Professional Documents
Culture Documents
To cite this article: Birgit A. Völlm & Mairead C. Dolan (2009) Self-harm among UK female
prisoners: a cross-sectional study, The Journal of Forensic Psychiatry & Psychology, 20:5,
741-751, DOI: 10.1080/14789940903174030
RESEARCH ARTICLE
Self-harm among UK female prisoners: a cross-sectional study
Birgit A. Völlma* and Mairead C. Dolanb
a
Department of Forensic Mental Health, University of Nottingham, Nottingham, UK;
b
Monash University, Victoria, Australia
(Received 25 July 2005; final version received 18 December 2008)
Introduction
The high prevalence of psychiatric morbidity in prisoners is well established.
In a recent systematic review including 22,790 prisoners from 62 surveys in
12 countries, Fazel and Danesh (2002) reported a six-month prevalence of
3.7% for psychosis, 10% for major depression and 65% for personality
disorders. Axis I disorders in women were even more prevalent with 4% for
psychosis and 12% for major depression while personality disorders were
Methods
Setting and participants
Three prisons housing adult women were identified in the North-West of
England. The management of one prison declined participation in the study.
Prisons included therefore were HMP Styal and HMP Buckley Hall. HMP
Styal accepts adult female remand and sentenced prisoners. HMP Buckley
Hall is a privately managed Category C prison that operated as a closed
female training prison between April 2002 and December 2005 but currently
only accepts male sentenced prisoners.
Study participants were women over the age of 18 years residing in these
two institutions on a given census date. For HMP Styal, there were two
census dates, 3 December 2001 for sentenced women and 17 December 2001
for women on remand. Over the two census dates, 426 women were resident
at HMP Styal of whom 399 were approached to participate in the study;
The Journal of Forensic Psychiatry & Psychology 743
27 women had left the prison before they could be approached. 376 (94.2%)
women consented to participate in an initial screening interview (see below).
At HMP Buckley Hall, 302 women were resident on the census date, 26
November 2003. Of those, 20 declined participation, 17 had left the prison
before being approached and three women had already completed the screen
at HMP Styal. Therefore, 262 women were included in the screening
interview.
Assessment instruments
Socio-demographic details collected from participants and/or case notes
included: age, status, current charge and length of sentence. For status,
prisoners were dichotomised into those who had been convicted (including
those awaiting sentencing) and remanded prisoners. For current charge, the
offence leading to the current period of imprisonment was recorded using
seven categories: homicide or attempted homicide, including conspiracy to
commit murder; other violent offences including threats of violence; arson;
acquisitive offences; breach offences; drug-related offences and miscella-
neous offences.
The Prison Screening Questionnaire (PriSnQuest; Shaw, Tomenson, &
Creed, 2003) was used to identify mental health problems. The PriSnQuest
consists of eight questions; four are designed to identify depressive
symptoms, three to identify symptoms of psychosis and one question
inquires about previous psychiatric contact. A cut-off of three or more
questions was used to indicate a positive mental health screening.
The questionnaire on suicidal intent and self-harm (adapted from
Singleton, Meltzer, Gatward, Coid, & Deasy, 1998) consisted of questions
about thoughts of suicide and self-harm, actual suicidal attempts and acts of
self-harm, methods of self-harm and timing of these thoughts and
behaviours.
The Camberwell Assessment of Need-Forensic Version (CANFOR;
Thomas et al., 2003) was implemented for use in those women who screened
positive on the PriSnQuest. This tool consists of 20 questions around
current met and unmet needs in relation to the present setting.
Interviews took 10 to 30 minutes.
Statistical analysis
Analysis was conducted using SPSS 15.0. Descriptive statistics were
performed using frequencies, proportions or means as appropriate. Two
sample t-tests and w2 tests were used to identify differences between
individuals by history of self-harm or suicide attempts. Backward logistic
regression was conducted entering all variables with a statistically significant
difference in this comparison in the model.
744 B.A. Völlm and M.C. Dolan
Results
Sample characteristics
Six hundred and thirty-eight women were included in the study. The mean
age of women was 30 years (range 18–68). Five hundred and fifty-two
(86.5%) were convicted while the remainder were on remand. Of those
women for whom this information was available (603), 45 (7.5%) were
charged with homicide or attempted homicide (including conspiracy to
commit murder), 133 (22.1%) with other violent offences, 15 (2.5%) with
arson, 156 (25.9%) with acquisitive offences, 28 (4.6%) with breach offences,
168 (27.9%) with drug-related offences and 58 (9.6%) with other offences.
