Most correctional systems have them--a small group of high-risk, high-need inmates who engage in repeated acts of self-injury and do not respond to traditional talk therapy or pharmacotherapy. The challenges such inmates pose are all too familiar to correctional administrators, mental health and medical staff. These inmates can engage in severe, potentially fatal self-injury, strategically holding their own bodies hostage as a means of obtaining a desired goal. These inmates can engage in self-injury when frustrated, angry, impulsive or simply bored. These inmates may pose danger to others through assaultive behavior. Common challenges include frequent mental health crises; protracted watches; on- and off-site medical care; correctional officer overtime; uses of force; therapeutic restraints; emergency medication administration; exposure to blood and other body fluids; contagion effects with other inmates; disciplinary hearings; restrictive housing placements; time-intensive staff meetings; litigation; staff alienation and staff burn-out.
However, the challenges do not end there. Quite unintentionally, crisis interventions that are essential to restore safety or provide treatment can raise the risk of future inmate self-injury among this group of inmates. Removal of property and placement on observation status in a suicide smock may be experienced by the inmate as punitive. Administration of pain medication following surgical repair of self-injury and "negative" attention involved in interrupting or treating self-injury may be experienced as rewarding. Whether the inmate becomes locked in a power struggle or is rewarded with reinforcing medications and outside hospital trips, or just "feels better" after self-harm, the pattern of self-injury can intensify over time. Repetitive self-injury both raises and masks the risk for completing suicide, like "the boy who cried wolf" parable.
Behavior Management Solutions
Done properly, behavior management interventions hold much promise in addressing these challenges and improving the quality of the inmate's life. The goal of behavior management is to reinforce (or reward) inmates so desired behaviors grow stronger than the inmate's problem behaviors. In the model described here, the correctional system accomplishes this using a structured, phase-based approach that reinforces small behavior changes with small incentives and larger behavior changes with larger incentives. Rewarding behavior that the inmates should already be doing can be a tough sell, particularly if the inmates in question have had assaultive, abusive or abrasive interactions with correctional staff. In correctional settings, the first instinct may be to punish unwanted behavior, not design a behavioral program to reward positive behavior. It is natural for staff to question the wisdom of providing incentives to the very inmates who repeatedly cause the most difficulty and danger.
Implementing behavior management interventions is a boot-strap operation when there is no outcome data to support the program. Once interventions can be demonstrated to reduce self-injury and create predictable routine responses for staff, "buy in" for incentive-supported programming is easier to achieve. Support from the top--including support from central office and facility administrators--is necessary to effect culture change. Seasoned correctional staff need to see it for themselves before they are convinced. Strong policies and procedures; multidisciplinary teamwork; staff training; program monitoring to ensure fidelity of behavioral interventions; and outcome measurement are critical.
Judicious application of behavior management is also needed. Inmate self-injury is heterogeneous, and behavior management interventions are not appropriate in all cases. Figure 1 shows four possible...