[Music] Scott: Hello and greetings everyone joining us from the various time zones across the country. My name is Scott Richards and I'm one of the correctional program specialists at the National Institute of Corrections. Thank you for participating in today's webinar, entitled "Solving the Dilemma of Self-Injurious Behavior in the Incarcerated Populations." Self injury continues to significantly affect correctional systems around the world, leading to adverse outcomes for the incarcerated people who participate in this behavior, and the staff charged with their supervision and care. To address this issue, correctional leaders need a better understanding of self-injurious behaviors, and the potential tolls that witnessing these actions can take our correctional officers and other key staff. We will emphasize the nuances of self-injury in the correctional setting, and the need for partnerships between multidisciplinary teams to maximize outcomes. Now, the last few things that I'd like to mention, for those of you that are just joining us right at the top of the hour, are some necessary housekeeping items. First, this webinar is scheduled to last about one hour and is being recorded. Once the recording is captioned, and made 508 compliant, it and the presentation slides will be available on the NIC website. Second, this is a listen-only event. There will be a few interactive polls that we hope you will participate in throughout the webinar. Now to keep our presentation moving along as scheduled, the poll questions will only be available for about one minute. So we ask that you respond as soon as you see the questions pop up. There are technically no right or wrong answers, but we are interested in your perspective and feedback. You are also encouraged to communicate and ask questions through the WebEx chat function at the end of this presentation to answer as many of your questions as possible. Next, if you experience audio issues during this webinar, please consider dialing in using the phone number that was included with your registration and reminder emails. Lastly, I do want to mention that the material presented during this webinar is not intended to constitute psychological or medical advice and should not be relied on in place of consultation with appropriate personnel in your own jurisdiction. The National Institute of Corrections has arranged for a fantastic speaker for today's topic. Dr. Hayden Smith is a professor in the Department of Criminology and Criminal Justice at the University of South Carolina. He will share a little bit more about his background as I totally turn the presentation over to him. I would, however, like to point out that his perspective benefits from a background in academia and research, combined with his firsthand experience, working with correctional agencies across the country, and around the world. Now, before I turn it over to Dr. Smith, let's do a quick two part kickoff poll. As I mentioned, the poll has two questions. So you might have to scroll down to see the second question. Once you've answered both questions, please make sure that you select the submit button in the bottom right hand corner. So like I said, the two questions are in which correctional setting do you work? Community, jails, juvenile prisons or other? And in which field do you work? Administration, case management, medical and mental health, operational staff or other? As those responses come in, I would like to mention that this is actually the second webinar that NIC has sponsored around the subject of self-injurious behavior in a correctional setting. And the first one we did, it was about a year and a half ago. And that webinar really focused on customizing an agency's information management system, so that it created profiles based off of data that was collected on inmates that were engaging in a serial self-injury. That data included things like triggering events. It included several other key pieces of information that was helpful in managing that special population. So we'll go ahead and include a link to that webinar in the chat box. So it looks like the poll is getting ready to shut down and we should be seeing the results here shortly. So the results are in and it looks like we have a pretty good mix. I think prisons is definitely well represented. And, of course, based on the topic, we do have a lot of medical and mental health folks on the line with us today. So, with that being said, let me go ahead and get this presentation started. As I pass it over to Dr. Hayden Smith. Dr. Smith? The floor is all yours. Dr. Smith: Thank you, Scott. And I'm looking through the participants, and we're almost at 500 from all across the country. So obviously, important topic or something that's motivated people to become involved. And I find people, staff members who are involved in this topic tend to be the ones that are focusing on the correctional setting itself and have a good read of the environment. And these inmates certainly impact the environment. My background, 15 years ago now, my interest is public health or mental health and corrections. And I entered a class action lawsuit that was happening between a state prison system and self-injurious behaviors was the the indication of untreated mental health. And it was a big deal in the state. And I realized that most of the research that existed on the topic of self-injury focused on an entirely different demographic. It was known incarcerated settings, white females usually in middle school or in college. And obviously, we have a very different situation, even though the behavior is the same. But we have a different demographic and a different manifestation of this behavior. So I've since worked on all sorts of proposals with this. I've done a bunch of technical reports for different agencies, academic publications, as well as having students do work on this. And so there's a lot of information that I've developed. And as Scott mentioned, my approach is somewhat different from Dr. Dean, who did an excellent presentation on the data system. This is big picture presentation, and it looks at the system as a whole and hopefully, you can gain some some things that can help you in your workplace. Most of the articles I've talk about today are actually my article. And