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To date, prison personnel have taken a reactive rather than a proactive stance toward self-injurious behaviour. If the frequency of self-injury is to be reduced, it is imperative that a proactive stance be adopted. The first step in injury reduction is determining the situations and/or factors involved in evoking a self-injurious response. It should be kept in mind that self-injury is not a problem in and of itself, but rather, is a symptom or outward expression of more fundamental issues. As my working hypothesis is that self-injury is a coping strategy adopted in response to childhood abuse, responses relating to childhood abuse will be the starting point for this discussion.
Seventy-four percent of the prisoners interviewed reported being victims of childhood abuse. Of these respondents, 50% reported experiencing both sexual and physical abuse, 28% reported exclusively sexual abuse, and 22% reported exclusively physical abuse. The figures relating to sexual abuse should be considered conservative for two reasons. First, as Russell (1986) indicates, women are often reluctant to reveal sexual abuse to an unknown interviewer (p. 20). This problem of non-disclosure can often be avoided by an interview format that is lengthy enough to ensure that rapport is developed between the interviewer and the respondent. The scope of the present study did not allow this luxury. Some interviews took no longer than 20 minutes. In addition, this is a highly studied population and many prisoners are quite fed up with answering questions for studies that they perceive ultimately do not result in positive change. Given these dynamics, it must be assumed that some women who were in fact sexually abused chose not to reveal this to me.
A defense mechanism often used to cope with childhood sexual assault is a second factor which impacts on disclosure rates. The dynamics of childhood sexual assault almost exclusively involve enforced silence on the part of the victim and often on any others who are aware of the abuse. Thus, the norm for this victimization is that it not be discussed. This enforced silence often encourages repression as a coping strategy. Obviously those who use repression to cope with their sexual abuse will not be accounted for.
The obtained results on childhood sexual abuse are highly significant and very disturbing given the factors working against disclosure. The responses indicate that 58% of the prison population disclose childhood sexual abuse. This is over double the rate reported in the population outside prison where 1 in 4 girls experience sexual abuse before age 14 (Russell, 1986, p. 61). It is critical to keep in mind that the actual rate of childhood sexual abuse experienced by prisoners is presumably even higher than the reported 58%.
Of those women who reported childhood abuse, 76% reported that they are currently experiencing emotional after-effects from the abuse. Many who believe they have resolved the emotional issues resulting from the abuse, expressed concern for other individuals. For example, one prisoner stated that through counselling she had resolved the issues relating to her abuse but that she still struggled with her concern for her sister who had presumably also been abused.
Seventy-three percent of those women who self-injure reported childhood abuse. As indicated above, this figure is undoubtedly a conservative estimate. There was no significant relationship between sentence length and self-injury. In addition, self-injury was not dependent on previous incarceration(s). There was, however, a significant relationship found between the time spent in the Prison for Women and self-injury, t (42) = 3.12, p < .03. Those respondents reporting self-injury had, on average, been in the Prison for Women three times longer (M = 41 months) than had those not reporting self-injury (M = 14 months). Although some would suggest that the above finding is indicative of self-injury being learned through association, two factors argue against this. First, there was no relationship between previous incarceration(s) and self-injury. Many previous incarcerations were spent at provincial institutions. Undoubtedly, self-injury also occurs at these facilities yet the behaviour does not seem to be learned there. Secondly, if learning is a key factor, 14 months (the average time spent by non-self-injurors at the Prison for Women) would surely be enough time to learn this behaviour.
A more plausible explanation for the connection between time spent at the Prison for Women and self-injury is that over time, more and more of the coping strategies used previously are found to be ineffective in the prison context. It is possible that in the absence of effective coping strategies one does look to others to see how they cope. Such a phenomenon would reflect not so much a learning of self-injury by association, but rather an adoption of this coping strategy as a last resort after alternative coping strategies have proven ineffective. Thus, one needs to examine the situational factors at work which lead to self-injury. Through the identification of these factors, changes can be implemented which increase the range of effective coping strategies. This in turn will reduce self-injury.
Overall, the prisoners responses indicated two areas that need to be addressed in reducing injury: environmental issues and counselling issues.
