Subtheme 1.1: high frequency and variety of self-harm in prisons

Witnessing a high frequency of self-harm was reported by prison staff in seven studies, described as occurring ‘all the time’ and ‘every time’ staff complete shifts.^{Reference Smith, Power, Usher, Sitren and Slade9,Reference Bantjes, Swartz and Niewoudt38,Reference Marzano42–Reference Moore, Andargachew and Taylor44,Reference Cresswell, Karimova and Ward62,Reference DeHart, Smith and Kaminski63}

Staff witnessed numerous types of self-harm, with cutting being the most mentioned.^{Reference Smith, Power, Usher, Sitren and Slade9,Reference Bantjes, Swartz and Niewoudt38,Reference Marzano42–Reference Moore, Andargachew and Taylor44,Reference Cresswell, Karimova and Ward62,Reference DeHart, Smith and Kaminski63}

Subtheme 1.2: staff's perceived capacity and ability to manage self-harm

Despite the high frequency of self-harm witnessed, prison staff frequently expressed low confidence in understanding, preventing and managing self-harm.^{Reference Smith, Power, Usher, Sitren and Slade9,Reference Ludlow, Schmidt, Akoensi, Liebling, Giacomantonio and Sutherland41,Reference Short, Cooper, Shaw, Kenning, Abel and Chew-Graham48,Reference Sweeney, Clarbour and Oliver49} This resulted in them feeling ‘helpless’ and ‘useless’, particularly if the self-harm was repetitive.^{Reference Ludlow, Schmidt, Akoensi, Liebling, Giacomantonio and Sutherland41–Reference Moore, Andargachew and Taylor44,Reference Short, Cooper, Shaw, Kenning, Abel and Chew-Graham48,Reference Liebling, Tait, Durie, Stiles and Harvey64}

To improve their confidence and skills, many prison staff highlighted a need for more self-harm training,^{Reference Smith, Power, Usher, Sitren and Slade9,Reference Bantjes, Swartz and Niewoudt38,39,Reference Ludlow, Schmidt, Akoensi, Liebling, Giacomantonio and Sutherland41,Reference Ramluggun45,Reference Short, Cooper, Shaw, Kenning, Abel and Chew-Graham48,Reference Sweeney, Clarbour and Oliver49,Reference Walker, Shaw, Hamilton, Turpin, Reid and Abel51,Reference Walker, Shaw, Hamilton, Turpin, Reid and Abel52,Reference DeHart, Smith and Kaminski63,Reference Ward and Bailey65,Reference Ward67} although some emphasised learning ‘on the job’.^{Reference Ludlow, Schmidt, Akoensi, Liebling, Giacomantonio and Sutherland41,Reference Liebling, Tait, Durie, Stiles and Harvey64}

Various occupational factors hindered staff's perceived abilities to care for self-harm. Inconsistent and insufficient staffing was felt to interrupt consistency of care and limit the identification and management of relevant risk factors. Staffing problems also reduced opportunities for multidisciplinary input for prisoners who self-harm, and decreased the time available for staff–prisoner engagement.^{Reference Smith, Power, Usher, Sitren and Slade9,Reference Bantjes, Swartz and Niewoudt38,39,Reference Ludlow, Schmidt, Akoensi, Liebling, Giacomantonio and Sutherland41–Reference Marzano, Adler and Ciclitira43,Reference Short, Cooper, Shaw, Kenning, Abel and Chew-Graham48,Reference Sweeney, Clarbour and Oliver49,Reference Liebling, Tait, Durie, Stiles and Harvey64}

Staff described various challenges caring for people who self-harm in prisons, which were portrayed as ‘anti-therapeutic’ and ‘punitive’ settings.^{Reference Bantjes, Swartz and Niewoudt38,Reference DeHart, Smith and Kaminski63,Reference Liebling, Tait, Durie, Stiles and Harvey64} Staff frequently reported tensions between their ‘security’ and ‘care’ responsibilities, and the prison ‘regime’ was positioned as taking priority over healthcare.^{Reference Smith, Power, Usher, Sitren and Slade9,Reference Ludlow, Schmidt, Akoensi, Liebling, Giacomantonio and Sutherland41,Reference Marzano, Adler and Ciclitira43,Reference Short, Cooper, Shaw, Kenning, Abel and Chew-Graham48,Reference Tait50,Reference Liebling, Tait, Durie, Stiles and Harvey64} In contrast, in one establishment with low rates of self-harm, staff felt that their roles of ‘carer’ and ‘security officer’ were well integrated.^{Reference Rivlin46,Reference Rivlin, Shuker and Sullivan47} A prison culture was sometimes reported whereby staff felt shamed from outwardly expressing concern for prisoners who self-harm,^{Reference Marzano42,Reference Liebling, Tait, Durie, Stiles and Harvey64} although this was less apparent among female staff.^{Reference Liebling, Tait, Durie, Stiles and Harvey64}