Thoughts and behaviours Yes, ever* Yes, within the last week
Ever thought life was not worth living 290 (46.6%) 84 (13.2%)
Ever wished they were dead 280 (44.0%) 80 (12.6%)
Ever thought of taking own life 259 (40.9%) 62 (9.8%)
Suicide attempt 220 (34.6%) 12 (1.9%)
Self-harm without suicidal intent 171 (27.9%) 28 (4.4%)
Needs assessment
A high number of needs were identified in those women for whom
CANFOR data were available (250). On average 8.5 needs were identified
(range 2–16); a mean of 4.6 needs were classified as unmet (range 0–14). The
largest areas of need were psychological distress, daytime activities,
treatment and information about treatment. The largest unmet need was
for psychological distress which was rated as unmet by over half of the
women.
Note: *Due to missing items actual n might be lower for some variables; **Including attempted
homicide and conspiracy to commit murder.
Discussion
In this cross-sectional study of female prisoners, we found high prevalence
rates of previous psychiatric contact and current psychopathology,
particularly symptoms of depression. Nearly half of the women had a
history of self-harm or suicide attempts and for about half of those the onset
of these behaviours post-dated their imprisonment. Women with a history of
self-harm had significantly higher rates of violent offending, psychopathol-
ogy and needs, but a large proportion of self-harming prisoners had not
been identified by the prison service’s risk assessment procedures.
Strengths of this study are the large sample size and high consent rates. It
is to our knowledge the first study to look at psychopathology, self-harm
and needs within the same sample in a female UK prison population.
In order to obtain a large sample of consenting women, assessments had
to be brief. Consequently, we were not able to conduct structured interviews
to provide psychiatric diagnoses, including assessment of personality
factors, or obtain independent verification of the information given by the
women on their mental health. Although this appears to be a weakness, one
should bear in mind that, considering the limited resources within the prison
system, the use of comprehensive assessment instruments would not be
feasible in day-to-day practise. The use of brief, easy to administer tools
could therefore be seen as an advantage as it potentially allows their
introduction into routine care. However, the brevity of the assessment
procedure in this study precluded a more detailed assessment of potentially
informative parameters, such as precipitants and circumstances of self-harm
and suicidality and details of current treatment.
Previous UK studies looking at the mental health of prisoners have
found high rates of psychiatric disorders, ranging from 10% to 30% for
serious mental illness using established diagnostic instruments (Birmingham,
Mason, & Grubin, 1991; Brooke, Mason, & Grubin, 1996; Fazel & Danesh,
2002; Gunn, Maden, & Swinton, 1991; Gunn, Robertson, Dell, & Way,
1978; Singleton et al., 1998). Few studies have specifically focussed on
female prisoners. Parsons, Walker, and Grubin (2001) found that 59% of
remand woman prisoners had at least one mental disorder with 11%
suffering psychotic symptoms. The authors noted that reception screening
did not identify the majority of these cases. Lower rates, particularly for
severe mental illness, had been reported by Maden, Swinton, and Gunn
(1994) in sentenced prisoners. Studies including both genders have reported
higher rates of psychiatric morbidity in women compared to men (Fazel &
Danesh, 2002). Fazel et al. (2006) commented specifically on the
disproportionately high rate of substance abuse in women which has been
found to be a risk factor for completed suicide in prison. Our study assessed
symptomatology using a brief check list as reported by Shaw et al. (2003) for
use in Magistrates’ Courts rather than more elaborate diagnostic schedules.
748 B.A. Völlm and M.C. Dolan
Shaw et al. (2003) reported good sensitivity and specificity of this instrument
in their sample, detecting the majority of cases with serious affective or
psychotic illness; however, their study did not investigate associations with
self-harming behaviours.
Studies on completed suicides in prisoners have identified a three- to ten-
fold increase compared to the general population (Crighton & Towl, 1997;
Dooley, 1990; Topp, 1979). More recent reports (Konrad et al., 2007; Shaw,
Baker, Hunt, Moloney, & Appleby, 2004) suggest that age-standardised
rates for suicide in female prisoners are higher than for their male
counterparts and that the difference to suicide rates in the general
population is also more prominent in women. In our study, a large
proportion of women, nearly half of the sample, reported a history of self-
harm or suicide attempts. Given the association between suicide attempts
and completed suicide (Hawton et al., 1998), one has to assume that the risk
of suicide in this sample was also high. Power and Moodie (1997), in a
Scottish mixed gender prison sample, found that just over 1% of their
sample openly talked about suicide on reception and about 0.5% did so at a
later time during their imprisonment. Shaw et al. (2004) reported that 16%
of prisoners who later committed suicide had disclosed thoughts of self-
harm or suicide at the reception screening. The lower figures in these studies
may reflect a reluctance of prisoners to disclose such thoughts to prison staff
and the different gender composition of the samples. Furthermore, Power
and Moodie (1997) focussed specifically on suicidal thoughts rather than
any self-harming behaviour. Other studies (Dooley, 1990; Power & Moodie,
1997; Singleton et al., 1998) using the broader concept of self-harm have
found similarly high figures as our study with some suggestion of higher
rates of such behaviours in women compared to men.