you can find them on this research gate link. And then there's also some additional information. But I'll kind of summarize them briefly and move somewhat quickly through them. The learning objectives are stated here. Really, what I'm going to focus on today is three categories. The behavior of self injury, itself, thinking about definitions, prevalence, the manifestation and costs, kind of the nuts and bolts. People, I make the argument in this presentation that the people involved, particularly inmates and staff, really is the core of what's going on here. And that's where the solution can be found, and then wrapping it up with an idea of place, and what's the role of corrections, and its impact on on self-injury? What can we actually do? So the behavior, itself self injurious behaviors, as I start this presentation, I will point out that I purposely removed any sort of triggering images, or graphic images. You don't know who in the audience, particularly when it's a webinar, may be triggered by this behavior. But if you have any troubling reactions or triggered yourself, please disengage and seek any sort of resources. And this applies also for audience members who are watching, delayed broadcast or repeat of this. One of the things I talked about today, looking after ourselves, and self care. And so it starts with a bit of a trigger warning here. Okay, so self-injury, we've had a long established definition from about 1989. It's the deliberate destruction or alteration of body tissue. And the underlying part is the crucial part, without conscious suicidal intent. Now, there's obviously an overlap between self-injurious behaviors, and suicide. Those behaviors are almost a comorbidity. They go together; however, we'll see that there are important differences between the two. In general, self-injurious behaviors, it's an expression towards life or leaving or negotiating some sort of pain, physical or psychological pain. And suicidal intent is more move towards escaping pain or death intention. So there is a split in terms of motivation, and that's starts with our understanding of the definition. With that said, we also have a definition of major self-injury, which is a very uncommon in the non-incarcerated world. You may find it in a mental health hospital, but much more common in our correctional systems, particularly prison and the mental health staff who are here to receive this information. Major self-injury can is usually focused on targeting the face, removal of the eyes, full amputation or targeting like major body organs. The correct terms for both of these for self-injurious behavior is self-injurious behavior, SIB, or NSSI, non- suicidal self-injury. The non- suicidal being part of that definition. The intent is not towards suicide. Some older terms that you may hear that we shy away from because it doesn't match the definition, para-suicide, which means a quasi- suicidal type of a suicide. That's not really an accurate description, mutilation or self mutilation. The reason we don't use that is because people who engage in self-injury, very clearly articulate that they're doing it for a reason. And mutilation implies that there is no logic or no reason underpinning the behavior. Also, in corrections, I know we're apt to call these population cutters. I've even written an article titled "What to do with the Cutters," because that's the vernacular. But as a general term, self- injurious behaviors is preferable than some of these other ones. So turning over to Scott to get a better understanding of your perceptions of this behavior. Scott: Thank you, Dr. Smith. Now, we're launching our second poll here, and you are encouraged to start responding as soon as you see it. This question focuses on the number of incarcerated persons at your correctional facility or agency who are engaging in self- injurious behavior. Please remember to click on the submit icon in the lower right hand corner once you've answered the question. Again, this question is thinking of the correctional setting you work in, what percentage of the incarcerated population engages in self- injurious behavior? Zero to twenty percent? 21 to 40 percent? 41 to 60 percent? 61 to 80 percent or 81 to 100 percent? Now, as we wait for our participants to respond to this poll question, I wanted to also offer some additional resources that are available. Dr. Smith has already mentioned that he's published, or author of several articles that have to do with this topic. And all of them are about self- injury, and they're also about specifically about self-injury in a confinement setting. So one I'd like to bring to your attention is called "A Call to Action, Mental Illness and Self- injurious Behavior Occurring in Jails and Prisons." And you should receive a link to that in the chat. Scott: So back to the poll. The results are in and, Dr. Smith, how do these responses compared to the national data? Dr. Smith: Well, we have a representative sample here. So if we look at all of the research on self- injury in corrections, female populations tend to be somewhere between five to twenty-four percent, males two to eighteen percent. And that fits right into what we responded with, we have from our respondents here. However, we also do know that prevalence rates generally are pretty hard to be sure about. They're estimates. and the reason for that is we know that inmates who engage in self-injury will cluster within correctional systems, and also within prisons, themselves, into particular units or dorms. So within a correctional institution, they will cluster in certain environments. For example, I did a study that had 26 different prisons in a system, and out of the 26, four of them accounted for three quarters of all of the self- injuries reports. So four of them were taking on the overwhelming majority of these cases and reports that these inmates were filtering into mental health unit, locked up units and the maximum security or the highest security levels. Another challenge that we face with prevalence rates is, and this is a gender issue, too, is that there's no consideration of the severity of the act. And so each individual event is counted as one. But we know that there's a big difference between what we'll find typically more in the male populations