The majority of women who self-injure identified situations producing feelings of helplessness (47%), powerlessness (42%), or isolation (6.7%), as being those that make them want to self-injure. As noted in the introduction, the experience of childhood sexual abuse involves total control over the self, the body, and, indeed, over life and death being stripped from the child. In the absence of resolution of the feelings evoked by the abuse, situations in later life that approximate the feelings of defenselessness experienced as a child will be difficult emotionally for the individual. The reduction of self-injurious behaviour necessarily involves replacing the self-injurious attempts at control over the self with more constructive coping strategies. Until these alternative coping strategies are learned, every attempt should be made to provide the woman with feelings of personal control (efficacy).
The prison environment by definition strips a person of control (i.e. freedom of movement). The prisoners responses reveal that, overall, this aspect is not a major determinant in feelings of lack of control. Only 3% of the respondents reported sentence length as being a motive to self-injure. In addition, as mentioned earlier, there is no significant relationship between sentence length and self-injury. The women by and large accept that due to their sentence they will have no control over where they spend their next years. Nonetheless, there are a number of aspects of the prison situation that the women do feel is/should not be inherent in the prison experience and it is these aspects which increase feelings of powerlessness and lack of control. Primarily these aspects are ones which create a sense of injustice. Repeatedly encountering injustice in the absence of strategies to right perceived wrongs may, over time, cumulatively escalate feelings of powerlessness. When a certain threshold is reached, the feelings of powerlessness may be so great that previously utilized coping strategies are rendered ineffective. At this point, self-injury may become the coping strategy of choice. Such a scenario would explain the significant relationship between time spent in the Prison for Women and self-injury. In order to understand self-injury, therefore, it is imperative to examine the situations which create the feelings of powerlessness/helplessness.
Many prisoners (51%) mentioned inconsistency and/or pettiness of rules as a difficult aspect of prison life. Many believe that charges are often unfairly laid and that there is no recourse. Although women who are charged are given a court appearance, the overall belief is that in these hearings their word as a "con" will not be taken over the word of security staff personnel. A woman can grieve a staff members behaviour/actions, but the Warden indicated that the women most often did not take advantage of this option for fear of negative sanctions. The result is that the women believe they have little power in responding to those CX staff members who are perceived to be treating them unfairly.
The security staff themselves recognize that some staff members act in an inappropriate manner. Many are disturbed by this, believing that the actions of a few reflect upon them all and that this creates a barrier between them and the prisoners. The possibility of improving prisoner/staff relations would, therefore, not only decrease the instances of feelings of powerlessness among prisoners but would strengthen relations with the CX staff that the women do respect and trust.
A second issue identified by the women as creating feelings of powerlessness and injustice was the use of mass punishment. For example, it was reported that in December, 1988, a dance was cancelled because alcohol was found in one of the cells. A second often cited example was the recent hourly cell lock-up procedure implemented because of the fear of violence by a few prisoners. In these situations, all prisoners suffered due to an attempt to limit the actions of a few. Feelings of injustice with no possibility of recourse decrease feelings of personal efficacy. This powerlessness escalates the need to gain feelings of control through self-injury as was evidenced by the increase in slashings following the implementation of the hourly cell lock-up.
A third environmental issue identified by the prisoners was the lack of opportunity to express emotion. If a woman requires time alone she can request permission to be placed in the quiet side of segregation. These cells, however, are often anything but quiet. In addition, the lack of privacy afforded by these cells is not conducive to a woman venting such emotions as anger or sadness.
Given the lack of training of CX staff, this personnel is not in a position to assess whether emotion is merely expressive or is indicative of an emotional crisis. Thus, the staff are often compromised by perhaps wanting to allow the women to emote and yet having responsibility for ensuring that the situation does not get out of hand. This results in the CX staff having a vested interest in emotions being suppressed.
There is also no systemic acknowledgement that emotional difficulties can impact on work performance. Women are expected to carry on their daily duties regardless of what they are working on emotionally. In fact, women who do not report to work are placed on charge unless they have a sick pass. This is not an accepted norm in the population outside the prison. Society has come a long way in recognizing that mental health issues must be addressed. As such, many companies allow employees one mental health day a month. In addition, programmes for individuals who are in emotional distress not only acknowledge that emotional distress can result in an inability to work but provide a means of support while the individual concentrates on emotional issues.