Staff generally felt more confident and able to manage self-harm when working in multidisciplinary teams. This allowed them to draw on broad skills and knowledge, resolve prisoners’ issues more quickly and achieve greater consistency of care.^{39,Reference Ludlow, Schmidt, Akoensi, Liebling, Giacomantonio and Sutherland41,Reference Marzano42,Reference Cassidy and Bruce54} However, staffing and communication difficulties sometimes prevented effective teamwork, in addition to conflicting team perspectives and complex team structures.^{Reference Bantjes, Swartz and Niewoudt38,Reference Ludlow, Schmidt, Akoensi, Liebling, Giacomantonio and Sutherland41,Reference Ramluggun45,Reference DeHart, Smith and Kaminski63}

Subtheme 1.3: emotional effects of self-harm on prison staff

Numerous reactions to self-harm were described by prison staff, varying from frustration and feeling attacked to feeling ‘sad’ and ‘touched’.^{Reference Bantjes, Swartz and Niewoudt38,Reference Marzano42,Reference Ramluggun45,Reference Tait50,Reference Walker, Shaw, Hamilton, Turpin, Reid and Abel52,Reference DeHart, Smith and Kaminski63,Reference Liebling, Tait, Durie, Stiles and Harvey64} Many staff reported stress, anxiety, ‘burnout’ and ‘exhaustion’, which negatively affected their attitudes and care toward prisoners.^{Reference Smith, Power, Usher, Sitren and Slade9,Reference Bantjes, Swartz and Niewoudt38,Reference Ludlow, Schmidt, Akoensi, Liebling, Giacomantonio and Sutherland41–Reference Marzano, Adler and Ciclitira43,Reference Sweeney, Clarbour and Oliver49,Reference Walker, Shaw, Hamilton, Turpin, Reid and Abel52,Reference DeHart, Smith and Kaminski63,Reference Ward67} Some staff felt ‘traumatised’ from witnessing self-harm and developed features of post-traumatic stress disorder,^{39,Reference Ludlow, Schmidt, Akoensi, Liebling, Giacomantonio and Sutherland41,Reference Marzano, Adler and Ciclitira43,Reference Sweeney, Clarbour and Oliver49,Reference Walker, Shaw, Hamilton, Turpin, Reid and Abel52,Reference Ward67} and others reported that they became clinically depressed and self-harmed themselves.^{Reference Marzano42,Reference Sweeney, Clarbour and Oliver49}

Many staff were fearful of being blamed or punished for prisoners’ self-harm, especially in Coroner's court.^{Reference Ludlow, Schmidt, Akoensi, Liebling, Giacomantonio and Sutherland41–Reference Marzano, Adler and Ciclitira43,Reference Ramluggun45,Reference Walker, Shaw, Hamilton, Turpin, Reid and Abel52,Reference Liebling, Tait, Durie, Stiles and Harvey64,Reference Ward67}

Various coping strategies for dealing with the emotional effects of self-harm were described. Some staff viewed self-harm pragmatically as ‘part of the job’.^{Reference Smith, Power, Usher, Sitren and Slade9,Reference Marzano42,Reference Sweeney, Clarbour and Oliver49,Reference Walker, Shaw, Hamilton, Turpin, Reid and Abel52} Perceiving suicide as a rational ‘choice’ or ‘determined effort’ was suggested to allay feelings of guilt and responsibility.^{Reference Smith, Power, Usher, Sitren and Slade9,Reference Ludlow, Schmidt, Akoensi, Liebling, Giacomantonio and Sutherland41,Reference Marzano42,Reference DeHart, Smith and Kaminski63} Other coping strategies included using humour,^{Reference Marzano42,Reference Marzano, Adler and Ciclitira43,Reference Sweeney, Clarbour and Oliver49} taking ‘time out’ following incidents,^{Reference Walker, Shaw, Hamilton, Turpin, Reid and Abel52} seeking support from colleagues^{39,Reference Ludlow, Schmidt, Akoensi, Liebling, Giacomantonio and Sutherland41,Reference Sweeney, Clarbour and Oliver49,Reference Walker, Shaw, Hamilton, Turpin, Reid and Abel52,Reference DeHart, Smith and Kaminski63} and maintaining a good work–life balance.^{Reference Marzano42,Reference Sweeney, Clarbour and Oliver49,Reference Walker, Shaw, Hamilton, Turpin, Reid and Abel52} Some staff described maladaptive coping methods, such as alcohol intake and avoidance behaviour.^{Reference Marzano42,Reference Marzano, Adler and Ciclitira43,Reference Sweeney, Clarbour and Oliver49,Reference Tait50,Reference Walker, Shaw, Hamilton, Turpin, Reid and Abel52}

