Women Living With Self-Injury
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There is no stand-alone specialized facility to treat chronic self-injurious women offenders in federal corrections.
Some of the most challenging and complex cases are managed in the Churchill Unit, a recently expanded bed female wing co-located at the otherwise male Regional Psychiatric Centre RPC Prairies in Saskatoon. Two women spent over 18 months in clinical seclusion at this facility under IPC status during the review period. One of these women has since been released on parole and was able to spend some months at a community psychiatric hospital where seclusion was not used as a response to her self-injurious behaviour or ideations. She described her time incarcerated in IPC in these words:.
During her time at the community psychiatric hospital, the frequency and severity her self-injurious behaviours diminished dramatically. Two women were managed on the Management Protocol until it was rescinded by the CSC in May consistent with a recommendation by this Office. Footnote 12 Under the Protocol, these women were housed in segregation for extensive periods of time. Following the rescinding of the Management Protocol, these women continued to spend a significant amount of time in both voluntary and involuntary segregation.
Within a prison milieu, security staff are almost always the first responders to self-injury incidents. Policy directs that all interventions to manage or control security incidents must be consistent with the Situation Management Model SMM and the client, acquiring and analyzing, partnership, response, and assessment client, acquiring and analyzing, partnership, response, and assessment problem-solving model. The client, acquiring and analyzing, partnership, response, and assessment model details a range of responses from dynamic security and verbal negotiations to the use of restraints.
To comply with the SMM and client, acquiring and analyzing, partnership, response, and assessment model, staff are required to continually assess and re-assess a situation and formulate a response based on situational information.
Compliance with the SMM and client, acquiring and analyzing, partnership, response, and assessment models should yield different responses when intervening with mentally disordered offenders in comparison to non-mentally ill offenders. Clinically driven intervention is based on the understanding that mentally ill persons should not be punished for the behaviours associated with their mental illness.
At times of extreme emotional deregulation, female offenders, many of whom have significant cognitive deficiencies, often have difficulty responding to control orders. The investigation found that, in most incidents, staff response to the self-injurious behaviour was not consistent with the objectives of CD — Management of Security Incidents or with CD — Management of Inmate Self-Injurious and Suicidal Behaviour.
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This finding is consistent with findings from previous CSC National Board of Investigation National Board of Investigation reports with regard to repeat self-injurious incidents. A number of internal investigations emphasize the importance of managing self-injurious behaviour through an ongoing dynamic risk assessment process involving four key principles: least restrictive intervention s ; humane treatment; clinical management; and collaborative planning.
A security response is one in which incidents are characterized and treated as compliance issues—i. When responding to self-injurious behaviour, staff are required to assess the individual risk and needs of the offender and formulate a response. Compliance with the least restrictive principle requires balancing the interests or needs of the offender with the correctional purpose of the intervention. In all cases, the principle requires minimal impairment; the correctional response must be necessary and proportionate to the level of risk presented by the self-injurious behaviour.
Resistive or assaultive behaviour most often occurs only after correctional staff intervene and is most frequently observed in the context of mandatory strip searching as part of a segregation or observation cell placement following a self-injury incident. Numerous staff mental health, security, and medical admitted that their response often runs counter to their instincts or awareness as to how to better handle a highly charged emotional situation.
The majority of staff attribute the security-driven response to self-injury to their accountability for keeping the institution in control at all times. Some officers disclosed that they did not feel qualified to intervene with mentally ill offenders despite the mandatory training on suicide prevention and the basic mental health awareness training that they had received. The investigation found that security or control interventions are generally disproportionate to the risk presented and often inappropriate from a mental health needs perspective. In most cases, these measures simply contain or reduce the immediate risk of self-injury; they are not intended to deal with the underlying reasons or symptoms of mental illness manifested in self-injurious behaviour.
Based on Office interviews, as well as documentation from the incidents, the Pinel Restraint System PRS appears to be a primary intervention measure to manage self-injurious behaviour, particularly at the RPC. Pinel restraints were used in over half of the incidents to manage self-injurious behaviours. RPC staff informed the Office that the Pinel restraint table is prepared immediately when a self-injury incident occurs.
Two women were responsible for a disproportionate number of the incidents in which the Pinel restraints were applied; one of these women spent a period of some months restrained either in a Pinel bed or a Broda chair Footnote 13 for up to 23 hours a day. The PRS was often applied after the behaviour escalated or deteriorated and following other interventions e.
Policy is also clear that physical restraints should not be used as a form of punishment or retaliation or coerced inducement and should be used only as the least restrictive alternative available.
The Office also noticed a pattern of women requesting Pinel restraints after protracted negotiations with security staff often involving resistance to a strip search or a segregation placement. In some of these cases, staff intervention had escalated to the point at which the women could no longer cope with the situation at hand.
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As this Office has stated elsewhere, placements in Pinel and other physical restraints such as the Broda chair are exceptional interventions that should be used as a last resort and only when an offender presents an immediate and extreme risk of self-injury or harm to others. Consistent with the least restrictive principle, these placements should be used for the shortest time possible and should be subject to the most rigorous accountability and monitoring framework possible.
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In many cases, the documentation stated that pepper spray was required to stop an offender engaged in self-injurious behaviour. This is concerning, particularly given that a disproportionate number of prison self-injury incidents occur in segregation or observation cells. As a consequence of their behaviour, resistive women were often placed in more restrictive conditions of confinement. In the spring of , the Service completed construction of a padded cell at the RPC.