A fourth environmental issue glaringly apparent through my observations at the prison is the extent to which security issues supersede mental health issues. Two examples will illustrate this. During my time spent at the prison, one of the prisoners indicated to me that she was in emotional distress and needed counselling. As the prison psychologists were unavailable at the time, she asked if I would meet with her. Discussion with this prisoner revealed that a number of situational factors at the prison were overwhelming her emotionally. The prisoner was not suicidal but needed support to assure her that she was reacting normally to stressful situations and in fact, given what she was dealing with, was coping very well. In the midst of our discussion, a CX staff person knocked on the door to announce that the 4:00 count was going on and the prisoner had to immediately return to her cell. I believed that this woman needed to finish her conversation with me but the rules of the institution took precedence. That night, the prisoner in question slashed. I am confident that this slashing could have been avoided had there been some forum to circumvent established count protocol, thus, allowing the counselling session to continue.
In a second case, while I was interviewing CX staff on the A Range post it became apparent that one of the women on the range was in emotional distress. A number of prisoners approached the barricade and requested that I be allowed to speak to the woman. After negotiations with the security staff on duty this was allowed, and I spent about an hour and a half counselling this woman. The prisoner involved has a long history of severe slashing and my intervention allowed her to talk about her feelings enough that she was able to make it through the night without incidence. It should be noted here that the security staff involved were most supportive of my actions. My point is not that the CX staff always conform to protocol despite the ramifications to the women, but rather, that to ensure the safety of the women, the security staff may have to make the decision to break with protocol. To place staff in a position where they must accept responsibility for breaking protocol is unreasonable and places an unfair burden on the CX staff.
It was almost universally agreed upon by prisoners (98%) and CX staff (93%) alike that existing counselling services are insufficient. The two psychologists on staff at the prison provide excellent services to the extent that their case load allows, but at present, both have an eight month waiting list. For years it has been known that women make more use of mental health services than do men. Women comprise almost two thirds of the adult population of general psychiatric, community mental health, and out-patient psychiatric facilities (Greenspan, 1983). This fact alone argues for the necessity of broad based mental health services in any facility dealing with women. In the case of the Kingston Prison for Women, the population is largely comprised of women who have experienced major physical, sexual, and/or emotional abuse. Existing mental health services do not reflect or address this fact.
A second issue reported by many of the prisoners is the availability of mental health services only during normal business hours. Unfortunately, emotional crises are not restricted to these hours. The psychologists at the prison have tried to be available for after-hour emergencies but this presents two problems. First, this alternative is premised on being able to contact a psychologist after hours. This is not always possible. Secondly, in times of severe stress at the prison, the psychologists can expect to be called quite often. This situation will soon lead to burn-out on the part of the psychologists.
At present, if a psychologist cannot be reached after hours, the CX staff has few alternatives but to put a woman in emotional crisis in segregation to be monitored. The isolation imposed by segregation and the perceived punishment mentioned earlier can only be expected to exacerbate a crisis situation.
A third issue relating to counselling services is the lack of services for native women. Although these women do have access to psychology services, cultural aspects may limit the ability of existing services to meet these womens needs.
The two prison psychologists provide excellent services and the prison should be commended for their wisdom in selecting two individuals who are so conscious of the womens needs and are so qualified in dealing with womens issues. I believe the prison was also wise in hiring female psychologists. Although some argue that male therapists provide positive male role models for women who have been abused by men, my experience has been that positive male role models are useful only in the post recovery period. In the recovery stage, it is much more important to provide positive female role models. Women who have been abused by men have been given the message that to be female is to be powerless. The misuse of authority by male abusers teaches those abused to respond to males in a submissive, and often fearful way. Regardless of the sensitivity of a male therapist, it is often difficult for an abused woman to relate to him in a way that preserves her adult status. Often the best that can be hoped for is a paternalistic relationship between a male therapist and an abused woman.
Despite the quality of services presently provided by the two prison psychologists, eight month waiting lists and the absence of evening services result in the majority of prisoners not being able to access appropriate mental health services. The responses from the prisoners indicate that, in large part, they rely on one another for emotional support and crisis intervention. Many spoke of talking friends down in a crisis, of strategies for removing "sharps", or of the emotional support they themselves have received from others.
In accordance with the above three latter recommendations the following programme is proposed:
At present, a good deal of the counselling/emotional support that takes place in the prison is provided by the prisoners themselves. Many services outside of the prison (e.g., Sexual Assault Crisis Centres) acknowledge the usefulness of peer support by training individuals to act in this capacity. These para-professionals are then available to do crisis intervention. Many times, these services are all that are required. In the event that these services are not enough, the individuals are trained in identifying situations that require professional services. Thus, these para-professionals engage in crisis intervention and where required, referral.