Staff frequently reported needing more practical and emotional support from managers, including greater positive recognition for effectively dealing with self-harm and less emphasis on ‘the failures’.^{39,Reference Ludlow, Schmidt, Akoensi, Liebling, Giacomantonio and Sutherland41,Reference Tait50,Reference Liebling, Tait, Durie, Stiles and Harvey64} Several support mechanisms were described including post-incident debriefs and access to formal medical support, but many staff avoided engaging with formal support systems.^{39,Reference Marzano42,Reference Sweeney, Clarbour and Oliver49,Reference Walker, Shaw, Hamilton, Turpin, Reid and Abel52} This was because of concerns about preserving their masculinity, confidentiality and avoiding being touched by stigma, as well as perceptions that accessing support represents weakness or poor coping.^{Reference Marzano42,Reference Ramluggun45,Reference Walker, Shaw, Hamilton, Turpin, Reid and Abel52,Reference Ward67} Staff also felt that opportunities for support following self-harm incidents were limited by pressures to maintain their duties and ‘keep the regime going’.^{Reference Ludlow, Schmidt, Akoensi, Liebling, Giacomantonio and Sutherland41,Reference Marzano, Adler and Ciclitira43,Reference Ward67}

Subtheme 2.1: perceived risk factors for self-harm

Mental disorder was reported as a risk factor for self-harm by prison staff across 12 studies.^{Reference Pannell, Howells and Day30,Reference Bantjes, Swartz and Niewoudt38,Reference Kenning, Cooper, Short, Shaw, Abel and Chew-Graham40–Reference Marzano42,Reference Moore, Andargachew and Taylor44,Reference Ramluggun45,Reference Short, Cooper, Shaw, Kenning, Abel and Chew-Graham48,Reference Cresswell, Karimova and Ward62–Reference Liebling, Tait, Durie, Stiles and Harvey64,Reference Ward67} Substance misuse was most commonly mentioned,^{Reference Pannell, Howells and Day30,39,Reference Ludlow, Schmidt, Akoensi, Liebling, Giacomantonio and Sutherland41,Reference Marzano42,Reference Short, Cooper, Shaw, Kenning, Abel and Chew-Graham48,Reference Liebling, Tait, Durie, Stiles and Harvey64} although some staff referred to psychosis, schizophrenia, depression and personality disorder.^{Reference Pannell, Howells and Day30,Reference Bantjes, Swartz and Niewoudt38,Reference Ludlow, Schmidt, Akoensi, Liebling, Giacomantonio and Sutherland41,Reference Marzano42,Reference Short, Cooper, Shaw, Kenning, Abel and Chew-Graham48} Mental disorder was frequently associated with repeated self-harm,^{Reference Kenning, Cooper, Short, Shaw, Abel and Chew-Graham40,Reference Marzano42,Reference Short, Cooper, Shaw, Kenning, Abel and Chew-Graham48,Reference Cresswell, Karimova and Ward62,Reference Ward67} and seen as being more legitimate or ‘genuine’ relative to other risk factors.^{Reference Marzano42,Reference Marzano, Adler and Ciclitira43,Reference Cresswell, Karimova and Ward62} When self-harm was associated with mental disorder, prison officers often felt incapable of adequately supporting the prisoner.^{Reference Bantjes, Swartz and Niewoudt38,Reference Marzano42,Reference Short, Cooper, Shaw, Kenning, Abel and Chew-Graham48}

Negative childhood experiences and/or past abuse were highlighted as risk factors for self-harm by prison officers and healthcare staff.^{Reference Pannell, Howells and Day30,Reference Marzano42,Reference Rivlin, Shuker and Sullivan47,Reference Short, Cooper, Shaw, Kenning, Abel and Chew-Graham48} Staff across several studies recognised stressors within prison environments including boredom, isolation, loneliness, bullying and borrowing between prisoners,^{Reference Pannell, Howells and Day30,Reference Bantjes, Swartz and Niewoudt38–Reference Marzano42,Reference Ramluggun45,Reference Short, Cooper, Shaw, Kenning, Abel and Chew-Graham48,Reference Sweeney, Clarbour and Oliver49,Reference Liebling, Tait, Durie, Stiles and Harvey64,Reference Ward and Bailey66,Reference Ward67} which some officers viewed as self-inflicted, illegitimate reasons for self-harm.^{Reference Marzano42}

Arrival into prison was described as a particularly vulnerable period,^{39,Reference Ludlow, Schmidt, Akoensi, Liebling, Giacomantonio and Sutherland41,Reference Liebling, Tait, Durie, Stiles and Harvey64,Reference Ward67} along with status change from remand to convicted and receiving very short or long custodial sentences.^{Reference Ludlow, Schmidt, Akoensi, Liebling, Giacomantonio and Sutherland41,Reference Marzano42} Other recognised risk factors included aggression, receiving bad news, bereavement, domestic, family and financial stressors, low self-worth and recent negative experiences.^{Reference Pannell, Howells and Day30,Reference Ludlow, Schmidt, Akoensi, Liebling, Giacomantonio and Sutherland41,Reference Rivlin, Shuker and Sullivan47,Reference Ward67}