Of particular concern in our study was the large number of prisoners
who only started self-harming following imprisonment, possibly indicating
difficulties in adjusting to prison life. Shaw et al. (2004), in a sample of
prison suicides in men and women, found that only just over half of the
prisoners who eventually committed suicide had a previous history of self-
harm. This suggests that additional indicators have to be taken into account
in order to identify those at risk of suicide.
Our study showed that a higher percentage of women with than without
a history of self-harming behaviour were on an ‘open’ Form 2052SH. While
this is encouraging, it is also of note that nearly 30% of women with self-
harming or suicidal behaviour in the previous week were not identified by
this procedure. Furthermore, Shaw et al. (2004) reported that a quarter of
suicide completers were on an ‘open’ F2052SH at the time of death,
suggesting short falls in this procedure even if individuals were identified as
at risk.
Age, being on remand, recent incarceration, long sentence, foreign
nationality, violent offending, history of substance abuse, use of
The Journal of Forensic Psychiatry & Psychology 749
psychotropic medication, psychiatric history and morbidity and history of
suicidality have been identified as risk factors for completed suicide in
prisoners (Daniel, 2006; Fruehwald, Matschnig, Koenig, Bauer, & Frottier,
2004; Lohner & Konrad, 2007; Topp, 1979; Way, Miraglia, Sawyer, Berr, &
Eddy, 2005). However, none of these studies have specifically focussed on
women and few have investigated self-harming or suicidal behaviour as
opposed to completed suicide or have compared those with such behaviour
to those without. We found a trend for age with those women of a younger
age being more at risk of self-harming behaviour; a similar effect has been
described in the general population (Schmidtke et al., 1996). Our results
further suggest that index offences involving violence or arson are risk
factors for self-harming or suicidal behaviour. Impulsivity might be the
common factor in these behaviours but this would need further investiga-
tion. We found higher rates of psychiatric symptomatology and previous
psychiatric contact in women with a history of self-harming behaviour
compared to those without such history. Our results further suggest that
depressive symptomatology is particularly pertinent in this respect as our
logistic regression model did not show any independent effect of psychotic
phenomena.
We are not aware of any research looking at met and unmet needs in
prisoners. Brooke et al. (1996) have specifically explored treatment needs
reporting 55% of their male samples were in need of some form of
psychiatric treatment. Studies using the CANFOR in non-prison population
samples suggest considerable lower levels of needs than in our population;
for example, mean needs of 6.8, of which 2.2 were unmet, have been
reported in a high-security sample (Leese et al., 2006) although data are not
reported by gender. This suggests that female prisoners may present a
similarly or even more complex patient group compared to those in
forensic-psychiatric hospitals; yet the level of input they receive is
considerably less.
Conclusions
Our results suggest that female prisoners are characterised by significant
psychopathology, high levels of self-harming behaviour and risk as well as
a high levels of complex needs. While historical factors associated with risk
of self-harm cannot be changed, psychopathological indicators can and
should be targeted in order to reduce the risk of the most vulnerable
prisoners. Our study suggests that simple check lists may be useful to
identify those at risk of self-harm. However, this risk is not static;
therefore risk assessment has to be a continuous process and should not be
restricted to reception screening. Even those with no previous history of
self-harm may develop such behaviour during their incarceration. Given
the high levels of disturbance and need in this population, it is unlikely
750 B.A. Völlm and M.C. Dolan
that any significant impact is going to be made without the allocation of
additional resources. Future research should focus on the characteristics
and precipitants of self-harming behaviour in order to increase our
understanding of those indicators not readily identified by current
screening procedures.
Note
1. A prison service form which was filled out for regular monitoring when an
individual was deemed to be at risk of suicide. This has since been replaced by
the ACCT (Assessment and Care in Custody Teamwork) form.
References
Birmingham, L., Mason, D., & Grubin, D. (1991). Prevalence of mental disorder in
remand prisoners: Consecutive case study. British Medical Journal, 313,
1521–1524.
Blaauw, E., Roesch, R., & Kerkhof, A. (2000). Mental disorders in European prison
systems. Arrangements for mentally disordered prisoners in the prison systems
of 13 European countries. International Journal of Law and Psychiatry, 23,
649–633.
Brooke, D., Taylor, C., Gunn, J., & Maden, A. (1996). Point prevalence of mental
disorder in unconvicted male prisoners in England and Wales. British Medical
Journal, 296, 1779–1527.
