Journal of Forensic Psychiatry & Psychology

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Near-lethal self-harm in women prisoners:

contributing factors and psychological processes

Lisa Marzano , Seena Fazel , Adrienne Rivlin & Keith Hawton

To cite this article: Lisa Marzano , Seena Fazel , Adrienne Rivlin & Keith Hawton (2011) Near-
lethal self-harm in women prisoners: contributing factors and psychological processes, Journal of
Forensic Psychiatry & Psychology, 22:6, 863-884, DOI: 10.1080/14789949.2011.617465

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The Journal of Forensic Psychiatry & Psychology
Vol. 22, No. 6, December 2011, 863–884

Near-lethal self-harm in women prisoners: contributing factors

and psychological processes
Lisa Marzano, Seena Fazel, Adrienne Rivlin and Keith Hawton*

Department of Psychiatry, University of Oxford, Oxford, UK

(Received 9 March 2011; final version received 15 August 2011)

We investigated the circumstances and psychological processes involved in

the near-lethal self-harm acts of 60 women prisoners, using qualitative and
quantitative methods. Most incidents involved hanging or ligaturing and
high levels of suicidal ideation, and were attributable to individual
and prison-related factors. Half of the incidents were described as
impulsive, but mostly occurred against a background of longer-term
suicidality and multiple repeated attempts. Hopelessness and images of
past trauma were common in the lead-up to the acts. These findings have
implications for prevention of suicidal behaviour in female prisoners.
Keywords: suicide; prison; near-lethal self-harm; women; qualitative
methods; prevention

Introduction
Internationally, suicide is a leading cause of death in prisons. A recent study
of 12 countries showed that, compared with the general population, crude
relative rates of suicide were between three and eight times higher in male
prisoners and typically over six times elevated in female prisoners (Fazel,
Grann, Kling, & Hawton, 2010). Rates of self-harm have also repeatedly
been shown to be higher in prisoners than in the general population (Lohner
& Konrad, 2006; Meltzer, Jenkins, Singleton, Charlton, & Yar, 1999).
Although much of the research in this area has focused on male prisoners –
who worldwide represent on average 95% of the prison population (Walmsley,
2009) – there is evidence that rates of suicide are at least as high in female
prisoners (Charles, Abram, McClelland, & Teplin, 2003; Mackenzie, Oram, &
Borrill, 2003), despite the lower suicide risk of women in the general
population (Hawton & Van Heeringen, 2009). In England and Wales, suicide
rates in imprisoned women were reported to be 20 times higher than those
recorded in women of the same age in the general population, a proportional
excess greater than for male prisoners (Fazel & Benning, 2009). More research