Subtheme 2.2: perceived reasons for self-harm

The most frequently reported reason for self-harm by multiple staff roles was to ‘manipulate’ others.^{Reference Smith, Power, Usher, Sitren and Slade9,Reference Bantjes, Swartz and Niewoudt38–Reference Marzano, Adler and Ciclitira43,Reference Ramluggun45,Reference Short, Cooper, Shaw, Kenning, Abel and Chew-Graham48,Reference Sweeney, Clarbour and Oliver49,Reference Walker, Shaw, Hamilton, Turpin, Reid and Abel52,Reference Cresswell, Karimova and Ward62–Reference Liebling, Tait, Durie, Stiles and Harvey64,Reference Ward67} Prison staff listed benefits that ‘manipulative’ self-harm aimed to achieve, including more relaxed prison regimes; access to goods, medications, care or services; transfer to hospital and escape from other inmates.^{Reference Ludlow, Schmidt, Akoensi, Liebling, Giacomantonio and Sutherland41,Reference Marzano42,Reference Ramluggun45,Reference Short, Cooper, Shaw, Kenning, Abel and Chew-Graham48,Reference Sweeney, Clarbour and Oliver49,Reference DeHart, Smith and Kaminski63,Reference Ward67} In contrast, some staff felt that self-harm was an expression of needs and/or a ‘cry for help’.^{Reference Pannell, Howells and Day30,Reference Marzano42,Reference Marzano, Adler and Ciclitira43,Reference Ramluggun45,Reference Short, Cooper, Shaw, Kenning, Abel and Chew-Graham48,Reference Sweeney, Clarbour and Oliver49,Reference Liebling, Tait, Durie, Stiles and Harvey64,Reference Ward67} Other commonly perceived functions of self-harm included ‘attention-seeking’,^{Reference Pannell, Howells and Day30,Reference Ludlow, Schmidt, Akoensi, Liebling, Giacomantonio and Sutherland41,Reference Marzano42,Reference Moore, Andargachew and Taylor44,Reference Ramluggun45,Reference Short, Cooper, Shaw, Kenning, Abel and Chew-Graham48,Reference Cresswell, Karimova and Ward62,Reference Liebling, Tait, Durie, Stiles and Harvey64,Reference Ward67} emotional expression and relieving tension,^{Reference Pannell, Howells and Day30,Reference Kenning, Cooper, Short, Shaw, Abel and Chew-Graham40–Reference Marzano42,Reference Moore, Andargachew and Taylor44,Reference Rivlin, Shuker and Sullivan47,Reference DeHart, Smith and Kaminski63,Reference Ward67} and a coping mechanism for difficult experiences.^{Reference Kenning, Cooper, Short, Shaw, Abel and Chew-Graham40–Reference Marzano42,Reference Rivlin, Shuker and Sullivan47,Reference DeHart, Smith and Kaminski63,Reference Ward67}

Some staff described ‘copycat’ self-harm where inmates replicated that of others, ^{Reference Kenning, Cooper, Short, Shaw, Abel and Chew-Graham40,Reference Ludlow, Schmidt, Akoensi, Liebling, Giacomantonio and Sutherland41,Reference Short, Cooper, Shaw, Kenning, Abel and Chew-Graham48,Reference Cresswell, Karimova and Ward62,Reference DeHart, Smith and Kaminski63,Reference Ward67} and reported prisoners being encouraged to harm themselves by peers and ‘less-seasoned staff’.^{Reference Smith, Power, Usher, Sitren and Slade9,Reference DeHart, Smith and Kaminski63,Reference Liebling, Tait, Durie, Stiles and Harvey64} Other described functions of self-harm included providing empowerment or control,^{Reference Kenning, Cooper, Short, Shaw, Abel and Chew-Graham40,Reference Marzano42,Reference Sweeney, Clarbour and Oliver49,Reference Cresswell, Karimova and Ward62,Reference Ward67} giving enjoyment including sexual pleasure,^{Reference Pannell, Howells and Day30,Reference Marzano42,Reference DeHart, Smith and Kaminski63,Reference Ward67} and punishing oneself.^{Reference Marzano42,Reference Ward67}