with major self- injuries, and much less severe in the female populations. But all of those things are counted equally. And so prevalence rates, we have a generalities, but we also have to recognize the weakness of these measures. So many moons ago, when I first got into this research, about 2008, I realized that nobody had done a national survey to get an estimate of this prevalence. So I had heard that it was an epidemic, anecdotally, but I wanted to get some data to see if this was the case. So I did the first national survey on the topic and we use the the census of adult correctional facilities and targeted all state prisons that reported providing mental health services and housed 100 or more inmates. We got about 230 surveys back about a 60 percent response rate, which is pretty good. And about 90 percent were in the mental health field, so it matches our group, the dominant group who were in attendance today. Chiefs, directors, clinical directors, chief psychologist, psychologist, etc. Program managers. The remaining about six percent, the wardens assistant wardens or some sort of coordinators, superintendents. We were very shocked when we got the data back, because we found that the epidemic was in fact, identifiable in the data. And that almost all institutions had at least some inmates who was self injuring. Upwards of 98 percent had some identifiable inmates record of self-injurious events occurring within their prison. It was about 98 percent that responded in this way. We also asked about major self-injury. And, well, you can see here the there was an increase in terms of facilities that had not seen this. That's because these inmates typically transferred out of these facilities, maybe they're lower level, etc. But there wasn't a higher group that you would expect that don't see this behavior too much. But there are also a fair portion of respondents who did see major self-injury. There was typically the most was, like these respondents, could identify between one and five inmates who were engaging in a major self- injury. And there was a qualitative aspect of this where respondents would point out the often very severe, bizarre, and potentially lethal forms of major self-injury. Self- concentration, the cutting of major organs, rubbing feces into an open wound, and some very severe behaviors that were pretty much occurring in a lot of institutions. So when we turn to the manifestation of self-injury, how does this thing emerge? How do we see it in corrections? One thing that does match the non- incarcerated world is the most common manifestation is cutting with an object. This is what you find in our middle schools, and colleges. It's the same type of behavior. There is a meaning expressed through the way that this manifests. There's usually a message even though staff may often see as pointless or meaningless, and we'll get into the meaning in a little bit. But the meaning does kind of change with each of these four groupings of behaviors. Now, note, these groups that I have here, these four groups you see on the left. They're based on groupings of self-injury events. So they're a grouping of the behavior, not of the person. An inmate could move between all four of these at different times, however, they'll generally stay in one of the four groups, and they do kind of increase in severity. So when our second highest group that you see more often corrections than in the non-incarcerated world. You see a wide range of behaviors were starting to increase in severity and intensity, as you add more of those behaviors. It's kind of like taking a drug and drinking. It's not one plus one is two. It's the same concept where one plus one is three, or four or five, because there's an interaction. This is burning, self-hitting, head-banging, scratching, hair pulling, even slamming an arm in a door to break a bone. We're increasing in severity as multiple methods is used. The third group, and one that certainly emerges and is very different from the non- incarcerated world, is if there's a group of behaviors that focus on ingestion, and the inmates are engaging in this behavior, there seems to be a very impulsive component, such as they come across a room with a bleach or a cleaning solvent, and they just drink it. And it's very hard for them to explain the logic. They're not planning to have a razor blade or something to cut themselves. It's a more of a very quick impulsive act. And it can also include ingesting things like paper clips, and materials, that over time, can be very expensive for the correctional system. And the last group is major self-injury, which once again, is relatively rare compared to these other manifestations. They require a very quick staff response. They're often seen with things like a psychotic event, if an inmate has bipolar disorder, schizophrenia, and in this state, the inmate will, in my research, will tell you they're very detached from reality. They find themselves unable to stop. They are present. They know what's going on. They can observe, but it's almost they say that they when they're conducting major self-injury, they're almost watching themselves do it from a distance. These events can be very severe. They are kind of the great white shark of costs, because while they are rare, they're extremely expensive; however, I would say if you added up all of the costs, ingestion is more common, and therefore, it's more costly because they still require trips too often and trips to a hospital to remove the ingested object. When we did this survey, and in subsequent surveys, we asked staff what type of procedures are in place and what type of procedures do you validate. And you can see the list here starts with intake assessment, followed by therapeutic counseling, and watch cell. What you generally find with the qualitative responses as we go along with this, is they tend to be a split sometimes between using a punitive approach to self-injury and a therapeutic approach. You also, with the survey and other surveys that I've done, staff will often say, they're often unsure about what policy is best. And so they'll go back to using a suicide protocol, because they're not sure of the best approach, and they already have suicide protocols in place. Sometimes there can be a reliance on