*Corresponding author. Email: keith.hawton@psych.ox.ac.uk

ISSN 1478-9949 print/ISSN 1478-9957 online

Ó 2011 Taylor & Francis
http://dx.doi.org/10.1080/14789949.2011.617465
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864 L. Marzano et al.
is needed to understand the processes that lead to such disproportionately high
rates of suicide in prisons, especially in women. This may assist in developing
models of prevention policy in institutions in general, including detention
centres and psychiatric hospitals.
It has been argued that suicide is best understood as ‘both an event and a
process’, the event being ‘a self-intended, self-inflected death’, the process ‘a
multidimensional sequence of events’ (Buchanan, 1991). This process is
thought to develop in such a way that suicidal ideas become plans, and plans
are acted upon (Runeson, Beskow, & Waern, 1996). It is rarely the
consequence of a single cause or stressor, but rather depends on several state
and trait-dependent factors (Hawton & Van Heeringen, 2009). An
important implication of the concept of suicide as a process is that ‘it is
something in which one can intervene’ (Buchanan, 1991), potentially on
several levels. In order to do so, an understanding of the duration,
development and characteristics of this process is needed.
However, reflecting a more general trend in the wider suicide literature,
previous studies of prisoner suicide have tended to focus on suicide as an
event, rather than a phenomenon which develops over time. The resulting
emphasis on identifying a profile of the suicidal prisoner has led to empirical
and conceptual advances regarding risk factors for prison suicide (Fazel,
Cartwright, Norman-Nott, & Hawton, 2008), but has little explanatory
power, and provides limited insight into the pathways leading to suicidal
behaviour.
Research in the general population has shown that insights from
individuals who have attempted suicide are both theoretically important and
significant in planning interventions with vulnerable individuals and groups
(Chesley & Loring-McNulty, 2003; Douglas et al., 2004; Herrera,
Dahlblom, Dahlgren, & Kullgren, 2006). Unlike ‘psychological autopsy’
studies of the suicidal process in suicide victims, they provide access to
information about personal issues and psychological mechanisms of which
key informants may be unaware (Fortune, Stewart, Yadav, & Hawton,
2007), and which are often not reliably recorded in clinical and prison
records of prisoners who have taken their own lives (Crighton, 2002;
Liebling, 1992). In addition, they may help to identify factors that
contribute to survival following a suicide attempt. With 30% of female
prisoners engaging in self-harm whilst in prison (Offender Management,
Sentencing Analytical Services [OMSAS] 2011), and 5% of female prisoners
having attempted suicide in custody in the past month (Borrill et al., 2003),
the significance of this approach and its implications for reducing the burden
placed on women’s prisons and their mental health services are clear.
Focusing on the subjective experience of individuals who have made
medically serious suicide attempts is especially important, given their
increased risk of suicide compared to other suicide attempters (Rosen,
1976).
 The Journal of Forensic Psychiatry & Psychology 865
With the exception of few studies focusing on narrow and confined
aspects of the suicidal process, mostly its triggers and motivations (see e.g.
Liebling & Krarup, 1993; Snow, 2002), to our knowledge there has been no
previous investigation of the suicidal process in prisoners, or indeed in
institutionalised populations more generally. In this study, we aimed at a
further understanding of the pathways leading to suicidal behaviour in
women prisoners by interviewing survivors of a near-lethal self-harm
incident using a mixed methods (qualitative and quantitative) approach.
While some studies of the suicidal process have examined events and
difficulties occurring over a long period, often many years (Fortune et al.,
2007; Runeson et al., 1996), we have focused on the period shortly before
and after the near-lethal self-harm. This is likely to help us understand more
about the nature and development of suicidal thinking in the prison context,
and its immediate consequences. Our specific objectives were to investigate
(a) the cognitive, affective and visual imagery processes preceding the near-
lethal act, (b) the circumstances surrounding the incident and (c) the
thoughts, feelings and experiences which followed it.

Method
Sample and selection criteria
Face-to-face interviews were conducted with 60 female prisoners over the
age of 18 years who had carried out near-lethal self-harm acts within the
previous month. Participants were selected from all 10 ‘closed’ female prison
establishments in England (‘open’ establishments, which have lesser security
levels and restrictions, have low rates of suicide and suicide attempts and
were therefore excluded from the study). Between November 2007 and
October 2008 each establishment was visited every four to six weeks to
identify prisoners who had been involved in an act which (a) could have
been lethal had it not been for intervention or chance and/or (b) involved
methods which are associated with a reasonably high chance of death.
Detailed criteria based on the method of self-harm used and its
consequences were developed to assist prison officers to refer suitable cases.
Suicidal intent was not a criterion, but was also assessed. All prisoners who
had carried out a near-lethal act within the past month were approached and
invited to participate. Twenty-six potentially suitable prisoners were
excluded from the study. See Marzano, Fazel, Rivlin and Hawton (2010)
for description of inclusion and exclusion criteria and the same publication
and Marzano, Rivlin, Fazel and Hawton (2009) for rationale.

Interviews
Interviews were carried out by the first author (LM) in a private room, with
prisoners’ written informed consent. They were audio-recorded and lasted
866 L. Marzano et al.
between 45 and 90 minutes. A semi-structured interview schedule was used
to gather information about the following.

History of self-harm and attempted suicide

Participants were asked whether they had previously self-harmed without
suicidal intent or attempted suicide (the distinction between self-harm and
attempted suicide was based on self-reported intent), in prison and outside.

Details of the near-lethal act

We gathered information about prisoners’ location at the time of their near-
lethal act and methods of self-harm. We also recorded whether participants
were deemed to be ‘at risk’ when the incident took place by asking whether
they were on ‘ACCT’ (Assessment, Care in Custody and Teamwork), a
procedure initiated in English and Welsh prisons when staff are concerned
that a prisoner may harm him/herself (following an initial assessment, an
individualised care plan is drawn up and reviewed regularly by a multi-
disciplinary team, and an ongoing record kept of significant events,
conversations and observations).