Subtheme 2.3: relationships between self-harm and suicide

Non-fatal self-harm was often seen as distinct from and unrelated to suicide.^{Reference Ludlow, Schmidt, Akoensi, Liebling, Giacomantonio and Sutherland41,Reference Marzano42,Reference Moore, Andargachew and Taylor44} Prison staff acknowledged that self-harm could result in death, but felt this was a result of ‘determined misadventure’ or going ‘too far’ and not a ‘genuine suicide attempt’.^{Reference Ludlow, Schmidt, Akoensi, Liebling, Giacomantonio and Sutherland41,Reference Marzano42,Reference Liebling, Tait, Durie, Stiles and Harvey64} Some prison staff believed that suicide was unpreventable, stating that ‘if someone's determined to kill themselves, they'll always find a way’.^{Reference Liebling, Tait, Durie, Stiles and Harvey64} It was frequently suggested that prisoners who intend to die use more lethal self-harm methods and conceal their intentions and distress more than those with non-suicidal motives.^{Reference Ludlow, Schmidt, Akoensi, Liebling, Giacomantonio and Sutherland41,Reference Marzano42,Reference Moore, Andargachew and Taylor44}

Subtheme 3.1: effects of repetitive self-harm

Repeated self-harm was viewed most negatively by prison staff, and often regarded as being fundamentally different from isolated incidents.^{Reference Marzano42–Reference Ramluggun45,Reference Short, Cooper, Shaw, Kenning, Abel and Chew-Graham48,Reference Liebling, Tait, Durie, Stiles and Harvey64} Repetitive self-harm was described as ‘draining’ staff patience, optimism and resources, and was associated with critical comments, perceived ‘attention-seeking’ and staff frustration.^{Reference Marzano42,Reference Moore, Andargachew and Taylor44,Reference Ramluggun45,Reference Liebling, Tait, Durie, Stiles and Harvey64} Although some staff identified that ‘ongoing’ interactions with prisoners who repeatedly self-harm made them feel closer to them, many officers and healthcare staff reported that this was desensitising and reduced their empathy.^{Reference Marzano42,Reference Ramluggun45}

Subtheme 3.2: effects of gender

Male staff more frequently recommended maintaining emotional distance from prisoners, whereas females emphasised relationship building.^{Reference Ward67}

Male prisoners were thought to self-harm more severely and discreetly, generally afforded less sympathy and deemed to have less ‘genuine’, ‘serious’ or ‘complex’ issues relative to females.^{Reference Marzano42,Reference DeHart, Smith and Kaminski63} Prison staff occasionally portrayed self-harm as childish and emasculating, commenting that it was ‘such a young female kind of thing to do’.^{Reference Marzano42,Reference Liebling, Tait, Durie, Stiles and Harvey64}

Subtheme 3.3: effects of job role

Healthcare staff generally reported a greater understanding of self-harm compared with prison officers. They more often identified situational risk factors within prison environments,^{Reference Kenning, Cooper, Short, Shaw, Abel and Chew-Graham40,Reference Short, Cooper, Shaw, Kenning, Abel and Chew-Graham48} commented on the effects of childhood trauma and abuse,^{Reference Smith, Power, Usher, Sitren and Slade9} and recognised self-harm as a coping mechanism for emotional distress.^{Reference Marzano42} They also generally reported feeling more able to prevent self-harm.^{Reference Ludlow, Schmidt, Akoensi, Liebling, Giacomantonio and Sutherland41} Compared with prison officers, healthcare staff less frequently delineated perceived ‘genuine’ and ‘non-genuine’ self-harm,^{Reference Kenning, Cooper, Short, Shaw, Abel and Chew-Graham40,Reference Short, Cooper, Shaw, Kenning, Abel and Chew-Graham48} and less often directly described self-harm as ‘manipulative’ or being enacted to punish staff.^{Reference Marzano42,Reference Ramluggun45}

Compared with prison officers and healthcare staff, staff in specialist roles, such as governor, chaplaincy and suicide prevention coordinator, demonstrated more concern for the management of repetitive self-harm, more frequently emphasised its underlying causes and more frequently conceptualised people who self-harm as victims.^{Reference Marzano42}

One study found no variation in levels of expressed emotion toward self-harm between staff roles.^{Reference Moore, Andargachew and Taylor44}

Subtheme 4.1: labelling and dichotomising self-harm

Prison staff frequently dichotomised self-harm as being either ‘genuine/real’ or ‘non-genuine’ based upon their perceived functions of the behaviour. ‘Manipulation’ and ‘attention-seeking’ were typically labelled as ‘non-genuine’ illegitimate reasons for self-injury,^{Reference Kenning, Cooper, Short, Shaw, Abel and Chew-Graham40–Reference Marzano, Adler and Ciclitira43,Reference Ramluggun45,Reference Short, Cooper, Shaw, Kenning, Abel and Chew-Graham48,Reference Liebling, Tait, Durie, Stiles and Harvey64} and less severe ‘superficial’ self-harm injuries were more likely to be perceived as ‘non-genuine’.^{Reference Short, Cooper, Shaw, Kenning, Abel and Chew-Graham48}