Such a programme would go a long way in augmenting existing services. Therefore it is proposed that a number of prisoners be trained as support counsellors. It is suggested that this programme be under the joint domain of psychology and health care services. The selection, training, and implementation processes are outlined below.
A team of women comprised of representatives from each living area of the prison (A Range, B Range, Wing) would take part in the training programme. The initial training programme could accommodate 12 women. The selection of these women should be based on the following criteria:
- Expressed interest in the programme.
- An indication that the individual possesses the qualities that after training will result in an ability to counsel such as empathy, good listening skills, and respect for confidentiality. This would be determined during a screening interview and through on-going evaluations both during a screening interview and through on-going evaluations both during and after the training process.
- The ability of the individual to draw boundaries for herself such that she is able to refrain from counselling when she herself is undergoing particular stress. Again, this would be assessed during a screening interview and evaluated both during and after the training programme.
- As the best potential counsellors may not be individuals with the best institutional records, it is strongly advised that absence of charges or a specified charge free period not be a prerequisite for involvement in the training programme. In cases where it was questionable whether a particular woman was appropriate for the crisis/support team, psychology/trainers would be responsible for determining suitability with input from correctional supervisors.
The training programme would consist of 10 two hour sessions. The sessions would cover the following:
Session 1: The Role of the Support/Crisis Counsellor
Limitations of the Support/Crisis Counsellor
Session 2: The Impact of Childhood Sexual Abuse
Session 3: The Impact of Physical and Emotional Abuse
Session 4: Counselling Skills and Techniques
Session 5: Counselling Skills and Techniques
Session 6: Dealing with a Suicidal Individual
When to Refer
Session 7: Self-Injurious Behaviour
Session 8: Self-Esteem Issues
Session 9: Dealing with Anger
Session 10: The Impact of Counselling on the Counsellor
At the end of the training programme, an evaluation would take place. Upon successful evaluation, the individual would become part of the crisis/support team. This position would be in addition to whatever duties the woman currently undertakes at the prison but there would be monetary recognition of the hours involved through paid absence from her other work duties. For example, if a woman engaged in two hours counselling during the evening or night, she would receive two hours paid leave from her regular work schedule to compensate for her counselling time.
Training will be conducted by the psychology department. It is important that the individual responsible for training be a specialist in childhood sexual abuse. At present, Julie Darke fulfills this requirement. Given the nature of the training programme it is expected that outside speakers and resources will be utilized. It is suggested that two training programmes be offered the first year. Demand should dictate how many programmes are offered in subsequent years. As prisoners gain experience as members of the crisis/support team they should become involved in the training process.
The services of the crisis/support team would be available to the prisoners on a 24 hour basis. A woman requesting the service would be brought to health care services where she would be screened by the nursing personnel. Once the nursing staff established that it was a situation which could be handled by a member of the crisis/support team, the member on call would be brought to health care services. Counselling could take place in the room presently serving as the isolation ward. If at any time during the support session a team member deems that additional help/support is required, the member would be responsible for contacting the nursing staff who, in turn, would contact a psychologist if required.
Once the counselling/support session is completed, the prisoners would return to their regular routine. In the event that the session takes place during the night, if it would cause too much disruption to return the women to their cells, alternative sleeping arrangements would be found. If space permits, the two women would complete the night in the hospital area. If these beds are already filled, the women could be taken to segregation. In the latter case, the move to segregation would be for sleeping purposes only and both women would be released the following morning without the necessity of being seen by a psychologist or going before the Segregation Review Board.
To ensure adequate support for crisis/support team members, their job description would include weekly meetings at which they could discuss difficulties encountered in the counselling/support sessions. As it is being recommended that this crisis/support team be under the auspices of both psychology and health care services, it is suggested that as the primary liaison, nursing staff be present at these weekly meetings. This would necessitate nursing staff also completing the training programme.
On the fourth weekly meeting of every month, psychology should also be present. This would allow for professional advise and direction that was outside of the nursing staffs expertise. In addition, psychology could use this monthly contact to arrange additional workshops to upgrade the members counselling skills.