Crighton, D., & Towl, D. (1997). Self-inflicted deaths in prison in England and
Wales: An analysis of the data for 1988–1990 and 1994–1995. Issues in
Criminological and Legal Psychology, 28, 12–20.
Daniel, A.E. (2006). Preventing suicide in prison: A collaborative responsibility of
administrative, custodial, and clinical staff. Journal of the American Academy of
Psychiatry and La, 2, 165–175.
Dooley, E. (1990). Prison suicide in England and Wales, 1972–1987. British Journal
of Psychiatry, 56, 40–45.
Fazel, S., Bains, P., & Doll, H. (2006). Substance abuse and dependence in prisoners:
A systematic review. Addiction, 101, 181–191.
Fazel, S., Benning, R., & Danesh, J. (2005). Suicides in male prisoners in England
and Wales, 1978–2003. The Lancet, 366, 1301–1302.
Fazel, S., & Danesh, J. (2002). Serious mental disorders in 23,000 prisoners: A
systematic review of 62 surveys. The Lancet, 359, 545–550.
Fruehwald, S., Matschnig, T., Koenig, R., Bauer, P., & Frottier, P. (2004). Suicide in
custory: Case control study. British Journal of Psychiatry, 185, 494–498.
Gunn, J. (2000). Future directions for treatment in forensic psychiatry. British
Journal of Psychiatry, 176, 332–338.
Gunn, J., Maden, A., & Swinton, M. (1991). Treatment needs of prisoners with
psychiatric disorders. British Medical Journal, 303, 338–341.
Gunn, J., Robertson, G., Dell, S., & Way, C. (1978). Psychiatric aspects of
imprisonment. London: Academic Press.
Hawton, K., Arensman, E., Wasserman, D., Hulten, A., Bille-Brahe, U., Bjerke, T.,
et al. (1998). Relation between attempted suicide and suicide rates among
young people in Europe. Journal of Epidemiology and Community Health, 52,
191–194.
Konrad, N., Daigle, M.C., Daniel, A.E., Deaer, G.E., Frottier, P., Hayes, L.M.,
et al. (2007). Preventing suicide in prisons, Part I. Crisis, 28, 113–121.
The Journal of Forensic Psychiatry & Psychology 751
Leese, M., Thornicroft, G., Shaw, J., Thomas, S., Mohan, R., Harty, M.A., et al.
(2006). Ethnic differences among patients in high-security psychiatric hospitals in
England. British Journal of Psychiatry, 188, 380–385.
Lohner, J., & Konrad, N. (2007). Risk factors for self-injurious behaviour in
custody: Problems of definition and prediction. International Journal of Prisoner
Health, 3, 135–161.
Maden, T., Swinton, M., & Gunn, J. (1994). Psychiatric disorder in women serving a
prison sentence. British Journal of Psychiatry, 164, 44–54.
Parsons, S., Walker, L., & Grubin, D. (2001). Prevalence of mental disorder in
female remand prisoners. Journal of Forensic Psychiatry & Psychology, 1,
191–202.
Power, G., & Moodie, E. (1997). Characteristics and management of prisoners at risk
of suicide behaviour. Archives of Suicide Research, 3, 109–123.
Schmidtke, A., Bille-Brahe, U., Deleo, D., Kerkhof, A., Bjerke, T., Crepef, P., et al.
(1996). Attempted suicide in Europe: Rates, trends and sociodemographic
characteristics of suicide attempters during the period 1989–1992. Acta
Psychiatrica Scandinavica, 93, 327–338.
Shaw, J., Baker, D., Hunt, I.M., Moloney, A., & Appleby, L. (2004). Suicide by
prisoners: National Clinical Survey. British Journal of Psychiatry, 184, 263–267.
Shaw, J., Tomenson, B., & Creed, F. (2003). A screening questionnaire for the
detection of serious mental illness in the criminal justice system. Journal of
Forensic Psychiatry & Psychology, 14, 138–150.
Singleton, N., Meltzer, H., Gatward, R., Coid, J., & Deasy, D. (1998). Psychiatric
morbidity among prisoners in England and Wales. London: TSO.
Thomas, S., Harty, M.A., Parrott, J., McCrone, P., Slade, M., & Thornicroft, G.
(2003). CANFOR: Camberwell assessment of need – forensic version: A needs
assessment for forensic mental health service users. London: Gaskell.
Topp, D.O. (1979). Suicide in prison. British Journal of Psychiatry, 134, 24–27.
Way, B.B., Miraglia, R., Sawyer, D.A., Berr, R., & Eddy, J. (2005). Factors related
to suicide in New York state prisons. International Journal of Law and
Psychiatry, 28, 207–221.