Self-harm that was labelled ‘non-genuine’ or ‘manipulative’ was often regarded as less deserving of care and intervention, and some prison staff reported resisting opening ACCTs (Assessment, Care in Custody and Teamwork processes used in England and Wales to assess and manage self-harm risk) on these prisoners.^{Reference Kenning, Cooper, Short, Shaw, Abel and Chew-Graham40,Reference Ludlow, Schmidt, Akoensi, Liebling, Giacomantonio and Sutherland41,Reference Ramluggun45,Reference Short, Cooper, Shaw, Kenning, Abel and Chew-Graham48,Reference Liebling, Tait, Durie, Stiles and Harvey64} Staff also described ‘manipulative’ and ‘non-genuine’ self-harm as requiring more punitive management, such as isolation, boundary setting and reduced staff attention.^{Reference Smith, Power, Usher, Sitren and Slade9,Reference Liebling, Tait, Durie, Stiles and Harvey64} This contrasted to staff descriptions of optimal self-harm management, which generally involved building strong staff–prisoner relationships, getting to know individual prisoners and an emphasis on communication, rapport building and trust.^{Reference Smith, Power, Usher, Sitren and Slade9,Reference Ludlow, Schmidt, Akoensi, Liebling, Giacomantonio and Sutherland41,Reference Sweeney, Clarbour and Oliver49,Reference Walker, Shaw, Hamilton, Turpin, Reid and Abel51,Reference Liebling, Tait, Durie, Stiles and Harvey64,Reference Ward67}

Staff in one study recognised that patients whose self-harm is ‘non-genuine’ may also be struggling and require support.^{Reference Short, Cooper, Shaw, Kenning, Abel and Chew-Graham48}

Subtheme 4.2: staff protecting themselves from the effects of prisoner self-harm

Staff commonly reported ‘building up tolerance’, and becoming ‘desensitised’ or ‘hardened’ to self-harm following repeated exposure.^{39,Reference Ludlow, Schmidt, Akoensi, Liebling, Giacomantonio and Sutherland41–Reference Marzano, Adler and Ciclitira43,Reference Sweeney, Clarbour and Oliver49,Reference Walker, Shaw, Hamilton, Turpin, Reid and Abel52,Reference Liebling, Tait, Durie, Stiles and Harvey64} They additionally described maintaining emotional distance and becoming emotionally ‘switch[ed] off from prisoners’.^{39,Reference Cresswell, Karimova and Ward62,Reference DeHart, Smith and Kaminski63,Reference Ward67} These were generally construed as effective defence mechanisms to limit the emotional effects of self-harm and reduce burnout among prison staff. However, they were also thought to be associated with poorer risk identification and management, and intolerance, anger and cynicism toward prisoners.^{Reference Ludlow, Schmidt, Akoensi, Liebling, Giacomantonio and Sutherland41,Reference Marzano42}

Fear of being blamed for prisoners’ self-harm promoted defensive practices among prison staff. Staff described avoiding involvement in self-harm incidents, such as by avoiding night shifts and/or contact with prisoners who frequently self-harm.^{Reference Marzano42,Reference Marzano, Adler and Ciclitira43,Reference Tait50} Staff also reported refraining from using personal discretion and adopting risk-averse practice to protect themselves.^{Reference Ludlow, Schmidt, Akoensi, Liebling, Giacomantonio and Sutherland41,Reference Marzano, Adler and Ciclitira43,Reference Ramluggun45,Reference Walker, Shaw, Hamilton, Turpin, Reid and Abel52,Reference Liebling, Tait, Durie, Stiles and Harvey64} There were tensions described between healthcare and prison staff, whereby prison officers were reluctant to accept responsibility for caring for people who self-harm, particularly repetitive self-harm, and attributed this role to healthcare professionals,^{Reference Marzano42,Reference Ramluggun45,Reference Walker, Shaw, Hamilton, Turpin, Reid and Abel52,Reference Liebling, Tait, Durie, Stiles and Harvey64} whereas healthcare staff felt that officers should assume greater ownership.^{Reference Marzano42,Reference Ramluggun45}