isolation or restraints. So there does seem to be some disagreements that happen within staff groups about how to best respond. Moving on to the manifestation and kind of a big picture, idea of self-injury, this is the one image that I like to use. And I use it for my students because it helps people understand the behavior when they're initially, often if it's grotesque or overwhelms them, they have trouble understanding it. So there's often two pathways to self-injury. On the left is the pathway, of what I call being over stressed and on the right is being under stressed. On the left will make more sense to most of us, you're stressed, you feel overwhelmed, unable to cope. There's some sort of trigger, you conduct the self-injury, and then you're relieved or calm. With my students in college, I say what if you take self-injury and replace it with getting drunk on a Friday night? You have the same type of process. Those student may feel hyper stressed. They're overwhelmed. The trigger may be an exam. They go out on a Friday night, they get too drunk, they feel relieved or in control or calm short term and then they regret that behavior. So it has a similar process or pathway in terms of the triggers. On the right is more of a detachment, and the person may feel numb, lost, and the self- injurious act makes them feel alive. The information that we have, the data that we have, suggests that the trigger or the emotions right before the event tends to be based mostly in anger or frustration, sadness and desperation. Following this are the events prior that triggers, usually is around an interpersonal conflict or a life event. So it can be an argument with another inmate or an interaction with a staff member, are usually the events that triggers this group. And following the self-injurious act, the major emotion is relief and regret. So for staff, what you often find is that these inmates will present with very specific risk factors. When we use our statistical analysis, we find they are different from other inmates who do not self- injure with being more involved in major mental health treatment, more likely to be on institutional restriction, more likely to have disciplinary infractions, mostly from not being in a specific place at time. They tend to not be where they're supposed to be, but also fighting and a higher level of escapes, I found too. And so they present a unique profile. Inmates who have documented acts of self-injury, usually injure about two times according to what shows up on the on the data, two times per year. However, you, of course, have a subset where the numbers range from 10 to 20, to 30 and off the charts. You can see the disciplinary issue is here. And the statistics showing the need for mental health treatment. Costs. How much does this behavior cost us? Your gut probably says a whole lot. We know that it's very difficult to measure things like loss staff time and transporting these inmates to hospital, lost staff time for burnout, fatigue, but we can estimate it through some other efforts. The first one is staff time. This is analysis of a state prison system and looking at the number of staff that had to reply to one self- injurious event. So the average was about four staff members for every event. But 80 percent of them, these events, needed somewhere between two and five staff members. And you can see down the bottom that in some major self-injurious events, you have upwards of 10 and 20, staff members. And this usually involved almost lethal attempt, and a hospitalization and taking officers on that call. We also know that self-injury has a contagion effect, that if it happens within a particular unit, inmates will learn from each other and try the behavior out. It also can be addictive. So the what we call the "high flyers," or the inmates that you're familiar with that will do this a lot. They can be very expensive, because they don't know how to stop doing this behavior. And a lot of a lot of them will say I'm not going to stop the behavior. I did one estimate of these high fliers. This was 20 inmates in a state prison system that were doing this repeatedly as well as repeated suicidal attempts that were known to staff. They usually had a very major crime that they were in prison for and a long term sentence, and a diagnosis of usually schizophrenia and or bipolar disorder. And it took me five years to finally track down these 20 high flyers. And I asked the prison system of one particular person how much does this cost? And the best that she could get me for these 20 inmates per year in external hospitalizations, each of those 20 inmates were costing the agency $1 million. They were costing $20 million dollars per year, just for the external hospitalizations alone. That's a remarkable number and it was just an estimate. It's not something I could publish anyway. And at that time, it was about 40 to 60 inmates in the system who were operating on such a intense level. So a lot to absorb there. The next section I want to talk about, we spend most of it on behavior. It's already about 1:30, so I'll move quickly through this next component which deals with people. And this is really some information that you may not have heard before. If you've been on these trainings before or self injurious the behavior component you've probably heard about or you probably have an understanding already. The people aspect is something that really becomes fundamental and is maybe a new information for you. So I'd like to start to ask you a polling question to get started. Scott: Thank you, Dr. Smith. Now, remember, you are encouraged to go ahead and start responding as soon as you see a window open up. This final polling question focuses on staff perceptions about inmates that participate in self- injurious behavior. Now, I know most of you, if not all, will want to respond to numerous answers on this survey. But we're asking that you pick the single answer that you feel most strongly about. And remember, once you have selected your answer, go ahead and click on the submit, that way your answer gets counted. Again, the question is, what are the perceptions that staff have about the reasons that inmates self- injure? Is it A? To get special treatment or different placement in the facility? B, to cope with