Suicidal intent
Prisoners’ suicidal intent at the time of the near-lethal self-harm was
assessed using the Beck Suicide Intent Scale (SIS), a 15-item measure of
severity of suicidal intent (Beck, Schuyler, & Herman, 1974). Scores range
from 0 to 30 and are based on the objective circumstances of the suicide
attempt or self-harm act concerned, as well as self-reported motivations and
expectations at the time of the incident. The SIS has been used previously in
prison-based studies (e.g. Dear, Thomson, & Hills, 2000; Lohner & Konrad,
2006).

Circumstances and psychological processes

Prisoners were asked about the circumstances surrounding their near-lethal
self-harm, including motivations, social influences and trigger events.
Further information was gathered regarding the cognitive, affective and
visual imagery processes that lead up to the self-harm, including
participants’ state of mind whilst planning or preparing for the act, the
precautions taken (if any) and their reasons for using a particular method of
self-harm. Questions about visual imagery were adapted from Holmes,
Crane, Fennell and Williams’ (2007) suicide imagery checklist.
Participants were also asked how they felt during their near-lethal act
and afterwards. In the final part of the interview, they were encouraged to
 The Journal of Forensic Psychiatry & Psychology 867
discuss the immediate and longer-term consequences of the incident, and
their thoughts about having survived it.

Thematic and content analyses

Interviews were taped, transcribed and anonymised. Transcripts were read
at least twice, summarised and major themes were recorded. Analysis of
prisoners’ accounts suggested that factors contributing to near-lethal self-
harm were seen to vary in importance. We therefore classified these as
‘primary’ (when described as underlying reasons for engaging in near-lethal
self-harm), ‘additional’ (when contributing to the self-harm, but of
secondary importance compared to primary factors), ‘triggering’ (events
and feelings said to have precipitated the act, often described as a ‘last
straw’, rather than an underlying reason) and ‘preventive’ (factors which
could have prevented their near-lethal self-harm). Within each category,
contributing and preventive factors were in turn classified as ‘prison-
related’, ‘psychiatric and psychological’, ‘adverse life events’ and ‘other’.
A coding frame was developed to facilitate coding of interview
transcripts using NVIVO (Version 8.0, Qualitative Solutions and Research
(QSR International), 2008). Final identification of themes was based on
consensus discussion between two members of the research team (LM and
AR). In the results, denominators for some variables vary because of
missing information, due partly to the semi-structured nature of much of the
interview, time restraints and disinclination to answer some questions.

Ethical approval
This study received ethical approval from the Central Office for Research
Ethics Committee (Ethics number 06/MRE12/83) and the Prison Service
(Reference PG 2006 063).

Results
Participants
The sociodemographic and criminological characteristics of the 60 prisoners
interviewed are presented in Table 1. Most participants were white, single
and under the age of 30 years. A third of the prisoners interviewed were on
remand (awaiting trial or sentencing) and over half were in prison for a
violent offence (including violence, robbery and sexual offences) (34, 57%).
Many of those who had been sentenced were serving a sentence of 18
months or more (33/39, 85%), including 12 prisoners (31%) on indetermi-
nate sentences.
Most participants were deemed to be at ‘risk’ at the time of their near-
lethal act in that 53 (88%) were on ‘ACCT’.
868 L. Marzano et al.
Table 1. Sociodemographic and criminological characteristics of female prisoners
who engaged in near-lethal self-harm (N ¼ 60) at the time of the act.

N (%)
Age, median (years) 25.5
White ethnicity vs. non-white 52 (87)
Singlea 40 (67)
Parent or guardian of children 31 (52)
Educational qualifications (any vs. none) 30 (50)
Unemployedb 36 (60)
Remand statusc 21 (35)
Less than 30 days since being imprisoned 11 (18)
Less than 30 days in current prison 13 (22)
Index offence
Violence 21 (35)
Sexual 1 (2)
Robbery 12 (20)
Burglary 5 (8)
Other theft 5 (8)
Fraud and forgery 0 (0)
Criminal damage 6 (10)
Drug offences 4 (7)
Other 6 (10)

Notes: aIncluding divorced, widowed and separated; bIncluding sick/disabled and housewives;
c
Including prisoners awaiting trial and sentencing (vs. sentenced prisoners).