Subtheme 4.3: staff adherence to self-harm policies and procedures

To reduce intense workload and circumvent a lack of resources, staff described deviating from recognised self-harm policies and procedures. For example, although some staff reported having low thresholds to commence ACCT procedures and following them by the letter,^{Reference Ludlow, Schmidt, Akoensi, Liebling, Giacomantonio and Sutherland41,Reference Ramluggun45,Reference Short, Cooper, Shaw, Kenning, Abel and Chew-Graham48,Reference Walker, Shaw, Hamilton, Turpin, Reid and Abel52} others were discouraged by their colleagues from opening ACCTs,^{Reference Cresswell, Karimova and Ward62} resisted doing so and/or waited for others to accept this responsibility.^{Reference Ludlow, Schmidt, Akoensi, Liebling, Giacomantonio and Sutherland41} This was because of the perceived strain on staff time of completing multiple paperwork, which was felt to subtract from meaningful engagement with prisoners.^{39,Reference Ludlow, Schmidt, Akoensi, Liebling, Giacomantonio and Sutherland41,Reference Walker, Shaw, Hamilton, Turpin, Reid and Abel51,Reference Ward67} Similarly, some staff recognised the importance of individualising self-harm management, whereas others treated self-harm processes as ‘tick-box’ tools.^{39,Reference Ludlow, Schmidt, Akoensi, Liebling, Giacomantonio and Sutherland41,Reference Marzano42,Reference Sweeney, Clarbour and Oliver49,Reference Ward67} Prison officer attitudes and trust/distrust of specialist staff roles influenced the availability and effectiveness of multidisciplinary support for prisoners at risk of self-harm; for example, affecting the extent of specialist input during risk assessment and case reviews.^{Reference Liebling, Tait, Durie, Stiles and Harvey64}

Trauma Symptom Inventory

Two studies used the Trauma Symptom Inventory^{,Reference Briere, Elliot, Harris and Cotman68} tool to examine self-reported post-traumatic stress disorder (PTSD) symptoms among UK prison staff.^{Reference Cassidy and Bruce54,Reference Wright, Borrill, Teers and Cassidy61} Cassidy and Bruce found that 31.8% of prison staff closely involved in prisoner suicide in the past year reported clinical-level symptoms of PTSD.^{Reference Cassidy and Bruce54} Furthermore, Wright et al discovered PTSD symptoms reported by 36.7% of prison officers, and that experience of prisoner suicide predicted such symptoms.^{Reference Wright, Borrill, Teers and Cassidy61}

Attitudes towards Prisoners who Self-Harm Scale

Two UK studies administered the Attitudes towards Prisoners who Self-Harm Scale (APSH) to prison staff, one in two high security prisons and one to prison officers attending prison service college training.^{Reference Garbutt and Casey55,Reference Ireland and Quinn56} This self-report scale measures attitudes relating to self-harm.^{Reference Garbutt and Casey55} In both studies, staff achieved similar mean scores, both indicating generally positive attitudes, but some negative attitudes present.^{Reference Garbutt and Casey55,Reference Ireland and Quinn56} Among prison officers attending Prison Service College, positive attitudes toward the treatment of prisoners, as measured by the General Attitudes towards Prisoners Scale (ATP), significantly predicted more favourable attitudes toward self-harm.^{Reference Ireland and Quinn56} Female staff scored statistically significantly higher on the APSH than males in the same study, indicating more positive attitudes.^{Reference Ireland and Quinn56} Staff's perceptions of prisoner's behavioural characteristics significantly influenced attitudes toward self-harm, with less positive attitudes toward ‘disruptive’ compared with ‘well-behaved’ prisoners.^{Reference Ireland and Quinn56}

Another study administered the APSH and ATP to 176 prison officers in three Portuguese prisons.^{Reference Sousa, Gonçalves, Cruz and de Castro Rodrigues59} High proportions of prison staff believed that self-harm served ‘attention-seeking’ and ‘manipulative’ purposes and that prisoners who self-harm will not commit suicide. The majority of prison officers recognised self-harm as a coping mechanism. Perceptions of self-harm being ‘manipulative’ were more common among female officers, whereas male officers were significantly more likely to relate prisoner's self-harm to previous experiences of abuse. There was a significant positive correlation between prison officer's abilities to understand prisoners’ feelings and their understanding of self-harm. Officers that endorsed the strict discipline of prisoners were more likely to believe that prisoners who self-harm should be harshly treated and/or ignored, although this view was not shared by the majority.

Studies using statistical methods to analyse prison staff's attitudes, perceptions or experiences of self-harm

Five studies used quantitative methods to analyse factors affecting prison staff's experiences or perceptions of, or attitudes toward, self-harm.^{Reference Pannell, Howells and Day30,Reference Callahan53,Reference Slade and Lopresti57,Reference Wood-Schultz60,Reference Liebling, Tait, Durie, Stiles and Harvey64}

Slade and Lopresti utilised linear regression to examine factors associated with staff–prisoner relationships and staff resilience among 281 multidisciplinary UK prison staff and 169 community controls.^{Reference Slade and Lopresti57} They found that 61.2% of staff witnessed self-harm serious enough to warrant medical attention on ten or more occasions, which was associated with significantly less friendliness, understanding and support between staff and prisoners. More accepting attitudes toward suicide were predictive of better staff–prisoner relationships, along with staff members’ use of ‘surface acting’ and ‘deep acting’ emotional labour. Surface acting refers to the suppression of true feelings and/or presenting emotions that are different from those being felt, e.g. faking sadness and empathy. Deep acting, on the other hand, involves attempting to feel emotions that are deemed most appropriate, such as attempting to experience genuine empathy, rather than superficially faking this. Greater staff resilience was predicted by greater experience of prisoner suicide, advanced suicide prevention training, working in male prisons with low suicide and high self-harm rates, and greater deep acting and less surface acting of emotions. Staff in women's prisons perceived suicide as more preventable, displayed less condemning attitudes and reported less ‘faking of emotions’ compared with staff in men's prisons.