stress? C, to attempt suicide? D, to intimidate other people? Or E, due to delusions or severe mental disorder? Again, as we go through and wait for the results, during the question and answer period, we're going to share a document that has a number of different articles. Again, they're all about self- injurious behavior in a confinement setting, but they spanned quite a wide range of topics, everything from, you know, the cause of self-injurious behavior, data, that, you know, has been collected on inmates that engage in self-injurious behavior, self- injurious behaviors effect on the staff members that are present when inmates do serious self-injury. So like I said, again, we will actually share that document with the participants during the question and answer period. So it looks like our results are in. Dr. Smith, I know you did a study similar to this. And how do these responses compare? Dr. Smith: Well, let's take a look. They look pretty similar to me. And what you'll find is this split in staff perception. This is actually the very first article I did on the topic. I went and spoke to 54 mental health professionals working in corrections on the topic. And this was in 2009 and tried to force them into Well, why do you think inmates are doing this? Some qualitative responses. And the whole idea of was understanding staff perceptions, because we know perceptions can often drive behavior. What staff think about these inmates can drive how we and other professionals respond to them. Of course, there's policies, but there's also front line staff who do get a lot of discretion in terms of what they do. And so with a follow up phone calls, and we've gone into some depth, but what you find is two emerging beliefs or perceptions. The first one deals with special treatment and this tends to follow a line that there's some manipulation, or looking for movement or looking for some control. And then the second group tends to focus more on a therapeutic approach that this deals with stress and coping. And this is a very important difference in our staff perceptions. I don't think there's another group of inmates that you could put in a certain group that could split staff in terms of the way that they perceive them. In terms of behaviors, these same mental health professionals were asked how would you go about managing them. And of course, they wanted to select every one of these categories, but if you force people into picking just one, you find a similar split that comes as a result. Isolation, which tend to have an endorsement of punitive responses, restraints, isolation segregation strategies, or a therapeutic response, which dealt with counseling. So one thing you'll find within inmates who self-injure, is that splitting of staff is very common. It occurs within a group such as these mental health professionals. It also occurs between groups, such as correctional officers and mental health staff. Inmates who self-injure may say their therapy staff, for example, you understand me, you understand my behavior, you understand my background, but he don't and start to split the staff into good guys and bad guys. There's also differences that we find where inmates who self- injure, there's a split in terms of gender. I've looked at data of many different systems and what is a human response, you'll find those usually directed towards the male inmates doing this behavior. There's a perception that the more manipulative they're trying to [inaudible], or isolation and segregation is the response. The female inmates have viewed as coming from abusive backgrounds and is a coping mechanism and therapy's needed. And you finally split within staff, you also find that within staff personalities. It's an interesting dynamic because it leads into our behaviors, and then also leads into how we can best protect ourselves when dealing with this population. So to address this split, when I do trainings, the first thing I usually focus on is the findings that really support the link between some early trauma and coping. Of course, a large number of our inmate populations come from bad backgrounds. But what you tend to find in inmates who have self-injurious behaviors that are present, and particularly in the high flyers who are doing this a lot, is a very typical pattern of a more severe trauma, often [inaudible]. Often with physical, mental and emotional abuse, severe, it can be random. It can involve a parent who often has a mental illness and is unpredictable. They are usually devastated by the abuse, but also when they often abandoned have had cases where the person returned home and their entire family had moved elsewhere not told them, or they're placed in foster care. The abuse often continues through the parent's romantic partners or through foster care. And by early adolescence, this is a group that is disconnected from society. They may drop out of school, they may pretend to go to school, and they'll say something that's fairly unique, which I've heard quite a few times, which is, if you ask them about their friendship groups, they'll tell you, I've never had a friend. I had people I stole cars with, but I never really had a friend. The authority figures in their lives, their parents, the school teachers, etc, are seen as abusive. So they're often very defensive when it comes to what they perceive as authority figures. And self-injurious behaviors tends to emerge as a dysfunctional coping mechanism. And when you ask in research, how did this happen, it tends to be often impulsive. Something was there to cut or drink or to hurt themselves. But they'll often say the same thing, I've heard this in different states and different settings. They'll say, at that point in my life, I didn't know what to do. I just knew I had to do something. And self-injury does emerge as some sort of coping mechanism in terms of that, As the behavior develops, and it's now part of what they do to cope, if they find those addictive components actually help them, and this is a quote from a case study that I did that if I was to say, read something I did, this is the one thing to really understand the background of these inmates and the trauma that they've often experienced. This inmate had post traumatic stress, depression, anxiety, alcohol abuse, and a range of