History of self-harm and attempted suicide

The majority had previously self-harmed with no suicidal intent in prison
(37/59, 63%) and outside prison (39/59, 66%), and had a history of
attempted suicide, both outside prison (49/58, 85%) and in custody (49/
60, 82%). Prior to their near-lethal act, 50% of cases (n ¼ 30) had
attempted suicide in prison on five or more occasions, including 12
women (20%) who had been hospitalised or transferred to the prison’s
healthcare wing at least five times following a suicide attempt. Most had
also made repeated suicide attempts outside prison, with 41 (68%) having
done so at least twice.

The near-lethal self-harm acts

The following section reports prisoners’ accounts of the psychological
processes and external factors contributing to their near-lethal self-ham.
Section 1 deals with the circumstances and the cognitive, affective and
visual imagery processes immediately preceding the near-lethal acts,
section 2 with details of the incidents (including methods and locations
of self-harm), and section 3 with the thoughts, feelings and experiences
which followed them.
 The Journal of Forensic Psychiatry & Psychology 869

1. Before the near-lethal self-harm

Contributory factors. Primary factors in near-lethal self-harm: The factors
the prisoners reported to explain their near-fatal self-harm were often multiple
and varied (Table 2). Only four prisoners preferred not to discuss the reasons
behind their act (information about a further case was missing due to her
feeling unwell during the interview). Others described in detail the feelings and
events they perceived to have caused their act. In 23 cases (38%), these were
both prison-related and linked to personal and familial problems.
Amongst several prison-related reasons, problems with staff appeared to
be especially prevalent:

They [staff] are doing nothing at all [to help me], and they are being racists.
And they are doing nothing. I want to see the governor. They won’t allow me
to see the governor . . . I can’t do anything in here. I’ve had enough. I’ve really
had enough. (Case 17)

In some cases, problems with staff were linked to issues with the
administration of medication:

I’ve been on medication for my epilepsy and they stopped my tablets and like
75 mil of Valium, they stopped it . . . and I was pissed off because I couldn’t get
to see a doctor and I thought ‘oh fuck it, I’ve had enough’. (Case 59)

Arguments with other prisoners were also frequently mentioned as a

reason for having self-harmed:

I was just finding less and less to live for, you know. And I tried to make a bit
of an effort at Christmas but I was having problems with the girls. They were
just really controlling and manipulating, and it was really like playing head
games with me. And it was really damaging me. I was struggling obviously
over my knock back on parole anyway. (Case 10)

Eight prisoners (13%) also mentioned anxieties about sentencing, prison

transfers or being released:

I tried to commit suicide because I just couldn’t handle going through the
whole procedure of trials and . . . it’s horrible. (Case 53)

However, prison-related factors were seldom described as the only

factors behind prisoners’ self-harm. Indeed, 27 women (45%) reported
having self-harmed for reasons unrelated to their being in prison. Many
made direct associations between their near-lethal self-harm and previous
abuse, trauma and loss. Just over a quarter of cases were mourning the loss
of a loved one (in three cases (5%) by suicide, in six cases (10%) of their own
child), and said they had attempted suicide to end their pain or be reunited
with the person they had lost:
870 L. Marzano et al.
Table 2. Primary factors stated by women prisoners for their near-lethal self-harm.

