautioned that the preceding does not represent a substitution for either clinical judgment, or professional knowledge (14). In addition, the guidelines indicate that they are not meant to replace, and or supercede the responsibility of qualified health professionals in their rendering of decisions with respect to their patients.

The purpose of the guidelines are to aid professionals in good practice points as well as recommendations for medical treatment, along with psychosocial ,and interventions, with the aims to (14):

reach an evaluation of the specific medical as well as surgical interventions undertaken during the first forty-eight hours following an episode
reach an evaluation, where possible, of risk assessment for the individual involved
make an evaluation of the utilization, and role concerning the psychological as well as pharmacological interventions utilized in said episode
reach an evaluation concerning the role as represented by service delivery systems, along with service-level interventions regarding the treatment and care of individuals who have committed self-harm acts
to integrate all of the preceding to reach a determination of best practice representing the care, and treatment of those persons whom have committed an act or acts of self-harm.

The following guidelines are intended to focus upon those individuals that have committed act(s) of self-harm representing an expression that demonstrates personal distress, along with those situations whereby an individual specifically intends to injure themselves (14). It should be noted that the prison systems fall under the guidelines of the NHS, and the guidelines are applicable to these types of situations as such falls under what are termed statutory services (14).


The HM Prison Service (23) set forth a “Prison Drug Treatment and Self-Harm” “to introduce new procedures…” devised to “minimize the risk of self-harm” from occurring as a result of “reaction to the stresses” associated with certain drug treatments. It further stated that compliance with the guidelines requires (23):

appropriate information sharing to ensure that proper treatments are being conducted as well as to gather database information on treatment effectiveness inventions.
That under ‘Mandatory Action’ That the Directors along with Governors ensure:
That managers and staff in drug treatment positions are informed of the treatment guidance contents, and are following the prescribed outlines,
That case history information shall be detailed, including prior drug treatment as well as mental state, and such provided to a CARAT team while the assessment is being conducted. The preceding is also to be shared with other intervention treatment programs to further the informational base of how differing case histories, and approaches fair in terms of effectiveness to build the historical base of improved interventions in the future.
That prisoners under treatment are monitored for emotional as well as mental well being during the drug treatment process.
That providers administering drug treatment must have familiarity concerning the ‘multi-disciplinary risk management process’, termed ACCT, or F2052SH, as well as invoking these procedures upon the identification of someone found as being at risk concerning self-harm, and or suicide.
Lastly, drug treatment as administered by providers needs to actively promote as well as facilitate healthcare services access, along with the broad array of support services that are in prisons.

The national guidelines for prison treatment of self-harm and drugs, as set forth in “Prison Drug Treatment and Self-Harm” (23), advises that there are a number of important considerations which must be taken into account during the assessment of the potential utilization of treatment for individuals being treated for self-harm as well as the types of support needed. It advises that the management of the process for self-harm, and suicide represents a multi-disciplinary process that must include CARAT, ACCT, and or F2052SH in the risk management process after the identification of an individual with suicide, and or self-harm tendencies as well as a demonstrated history (23). The treatment of self-harm entails the inclusion of any and all prior treatment, and event histories that should be sought concerning the informational basis for the engagement of intervention (23). The intervention process needs to be cognizant of the individual’s prior treatment along with social, mental, and family problems as the concerns underlying the issue may lie in these areas.

The guidelines, and information as set forth under “Prison Drug Treatment and Self-Harm” (23) specify that the treatment programs as represented by CARATs, clinical services as well as Intensive Rehabilitation I are collectively the responsibility of the UK Prison system. CARAT represents the care coordinators for prisons with drug problems, and this agency maintains contact with each prisoner identified in their database. CARAT also maintains contact those instances whereby prisoners are transferred between institutions as well as treatment intervention transfers. Increased effectiveness under the shared informational context is seen as a result of the availability of prior history on prisoners, thus providing data on the path(s) taken, and the results achieved. The preceding also aids in the implementation of more effective intervention techniques. A mandatory facet of the guideline calls for the opening of an ACCT, and or F2052SH as soon as they are aware of an individual’s suicide, and or self-harm tendencies and or past actions (23).