conflicting and mixed diagnoses. You can see that he's trigger would happen when he was asleep and dreams. And he would wake up and know at that time, he was going to engage in major self- injury. It may not be right away, but at some point he was going to do this. The point of this is in the final couple of sentiments. The stressors gone, it works. And they will tell you that when that anxiety when the triggering happens, that this is one form, an easily available form of coping, that they recognize as dysfunctional, but it works for a number of them. So the important issue here for staff really focuses on this idea of inmate manipulation. I can provide some evidence, particularly with the high flyers, to show that yes, they are doing this behavior anyway, and yes, they may manipulate the behavior, however, it is really based -- the evidence suggests it's based in coping. And some of the reasons for that is these inmates were doing the behavior before they were incarcerated. They didn't learn it while they're incarcerated, a number of them, some did, but a number were doing it beforehand. And they will tell you that will do it after. A number of them are hiding acts of self-injury, particularly when there's a punitive sentence if they get time or isolation for being caught for doing this, such as fluffing blood down the toilet, or hiding the ax. And the biggest finding is you'll find the same coping mechanisms, whether it's quantitative/ qualitative data, and it's the same pattern emerges in Canada and UK and across the US. When you find the same behavior manifesting in the same way and explained the same way, you have to give some credibility that maybe this is not just done for inmate movement and manipulation. And in terms of staff responses, that also gives us a little more room to work in terms of what are the best responses. Now I will say I'm not naive. Inmates will exploit the behavior, but it is important. And I'll show you why for us not to assume that it's always manipulation. So one thing that you'll find with inmates who conduct self- injury, and Scott was nice enough to put on an officer wellness and resilience webinar that I did recently. And it basically overwhelmed the bandwidth. We had 1800 people sign up. In my experience, inmates who conduct self-injury, take the biggest toll on the on the health of staff, more than any other group of inmates. You'll also find a wall of denial in a lot of staff and I've published on this and you can see the citation below. The first thing you'll find is staff will dismiss an impact on their own personal mental health. They'll usually have bravado or dissonance and they'll say things like, oh, these inmates impact the environment I work in negatively, but they don't impact me. I'm just doing my job. But when you really dig down, when you do one on one interviews, when you use qualitative responses, and you ask what's really going on here, you do find that this inmate group really does impact our staff in a negative sense. One of the ways I think about this, an inmate who's conducting major forms of self- injury and doing this repeatedly with a major mental, serious mental illness, also engaging in suicidal behaviors. This type of person is not usually in the non-incarcerated world. You may find them in mental health hospitals, but most people who graduate as psychologists or psychiatrists are not going into interact with these individuals. Yet we send front line correctional staff in often with very little training daily, and we expect good outcomes. In a lot of cases, these inmates are overwhelming staff. And what I found in my research is it often centers around a battle for control and understanding this battle, usually is a way to find solutions. So if you think about the role of front line staff, they literally are in a battle for control, physical control. They're controlling people within a certain environment and not letting them escape. Their job description is based around the physical control. Now if we follow the research that shows that inmate controlling their emotions through this behavior, so self-injury is an expression of self control. They're trying to control their own emotions. Now you have one group that's in a physical battle of control, and another group that's in some sort of psychological battle for control. And you'll find that there's often a battle for control between the two groups that is happening right in front of your eyes. Staff who have other control issues, such as marital issues, alcohol issues, interacting with this group will aggravate their own vulnerabilities. And so understanding what's going on in our correctional system, this is where we're finding the most negative impact. And we find burnout, apathy, disengagement, turnover, and all of the other things that we don't want in our staff groups. So if I was to add up all of the technical reports and articles that I've done, I would say that this is a model and there's not one model. A lot of this, you will have to adapt for your own institution, but surrounding the behavior. This is my mantra. When I study this, and I go into the trenches, I go into the mental health dorms and maximum security prisons and spend hours and hours talking to inmates who are doing this severely, many of them have died since I've spoken to them from the behavior. And so I'm not naive on this topic, but my mantra is this, surround and defeat the enemy. So surround them with staff, and the four staff, your front line COs, your mental health staff, the correctional administrators who have to endorse these programs, and of course, your physical health staff, including the external staff or hospitalizations. You surround and defeat the enemy. The enemy is self-injurious behaviors, not the inmate. This removes that personal impact that staff will often get. They'll take self injury as a personal behavior directed at them. The one message I would have staff receive today, it is not a personal behavior. These inmates will do this regardless of your presence, or no presence. So surrounding defeat the enemy, the enemy is self-injurious behavior, not the inmate. Staff cohesion is the solution, kind of like the old wild west, where you would have to, you know, make a circle to protect yourself. The circle