N ¼ 60,
n (%)
Prison-related factors
Problems/fights with staff 9 (15)
Problems/fights with prisoners 8 (13)
Medication/detoxification issues 4 (7)
Anxieties surrounding trial and sentencing 3 (5)
Boredom and lack of purposeful activity 3 (5)
(time in cell perceived to be excessive)
Feeling let down/discriminated against by the system 3 (5)
Disappointment following parole board/sentencing 3 (5)
Anxieties around release 3 (5)
Fearing transfer to another prison/wing 2 (3)
Negative experience of prison (details undisclosed) 2 (3)
Being denied a shower (linked with 1 (2)
obsessive compulsive disorder)
Psychiatric and psychological factors
Feeling depressed/hopeless 16 (27)
Anger 7 (12)
Hearing voices 6 (10)
Frustration 6 (10)
Wanting to be at peace (temporarily or permanently) 6 (10)
Flashbacks of past trauma 5 (8)
Worthlessness 4 (7)
Guilt 2 (3)
Paranoia 2 (3)
Obsessive compulsive disorder 1 (2)
(and not being allowed to shower)
Adverse life events
Bereavement 16 (27)
Sexual abuse 11 (18)
Child/children being adopted 4 (7)
Arguments with/lack of contact from family 4 (7)
Close relative/partner ill or in difficulty 3 (5)
Serious illness/chronic pain 2 (3)
Relationship break-up 1 (2)
Serious money problems 1 (2)
Past trauma (details undisclosed) 1 (2)
Childhood bullying 1 (2)
Prisoner did not wish to discuss exact reasons 4 (7)
Poor memory of reasons 3 (5)
Missing data 1 (2)

Note: Percentage 4100 as some participants gave multiple responses.

I’d just had enough . . . I sat there and I thought ‘I might as well just die. And
get it over and done with and be with my [late] daughter where I want to be. In
peace’. (Case 6)
 The Journal of Forensic Psychiatry & Psychology 871
Almost a fifth of prisoners explained their near-lethal act in relation to
previous sexual abuse (in six cases (10%) when they were children), and
associated images, flashbacks, voices and negative feelings:

When I get flashbacks it kills me because I go back to feeling how I felt –

physically and emotionally. You know? I get the physical feelings of being
beaten or being [sexually] abused or whatever, and it just controls you, you
know. And sometimes that [suicide] is your only way out. You are so desperate
just to get that feeling away, that you feel that’s your only option. (Case 31)

Concerns about families and children, including difficulties in dealing

with a child or children being adopted, were also mentioned:

I’ve lost my kids and I was taking, I started taking heroin because of that . . .
and [when I came to prison and did not have heroin] for the first time it was
properly in my face. (Case 38)

Whilst some prisoners explained their near-lethal act in relation to

concrete events, such as bullying or having their medication taken away,
others reported having been primarily motivated by intense negative
emotions, particularly anger and frustration. Mental health problems were
also commonly cited, especially symptoms of depression and posttraumatic
stress disorder:
I was just hearing voices and I was really depressed. And I just wanted to kill
myself, so I tied a ligature and I don’t remember much else. (Case 22)

Triggers for near-lethal suicide self-harm: Most of the women prisoners

were able to identify one or more precipitating factors for their self-harm
(Table 3). These were for the most part events linked to their being in prison,
often involving an argument with prison staff or inmates:
I went to see the doctor last week and she just refused to help me in any way at
all. So I just came up, went to my room and thought fuck it. (Case 60)

Mental health problems, including flashbacks of abuse and hearing

voices, were also frequently mentioned as triggers for near-lethal self-harm:
It’s the voices in my head going on and on and on and on, even though I put
my music on they still kept going on and on. (Case 23)

Seven prisoners reported that their act had been triggered by distressing
news from outside prison, including finding out about their own or a
partner’s illness, and receiving news of a relative’s funeral.
Additional factors contributing to near-lethal self-harm: Other factors
prisoners said had contributed to, but not necessarily caused or triggered
the near-lethal acts were symptoms of drugs or medication withdrawal (6,
10%), missing family and friends outside prison (6, 10%), feeling upset
after a visit (1, 2%) and being disappointed at having to interrupt
872 L. Marzano et al.
Table 3. Triggers for near-lethal self-harm as stated by women prisoners.