Footnote 14 Prior to this, the RPC also requested and received an exemption to use a specially fitted helmet on the same woman, to manage her chronic head-banging. The concern is that such an extreme measure may be used to manage other cases. It is an expensive, extraordinary and ultimately inappropriate measure. This woman requires acute care and treatment that could be more safely and efficiently provided in an external mental health facility.
The principle of humane treatment requires that management strategies for self-injury not be meant as punishment but focus on the individual needs and risk of the inmate. Clinical seclusion remains a controversial intervention even in psychiatric settings. However, staff at both community psychiatric facilities stressed that the use of clinical seclusion as an intervention strategy for self injurious behaviour is based on an assessment of the individualized needs of each patient; it is not relied upon as a blanket response to all self-injury incidents.
For example, one of the women who spent considerable time segregated at EIFW due to her self-injurious behaviour was not segregated for the same behaviours at Institut Pinel, which believed that isolating her was counterproductive to clinical aims.
Prevalence and Correlates of Self-Harm in the German General Population
Moreover, the psychologist treating this woman at EIFW noted that managing her in segregation likely had a considerable negative effect, escalating the resistive and maladaptive responses and likely increasing her self-injurious behaviours. Best practices that identify seclusion as a tool in the management of self-injurious behaviour require that the process be ordered and implemented and managed by medical staff. Clinical seclusion must also be used sparingly and be based on acute risk of self-injurious behaviour.
The investigation revealed considerable confusion among staff regarding the use of clinical seclusion Footnote 16 and administrative segregation. Footnote 17 In some cases, security staff admitted to relying on administrative segregation and clinical seclusion CD to manage self-injurious behaviours despite clear direction by CSC in a Bulletin issued to staff that offenders who are self-injuring are not to be placed in segregation.
Footnote 18 In some cases, contextual factors led to more restrictive placements. For example, if the woman resisted the placement for clinical seclusion CD and began engaging in self-injury or refused orders to stop self-injuring, security staff may have decided to admit her to administrative segregation for jeopardizing the security of the penitentiary under CCRA 31 3 a. Staff confusion with regard to the intent of the different policies was also mirrored among self-injuring women.
The investigation found considerable confusion among the women with respect to the differences between segregation and clinical seclusion CD All of the women indicated that the immediate response when they self-injured was placement in segregation. None of them were aware of the actual difference s between segregation and clinical seclusion CD For example, one woman told us that she was in segregation for two years.
A review of her file indicated that she had never been placed in administrative segregation during the review period; however, she was under a clinical seclusion regime. When explained to her, she indicated that she had not been aware of the difference. It should also be noted that one woman who spent considerable time in the Intensive Psychiatric Care IPC unit of RPC Prairies informed the Office that although it is intended as a therapeutic environment, she did not perceive any difference between the IPC unit and the segregation range at any of the other institutions where she had been housed.
Blunting Emotional Pain
CD allows the Correctional Manager to designate a placement under CD if there are no other mental health professionals available. The Office noticed a pattern regarding CD placements: decisions were often made by security personnel rather than mental health staff, even when the latter were present within the institution.
Despite CD guidelines, the practice of isolating women seclusion who self-injure remains a significant management strategy, and correctional managers are often the principal decision-makers. Footnote 21 Research has found that these practices, even when used solely for monitoring purposes, are often perceived as punitive measures, which increases negative emotions and heightens the risk for further self-injury.
Self-Injury Reference Materials
Footnote 22 The Office noticed a disturbing trend whereby female offenders resisted strip searches that are required for an administrative segregation or CD placement, subsequent to self-injuring. The OSOR details information such as who, why, where, what and how an incident occurred within the institution. Moreover, the women who were already engaging in self-injury often escalated their self-injurious behaviour e.
Of particular concern, the process of strip searching women for placement in administrative segregation or CD often sets up a new form of negotiation between security staff and the women. The Office identified tensions that exist between staff and the female offenders when asked to strip search prior to being segregated for behaviours associated with mental health issues. Control-based strategies become clear aggravating factors in the escalation of the incident. One particularly distressing incident illustrates the tensions involving a self-injurious woman being forced to move to an observation cell.
The woman became combative when informed of this move. In order to be placed in the observation cell, she was required to complete a strip search. This request escalated her resistive behaviours and she begged not to be moved to segregation. She informed the Office that she removed her clothes but refused to remove her underwear because she was menstruating.
Physical handling was used to finally remove her underwear by way of holding her down and cutting them off. She was walked to the observation cell down the range with another officer holding up a blanket to cover her. She had refused to cooperate after being denied the dignity of wearing her undergarments. In community forensic hospitals, seclusion is part of a continuum of intensive psychiatric care that is used when there is a need to increase the observation of the patient.
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Community mental health practitioners emphasize the importance of using seclusion only when necessary based on the individualized needs of the patient and only for brief periods of time. Staff at Brockville Mental Health Centre similarly noted that seclusion placements are made very rarely and always after a psychiatric assessment has been completed. They further stressed the importance of engaging with the patient while waiting for a psychiatrist to arrive and during the seclusion placement. In community psychiatric care settings, the staff that deal with the identification, assessment and management of self-injurious behaviour are nearly always health care professionals.
During the review period, four women received some treatment at community psychiatric hospitals at different times. While in CSC facilities, these women spent long periods of time in either clinical seclusion or segregation due to their self-injurious behaviour. At one of the community hospitals, staff actively prevented one of the women from spending too much time in her room because the risk for self-injury was higher when she was alone.
However, the hospital did have to restrain this woman for a two-day period by way of a fixed chair and handcuffs to prevent her from self-injuring. During the time she was restrained, staff escorted her to the common room or programming room and then handcuffed her to a chair to minimize risk in an effort to keep her connected to other staff and patients.