can surround and cross the behavior. And you have to detach yourself from the inmate themselves and look through the inmate at the concept of the behavior of self-injury. Nuts and bolts, How do we do this? For self-injury, the answer is not the inmates. That's the most surprising thing I think you'll take away from today, I'm not going to give you a world of knowledge about what to do with them. Because I think the solution focuses mostly on staff. A wellness and resiliency plan for staff. And I know we have a crisis in terms of staffing, but basic trainings that talk about some of the concepts I've spoken about today, such as staff expectations, this behavior will never go away. A solution is not 100 percent of goals. A reduction using data to look at a reduction of the behavior. And looking at this link between trauma and coping intellectually helps staff not take the behavior personally. And this needs to be part of our trainings. Inmates who engage in self-injury are a physical group, that'll respond to actually more tactile things. They like to do art. They like to touch things. And you can see that in the way that behavior comes out on their body. Their body is a message to you. But they also will respond to crisis intervention and all of the other aspects that we do, stress management, and also the staff partnerships. That means getting staff together internally, but also sharing the responsibility with external agencies that can come in and help provide resources. I recently did an evaluation of a yoga program for a detention center, a very small one time thing. You wouldn't think that has anything to do with inmate who self-injury, but it does. The more our staff can engage in nutrition, wellness plans, yoga, all of the myriad of those programs, that gives you the best bang for the buck in terms of dealing with inmates. The last component, and I want to leave a little bit of time for follow up questions that we have, is place. And I'll move through this fairly quickly. So when we talk about place, we have to recognize that self- injury and suicide, they kind of often go together. They're reflections of mental illness. Self-injury by itself is not in the DSM as its own criteria. It's a indicator of things like borderline personality disorder, some other things. So it is associated with mental illness, but it's not mental illness itself. It's best described as a sign of mental distress. So solutions usually have to focus on the underlying mental health issue. But I would direct for looking at place and some ways to look big picture. This is looking at a system more than just your institution is the Ashley Smith case, which happened in Canada. Ashley Smith died while under suicide watch. There was a big inquest. Here's a couple of links that I'll invite you to look at later on. But this is really important because they went back and did an inquest of how this happened in terms of her death. And they provide some really good documents you can kind of go down and say, are we doing this in our system? And what are what are we doing well? And what are we not doing? There's five pillars. I'll touch on them really fast. Timely assessment. Once again, I've underlined some things here, but looking at mental health assessment and treatment, so not approaching necessarily self- injurious behaviors, but what is the mental health condition underneath? Effective management. What's the role of those segregation practices, if we have a negative and a punitive approach to this, we're often sending out inmates with mental health conditions into isolation, into lock down into punitive parts of prison system. And we know what that does to symptoms of mental health and mental illness. Sound intervention. There's a long list of best practices that you should look at in terms of these links, but they talk about some really cool things like partnerships, holistic approaches, which can often sound like fancy terms, but they give you things to think about. And most of all, this is foreign to a lot of people who work in correctional settings, sharing responsibility with the community. Staff in corrections are my heroes, but they'll often take these jobs on their own shoulders, and they will overwhelm themselves and get burnt out. These problems are not your problems, these problems are community problems. Ninety-five percent of our population in prison will go back to the community, including these people who are self-harming. So how do we want to deliver the best practices? And what community resources can we bring in as we know corrections is often a resource poor environment? Two other areas, ongoing training, or training is fundamental, particularly to address the concepts I talked about, DTB and other things. And the last area is robust governance and oversight, such as reports. I'll leave you with this idea of SIB, self-injurious behaviors, as a sentinel event. So a sentinel is the person that was on the guard tower who was looking out of the castle to see if there was a threat or a warning coming. I would argue that inmates who engage in self-injury, are one or if not the most expensive group that we have in our, particularly in a prison system. I would put them up against geriatric populations, pregnancy, HIV and other groups of illnesses and mental health conditions that we have. They're extremely expensive, but if you look at data, whether it's specific data like Dr. Dean's separate webinar, or even just looking at institutional reports, over time, they really send a message about what is going on inside that system. And if you see elevations of self- injury, it tells you something is coming. And if you see declines, once again, we're not going to stop this behavior, but once you see declines, you can start to assess what do we do that led to that? Is that a natural occurrence? Or do we do a policy or program or do we change something that made a difference here? With that in mind, I'll hand it you back to Mr. Richards. Scott: So that brings us to the end of our presentation. Please stick around for a short Q&A session. Dr. Smith, as always, thank you again for sharing this fascinating subject with us today. For our participants out there, please feel free to contact us with additional questions about this presentation. Our contact