Violence and Self-harm in a women’s prison CM Chris Kottler Dr Jared Smith Professor Annie Bartlett 30 September 2016 Who are we? Statistical analysis by Dr Jared Smith, academic oversight by Professor Annie Bartlett and project lead by me. Where did the study come form? Personal experience of working in Healthcare gave interest in the overlap between violence and self-harm; MSc dissertation on it and then expanded the study. This work was done in my spare time with ethical approval from both NOMS & NHS

Introduction Why? Increased suicide rate Increased homicide rate Women 5% prison population 50% of self harm incidents in prison Violence outside prison correlates with suicide and self harm in prison Both require resource violence threatens the imperative for “good order and discipline” So what are we going to look at next?

Aims Establish patterns of self harm and violence in a women’s prison Establish the characteristics of women with high frequency behaviour Establish the relationship of acts of violence and self harm to the prison regime

Study Design Retrospective analysis Routine data on violence and self harm 3 year time frame Variables for women who self harmed and/or were violent: Socio-demographic data Offence related data Duration of imprisonment Types of self harm and violence Limited data on entire cohort Data sources Prison data base on self harm (F213SH forms) Prison data base on adjudications (only violent adjudications) CNOMIS case work system (management reports)

Data Analysis Frequency data on rates of self harm and violence Statistical associations in two phases Characteristics of women with either or both violence and self harm compared with women who displayed neither behaviour Three group comparison: characteristics of women who self harmed, women who were violent and women who were both violent and self harming

How many in 3 years? 7304 receptions, 6246 releases and 1071 transfers out Average daily population 495 (range 396-576) 5486 individual women in prison over 3 years Substantial churn in the population – 7300 times a person came in – but only 5500 individuals; just over a quarter of reception interactions were for repeat visitors; roughly a third of the women came back one or more times – a challenge to improve & streamline the customer service function to settle people quickly in the first few days.

How long did they stay? Range 1-1096 days Median 54.55 days 4281(78%) had a single episode of imprisonment Range of the number of episodes 1-17 Again – this points to a high churn population

Violence and Self-harm only N=221 (4.0%) Violence N=288 (5.2%) No violence or self harm N=4832 (88.1%) Both N=145 (2.6%) 6.6% were recorded to have self-harmed 7.8% were recorded to have been violent MORE were recorded as having been violent than having self-harmed We know that proportionately more women get adjudicated than men; on this measure, at least, more women are violent than self-harm. This may be a comment on adjudications rather than actual behaviour but is of interest nevertheless. 12% were in the two groups – they are highly interrelated with a substantial overlap between the two groups – but are a minority of prisoners.

Self-harm 2703 acts of self-harm by 366 (6.7%) women Range 1 – 186 incidents person Women who self-harmed (N=366) did so at a rate of 5.33 incidents a year 79.5% (2148) of all incidents of self harm were done by 70 (1.28%) all women (20% of those who self-harmed) 54.6% (1477) of all the acts of self harm were done by 16 (0.29%) all women (4% of those who self-harmed) Just 6.7% recorded to self-harm 186 incidents suggests slow transfer times in indeed she was transferred to hospital 5.3 incidents per year – remember that figure for later OVER HALF the self harm is done by just 0.29% of the total population!

Methods of self-harm Three quarters: cutting and scratching A quarter: self-strangulation or hanging Both self-strangulation and swallowing objects were significantly more common in women who both self-harmed and were violent than those who only self-harmed Remember the both group

High frequency self-harm defined as >5 acts of self-harm (Hawton 2014): Start earlier than low frequency self-harmers No more likely to be violent than low frequency self-harm women no deaths in the three year period Multivariate analysis by the three groups unhelpful Hawton’s major 10 year epidemiological study found >5 incidents of self-harm in any rolling 12 month period may be associated with completed suicide by women in prison BUT notes it was an under-powered finding – we used it as a key variable to differentiate between high & low frequency self-harm. We found they start earlier – in first ten days. No more likely to be violent; (mercifully) we had no deaths and multivariate analysis was not helpful – REMEMBER the last slide – the 5.3 average? WE CAN’T predict!!

Methods of violence Half used threatening/abusive language/behaviour A third were assaultative Fire setting and assault were significantly more common in those women who both self-harmed and were violent than those who were only violent NOTE the both groups behaviour here.

High frequency violence 759 acts of violence by 433 women Women who committed violence did so at a rate of 3.2 incidents a year 71 (1.29% of all) women did just under half of all incidents (16% of those who were violent) 18 (0.31% of all) women carried out c. 20% of all violence (4% of those who were violent) High frequency violence (3 or more incidents) was associated with self harm (56.3%vs29%,OR=3.00,95%CI=1.77,5.08) High frequency violence was associated with self-harm – we know that works from outside prison to inside with violent offences; this demonstrates an association inside jail too.

High frequency violence and high frequency self harm 16 women fell in this category but we were statistically unable to differentiate them from women with low frequency behaviours Again – this highlights the great difficulty of prediction

Main findings of the study Few women are either violent or self-harming High proportions of the total number of acts of self harm and of violence are committed by tiny proportions of the overall population The two groups (v&s-h) are highly interrelated Rates of violence unsurprising and lends further support to the idea that many women could be found alternatives to custody MoJ – 281 per 1000 prisoners i.e 28.1% self harmed in the year to sept 15. Hawton sentenced women – figure of 20-24%2004-2009 Recommend a change in the way data is described as the official records seem misleading both in absolute terms and in terms of gender ratios as so many more men serve longer sentences making the daily population a more suitable way of recording than for the many short sentence women. Our figures triangulate with previous work both by Maden et al 1994 and Wilkins & Coid 1991 in custody for both men and women. The method used by the MoJ seems to derive from a period when prison records did not allow for unique identifiers. Towl (1998) suggested reception figures a better method nearly 20 years ago. We suggest unique identifiers are necessary and this allows in consideration of episodes of imprisonment. In turn our method would limit the feasibility of historical comparisons of trends. Two groups are highly interrelated – one consequence is that we may need to reconfigure how we care for women in Seg – including greater healthcare involvement.

Recommendations Alert for 5+ acts of self-harm in any rolling 12 month period and actual self-harm in first 10 days– with policy-mandated management response including clinical formulation Increase Healthcare involvement in Seg to improve care for self-harming violent women Work to improve hospital transfers times & quantities – this is a small number of individuals Start a new series of self-harm reporting based on Reception numbers & actual observed behaviour Include self-harm by women in the Violence Diagnostic Tool (the two groups are highly interrelated)

What next for research? Report the rest of the data – the relationship to the regime Add more data – this is about “within group” differences – add data for the remaining population Add more data – look at the meaning behind the incidents Add more data – compare with men’s estate Investigate the recent rise in deaths and others to design a study with adequate power to test Hawton’s (2014) finding (if not already being done)

chris.kottler@hmps.gsi.gov.uk 020 8196 6371 HMP & YOI Downview Thank you for listening! chris.kottler@hmps.gsi.gov.uk 020 8196 6371 HMP & YOI Downview