Wood-Schultz examined the effects of personal attitudes on the quality of suicide prevention responses by 84 prison officers, mental health and medical staff from the American Correctional Association.^{Reference Wood-Schultz60} Positive attitudes toward prisoners were significantly associated with increased quality of suicide prevention responses among all staff, whereas attitudes toward death and suicide were not predictors.

A study of 76 correctional officers in Australia presented staff with vignettes depicting self-harm and asked them to rate causes and functions of the behaviour.^{Reference Pannell, Howells and Day30} Officers frequently linked self-harm to poor coping, depression and drug misuse. Other highly reported functions of self-harm by officers included ‘crying for help’, attention-seeking and releasing emotions, whereas suicidal functions were least frequently recognised. In contrast with evidence from qualitative studies,^{Reference Marzano42–Reference Ramluggun45,Reference Short, Cooper, Shaw, Kenning, Abel and Chew-Graham48,Reference Liebling, Tait, Durie, Stiles and Harvey64} the severity and repetitiveness of self-harm did not significantly alter staff perceptions of its cause and function; however, low severity non-repetitive self-harm was linked by staff to prisoner distress, and higher severity self-harm was more often perceived as suicidal.^{Reference Pannell, Howells and Day30}

A study of 1877 security staff in the USA investigated staff experiences and views of mental illness and healthcare in prisons, using clinical vignettes and self-administered surveys.^{Reference Callahan53} Male and minority ethnic staff were significantly more likely to view prisoners, depicted in clinical vignettes, as at risk of self-harm. Prisoners were also more likely to be deemed at risk of self-harm if officers perceived their problems as caused by mental illness, chemical imbalance or genetics instead of ‘bad character’.

Staff and prisoner surveys and interviews, and participant observation, were used in UK prisons to evaluate the implementation and effectiveness of a programme to reduce self-harm and suicide.^{Reference Liebling, Tait, Durie, Stiles and Harvey64} Multiple staff across several prisons reported finding self-harm management ‘extremely stressful’, and many strongly agreed that further training and support were required. Improved quality of life of prison staff was significantly associated with greater effectiveness of suicide prevention and suicide prevention effectiveness correlated highly with strong communication, good work culture, appropriate staff roles and responsibilities, and positive working relationships with managers. In prisons where many staff perceived self-harm as manipulative and threatening their authority, higher levels of prisoner distress existed.

Studies reporting descriptive statistics

Six studies reported the proportion of prison staff describing particular experiences, perceptions and attitudes relating to self-harm.^{Reference Smith and Kaminski58,Reference Cresswell, Karimova and Ward62,Reference DeHart, Smith and Kaminski63,Reference Ward and Bailey65–Reference Ward67}

Four papers used data collected from the same sample of 68 multidisciplinary prison staff in the UK, using questionnaires.^{Reference Cresswell, Karimova and Ward62,Reference Ward and Bailey65–Reference Ward67} The most commonly perceived reasons for prisoner self-harm included emotional expression, exerting control and gaining attention;^{Reference Cresswell, Karimova and Ward62,Reference Ward67} 75% of prison staff thought that self-harm served to ‘manipulate’ others.^{Reference Cresswell, Karimova and Ward62,Reference Ward67} Mixed views were expressed regarding staff's perceived knowledge of self-harm, with this being presented as both a strength and a challenge;^{Reference Ward and Bailey65–Reference Ward67} 43% of prison staff reported needing more self-harm training, and lack of time was reported by 70% of staff as limiting optimal care.^{Reference Ward and Bailey65–Reference Ward67}

In a survey of 54 mental health professionals across 14 secure facilities in the USA, 91% of those working in prison viewed self-harm as a means to seek special treatment or transfer of location,^{Reference DeHart, Smith and Kaminski63} 85% of staff viewed self-harm as a stress-coping mechanism, and a minority attributed self-harm to suicidal motives or severe mental disorder. Only 4% of mental health professionals could not recall a self-harm incident in the previous 6 months.

In a survey of 230 mental health professionals across 473 USA correctional facilities,^{Reference Smith and Kaminski58} 98% of staff knew a prisoner who self-harms in prison. The most witnessed method was scratching/cutting with objects, which generated the most concern among staff.