information is there on the screen. And of course I'd also like to thank our wonderful producers that helped in the kind of behind the scenes today. My coworkers, Belinda Stewart, Chris Smith, Dena Williams, Destanie Overcash, Evelyn Bush, and Tashima Ricks. And so Dr. Smith, I'll go ahead and start with the questions and get this document out as soon as I can. So the first one I see here is are you aware of any research that has compared the rate of self-injurious behavior between the Department of Corrections and the Department of Mental Health? Dr. Smith: No, there's really not. I haven't seen a tremendous amount on Department of Mental Health. Almost, I would say 95 percent of the current research in the non- incarcerated world is focused like I said, on the middle school and the college. There is actually a group that does this. ISSS. It's long name and I've gone to their conferences and they don't deal with forensic patients, whether the mental health patients or not. There are some older articles where the sample will include both of those populations. But it's very, very limited and basically non-existent. I did see a pop-up question too about probation and parole, and I would put that same answer into that. It's an unexplored area of research. Scott: Okay, thank you and this one, the next one is, in a correctional setting, individuals who engage in self- injurious behaviors often end up being held closer together. What are the best practices to manage multiple individuals who feed off of each other's self- injurious behavior? Especially when separating them is not always feasible? Dr. Smith: Right. That's a really good question. So once again, staff comes first. What happens with self-injury, particularly if you have a dorm setting and, and there's some major self- injury, the shockingness of the behavior can often be very bloody and grotesque. It does consume us. It's hard not to. We're all humans. But what becomes invisible is the staff. So you always have to sit back in any environment, particularly an environment like that, and your staff comes first. And then we're dealing with a group that will interact with each other. Bear in mind, that's going to happen anyway. Yeah, if you can separate them into different dorms, but the criminal justice system, particularly prisons, is a default mental health system, right? The numbers are high. This group is going to filter into mental health dorms because that's where they can also get the treatment and the care. But there'll be very little that you can do in terms of stopping the actual behavior when that synergy between these groups occur. These inmates will get razors delivered to them with their food from other inmates. They'll even get it from some staff members. So a focus on tools and stopping the tools themselves, I would say you follow security procedures, but that's a lost cause. What you focus on is engaging them, keeping them busy, and asking them what solutions they seek getting a treatment plan, because they do want to stop the behavior. The ones that are really engaged in this, they're addicted to it, and they want it to stop. They just have no idea how. And so that's probably my answer and also recognizing that you're dealing in that environment with a tremendous amount of trauma. Those inmates, they're interacting in terms of how are you going to cut yourself? How are you going to hurt yourself? But they're really communicating about this is the trauma I've experienced my whole life, how was your trauma? It's a trauma competition that's going on. So thinking of ways to disrupt that conversation can be the most effective way to deal with it. Scott: Okay, thank you and we're just about out of time, but I would like to ask one more question. And I kind of have an idea about the answer on this one, but would you treat an inmate diagnosed with ASPD, who engages in self-injurious behavior for secondary gain the same as an inmate diagnosed with borderline personality disorder? Correctional staff don't like to give in to inmates and give them everything. Dr. Smith: Yeah, so that's a really great question. One of the things I bring up in my training is, particularly with front line correctional officers, if you're going to engage in this battle with them head to head, how far are you prepared to take it? How far are you prepared to put your mental health on the line? Because you have a physical manifestation of what they're prepared to do. They're showing you with their body how far out they will take their battle for their own emotional control. How far are you prepared to engage in that battle? Or is there another way to do it? I'm not naive. I recognize manipulation occurs. Those who are borderline personality disorder, they obviously fall into the the they love that looting of staff that is their go-to. Okay? Anti social is a whole other ball of wax. However, I've noticed it's a fairly small group relative to borderline personality, bipolar and schizophrenia. So it is hard for some staff to really accept that it is a coping mechanism. I totally understand that. Like I said, I'm not naive. I've sat down. I'll leave you with one quick story. I know we're out of time. But I did collect qualitative data one time in a maximum security prison, had no air conditioning, and I sat at a desk for seven hours just coding and writing this stuff down. Inmates told me story after story with trauma and self-injury. And when I drove home, I realized I was driving 100 miles an hour. And so I do realize like, whoa, that has an impact on me and I don't have to go back there the next day like front line staff do. I recognize I'm speaking as an academic, but I have been in the field. I recognize that if I was in the front row, it will be very easy to get consumed by manipulation. But I'm also endorsing this idea that comes from research, that this behavior really did start, in many cases before it got to corrections. And following the mantra that it's personal leads to really bad outcomes from staff. Scott: Okay, thank you again, Dr. Smith and thank you for all of our participants. We are out of time. We're a little bit over right now. And, again, I would like to thank you all and I hope that you all join us for the next NIC webinar. Have a good one. Dr. Smith: Thank you.