N ¼ 60,
n (%)
Prison-related factors
Incident/argument involving staff 12 (20)
Incident/argument involving other prisoner/s 12 (20)
Prison transfer 4 (7)
Concerns surrounding trial, parole board or sentencing 4 (7)
Being denied medication 2 (3)
Lack of distractions whilst in cell 1 (2)
Missing family and friends outside prison 1 (2)
Cancelled visit 1 (2)
Having no tobacco 1 (2)
Increased opportunity (level of observations reduced) 1 (2)
Psychiatric and psychological factors
Hearing voices 6 (10)
Flashbacks/images 6 (10)
Feeling low/depressed 4 (7)
Build up of frustration/pressure 3 (5)
Adverse life events
Receiving bad news from outside prison 7 (12)
Pressures from family 1 (2)
Failure to receive letter from family 1 (2)
Significant anniversary 1 (2)
Other
Severe premenstrual tension 2 (3)
Counselling evoking difficult issues 1 (2)
Drug relapse 1 (2)
Incident not connected to a particular trigger 4 (7)
Prisoner did not wish to discuss exact triggers 2 (3)
Poor memory or understanding of triggers 2 (3)
Missing data 1 (2)

Note: Percentage 4100 as some participants gave multiple responses.

counselling due to being transferred to another prison (1, 2%).

Several spoke of finding imprisonment difficult (14, 23%), not least
because being bullied and exposed to violent offenders evoked memories
of their own abuse (2, 3%), and due to difficulties in dealing with
problems in prison without drugs or alcohol (5, 8%), or other coping
strategies (4, 7%).

Psychological processes immediately preceding the near-lethal self-harm

Feelings during planning and preparation: When asked about their
thoughts and feelings just before carrying out their act, around a fifth of
 The Journal of Forensic Psychiatry & Psychology 873
prisoners (12/57, 21%) said they were focused, often exclusively, on wanting
to die and ‘just doing it’:
[I was thinking] just do it. Just get it over and done with. (Case 14)
For five prisoners (8%), thinking about and planning their own death
mostly involved focussing on ‘logical things – just how to do it, and how not
to get caught doing it’ (Case 43), whereas for 12 others (20%) it meant
weighing up the benefits and the ‘what ifs’ of their act. These included being
reunited and ‘at peace’ with a lost loved one (5, 8%), escaping or putting a
stop to their problems (3, 5%), the thought of being ‘better off dead’ (2,
3%), as well as concerns linked with ‘being caught in time’ (2, 3%), and
family members ‘saying I was a coward’ (1, 2%):
It is quite emotional to prepare your own death.. . . It’s like what happens if I
don’t die and I become a cabbage? (Case 13)

The lead-up to the near-lethal self-harm was not invariably described as

stressful. Four prisoners (7%) described feeling ‘always happy and very at
peace before I try and do it’, and getting an ‘adrenaline rush’:
At first the thoughts scared me but after a few weeks I started feeling calm and
. . . it felt good that I wanted to kill myself. I really did want to die. (Case 57)

However, in prisoners’ accounts, self-harming in a near-fatal way was

not always constructed as a ‘choice’ or the result of a careful decision-
making process. In some cases, this was because no real thinking was said to
have preceded the act; in others, because the act itself was described as
something over which they had no control, or indeed as the only choice they
had (5, 8%):
I’m just, you know, hopeless that I must, I have to, my life has to end this way.
I’ve got no other choice. (Case 17)

Feeling hopeless and unable to cope appeared to be common

emotions just before carrying out the near-lethal act, with 14 prisoners
(23%) reporting that their predominant thought at the time was that ‘there
was no purpose to life’ and ‘no future’. In seven cases (12%), this was in
turn linked with feeling ‘useless, like a waste of space’, and thinking that
family and friends would be ‘better off without me’ and ‘nobody would
miss me’:
[I was thinking] I don’t want to be here; there’s no point in living . . . a lot to do
with my self-esteem . . . I feel just worthless, no purpose and what’s the point.
(Case 46)

In the lead-up to their near-lethal act, others spoke of feeling down and
upset (8, 13%), angry and frustrated (5, 8%), numb (1, 2%), having ‘had
enough’ (4, 7%) and, most of all, thinking about, and sometimes ruminating
874 L. Marzano et al.
over specific problems and difficulties (20, 33%), including ones involving
prison staff (5, 8%) and family members (3, 5%):
I sat there and I thought ‘well the outside system has let me down; now the
inside system is going to let me down. Why, why is it happening to me again? I
might as well just die’. (Case 6)

However, not all prisoners seemed able or willing to discuss how they felt
once they had decided to carry out their act. Four prisoners (7%) preferred
not to discuss this, and a further three said not to remember (2, 3%) or fully
understand (1, 2%) what was going through their mind at the time. