BACKGROUNDER
Chronic Self Injury among Federally Sentenced Women

Overview

• The death of 19-year-old Ashley Smith in a federal women’s correctional facility in October 2007 underscored the importance of developing effective, evidence-based management and treatment strategies for complex self-injury cases.^{Footnote 1}
• Since Ashley Smith’s death, the number of self-injury incidents in federal penitentiaries has more than tripled. In 2012-13, there were 901 incidents of recorded prison self-injury involving 264 offenders.
• Last year, a relatively small number of federally sentenced women offenders (37 of 264 total) disproportionately accounted for just over 35% of all reported self-injury incidents. 
• The frequency and severity of self-injury is particularly concerning among Aboriginal women offenders. 45% of all incidents of self-injury among federally incarcerated women involved Aboriginal offenders.   

Purpose and Context

• This investigation provides an opportunity to review and assess how the Correctional Service of Canada (CSC) responds to incidents of chronic self-injury. It examines the use and impact of disciplinary and criminal charges, use of force and other security controls to prevent or manage chronic self-injury among federally sentenced women. 
• CSC case records, files and reports (e.g. psychology, security, use of force, discipline and dissociation) for eight chronically self-injurious women offenders were reviewed covering the period January 1, 2010 to June 30, 2012.  
• Visits to three federal regional women’s institutions – Grand Valley Institution (ON), Joliette Institution (QC) and Edmonton Institution for Women (AB) – as well as the Regional Psychiatric Centre (SK) were conducted to interview offenders and staff and to gather and review case files. Two provincial forensic psychiatric facilities – Institute Philippe-Pinel (Montréal, QC) and the Brockville Mental Health Centre (ON) – were also visited in order to observe and compare best clinical practices and community standards of care.

Offender Profile

• Six of the eight women are serving their first federal sentence, the average length of which is five years. The average age of the women is 25; the youngest is 19 and the oldest is 40. All but one was classified as maximum security. Seven of the eight women are Aboriginal.
• All have been the victim of physical abuse; seven have been sexually abused. Most spent their childhood in group homes or foster care. Four are mothers of young children. Most are estranged from their families and have little if any existing social supports.
• All were previously diagnosed with a significant mental disorder; six spent time in a mental health or psychiatric institution prior to federal custody. Six have identified cognitive deficiencies. Three have been diagnosed with Fetal Alcohol Syndrome. 
• All self-injure by way of slashing and/or cutting, most use ligatures to self-strangulate and some have inserted foreign objects into their body. All have self-injured by banging their head and all have a previous history of suicide attempt(s).

Findings

• Over the 30-month review period, a total of 802 institutional security incidents were recorded for these eight women; just over half of these incidents were reported as self-injury or suicidal events. Nearly one-third of the documented self-injury incidents involved a use of force intervention (e.g. physical handling, pepper spray, use of restraints).
• Seven women incurred a considerable number of institutional disciplinary charges (ranging from 19 to over 100 reported charges), some of which were directly related to resistive or combative behaviours resulting from self-harming actions (e.g. refusing to stand to count, disrespecting an officer, possession of unauthorized item(s) such as ligatures, and destruction of institutional property such as clothing).
• Reminiscent of Ashley Smith’s case, six women were convicted of other criminal offences resulting in time added to their sentence. Three were convicted for offences that occurred during staff interventions in acts of self-injury. Two had time added to their original sentence for these offences.
• In total, the women were involved in 22 transfers between the regional women’s facilities, the Regional Psychiatric Centre (RPC Prairies, Saskatoon) and/or provincial psychiatric hospitals. Some were transferred as many as six times between the RPC and other federal correctional institutions. All transfers were prompted by continuous escalation of deregulating and/or maladaptive behaviours associated with mental health problems.
• Seven of the women served considerable periods of time under some form of "clinical" seclusion. Five women were routinely placed in administrative segregation following acts of self-injury. Resistive or assaultive behaviour most often occurred after staff intervened in an act of self-injury and was most frequently observed in context of mandatory strip searching required for an administrative segregation or clinical seclusion placement.
• The investigation found considerable tension between mental health care and security-focused interventions. Perceived security concerns, regardless of individual risk, tended to trump clinical or mental health care needs. Even in CSC treatment centres, security personnel are typically the first or emergency responders to self-injury incidents. Some officers disclosed that they were not qualified to intervene with mentally ill offenders and conceded that safety and security concerns of the institution took first priority.
• In general, security and control responses were found to be disproportionate to the risk presented, inappropriate from a mental health needs perspective and counterproductive to therapeutic treatment aims. For example, for some women, prolonged periods of seclusion and isolation exacerbated the frequency and severity of their self-injury and/or escalated their resort to other resistive behaviours. Some women associated segregation as a form of discipline or punishment for their acts of self-injury.
• Similarly, the frequent use of physical restraint equipment to gain control of, manage or prevent self-injury was often found to be problematic. Although CSC policy directs that physical restraints are neither a medical or clinical measure, some of the treatment plans provided for the "consensual" use of restraints to manage or prevent self-injury. In some extreme cases, reliance on the near perpetual use of physical restraints was deemed to be a "life-preserving" measure.      
• Even in the most acute and chronic cases of self-injury, CSC makes only limited use of transfer to external psychiatric facilities. Visits and interviews at external psychiatric facilities confirmed that there were significant differences in community versus CSC treatment standards. Some of the women who were treated in external facilities experienced a dramatic reduction in the urge, frequency and severity of self-harm.
• Despite legislative and policy provisions that govern the care and treatment of Aboriginal offenders under federal sentence, the investigation found little evidence of awareness or application of culturally appropriate healing or treatment approaches to the problem of self-injurious behaviour among Aboriginal women. 

Recommendations

• In total, the report contains sixteen recommendations. Key recommendations include:
  • enhanced training for staff working with chronic self-injurious offenders;
  • strengthened monitoring and reporting on the use of physical restraints in the management of self-injury;
  • prohibition on placing self-injurious offenders in conditions of prolonged clinical seclusion or segregation; and 
  • appointment of an independent patient advocate or quality care coordinator at each of the five regional treatment centres, inclusive of the Churchill Unit, RPC, Prairies.
• Finally, as a necessary and immediate measure, the report calls on CSC to transfer the most chronic and complex cases of self-injury to external community psychiatric facilities.