Under the “Prison Drug Treatment and Self-Harm” (23), the former treatment, medical, and personal histories of individuals represent an important aspect in continuing as well as prescribing new treatment as it aids those in delivering care to build upon past information. Continuity of care is a vital facet in the setting forth of treatment and allied routines, and it also adds that the delivery of treatment, and intervention in isolation is unacceptable (23). Information with respect to the preceding historical aspects can be obtained by those administering treatment from (23):

Oasys assessments,
LIDS records that record prior episodes as contained in the ACCT or F2052SH database,
Healthcare services

The “Prison Drug Treatment and Self-Harm” (23) document states that prisons need to ensure that a written as well as observed policy on the institution’s “substance misuse service” that covers the following (23):

the clinical services that are provided as a result of healthcare,
the guidelines for detoxification for opiates, alcohol as well as bebzodiazepines,
that information representing assessment, the setting for treatment and overdose, along with essential observations are in keeping with the guidelines as set forth by the Department of Health,
that the health care treatment has been and is being administered in accordance with CARAT drug care plans, as well as
the fact that an NHS specialist is involved in the guideline preparations.

The foregoing procedural guidelines have been devised to reduce incidences associated with self-harm behaviour.

The use of drugs is also considered as a self-harm behavioural pattern. As such, clinical assessment concerning the misuse of substances represents an area definable through the first reception into the prison system as represented by initial medical examines as well as screening of the individual’s personal medical files, and sentencing records (23). The foregoing also applies to incidents of self-harm. Identified individuals that have self-harm, and drug use problems are thus referred for clinical misuse assessments (23). Under the “Prison Drug Treatment and Self-Harm” (23) guideline, prison systems have the responsibility to provide the appropriate settings for clinical interventions that permit unrestricted observation for patients that exhibit complex needs, with such observation available at all times (23).

The “Prison Drug Treatment and Self-Harm” (23) also provides for healthcare and CARAT teams to work jointly on protocols concerning the referral of individuals that exhibit self-harm risk as well as suicide, and other mental health facets. The preceding, protocols, require in addition to prison referral concerning the aforementioned to CARAT teams, that an ACCT, and or F2052SH must be opened concerning any case that has these symptoms (23). The CARAT assessment framework contains elements that are utilized to provide detailed information concerning individual records of treatment as well as health areas as such relates to self-harm. The following specifies the drug intervention record asks and or records the following under the:

A. Treatment Section (23):

If the individual is presently receiving drug use treatments, under section 5.12

This aspect represents the opportunity to determine the type(s) of treatment administered to the prisoner, and whether such prior treatment records should be obtained.

If the individual has had any drug use over the past two years, under section 5.13

Under this segment of questioning the CARAT worker should determine the type(s) of treatment the prisoner received, from the individual themselves as well as the treatment agency. Such data is useful in determining the treatment intervention(s) utilized and how such affected the prisoner, in addition to identifying if the individual had and or has any problems related to coping and related areas.

Has the individual had any treatment for drug use in prison, under section 5.13
Details representing prior treatment, help options and other relevant contact details, under section 5.15

B. Health Section (23):

If the individual has any mental and or physical health issues, under section 6.2

Under this facet, the CARAT worker seeks information from various agencies as well as healthcare concerning if prior treatment has either caused, and or raised any problems that might contribute to the prisoner’s physical, and or mental health areas.

C. Disclosure Form (23):

Informed Consent

Under the disclosure form, it is indicted clearly that the prisoner’s consent is not a requirement if the CARAT team thinks that the prisoner may be at the risk of committing self-harm. The consent form also permits that information can be shared between agencies, as well as disclosing the treatment the prisoner is receiving.

D. Referral Form (23):

This form is devised to allow for any other relevant information, such as risk to the prisoner as well as others, access problems, and related areas, to be recorded as part of the assessment, thus resulting treatment formulation.

E. Comprehensive Substance Misuse Assessment (CSMA) (23):

Under the ‘National Treatment Agency Model of Care’, a Comprehensive Substance Misuse Assessment (CSMA), along with the preparation of a corresponding care plan must be concluded before the administration of drug treatment. However, the foregoing is noted as to potentially not being possible for those individuals whose stay inside the prison system is relatively short.

History of Substance Abuse – Under section 1

Under this segment, the CARAT worker’s responsibility is to seek detailed information concerning the prisoner’s prior treatment through asking direct, and informed questions. In the exploration of the preceding, the CARAT worker needs to be mindful of as well as to take into consideration the processes utilised to achieve said outcomes as discovered

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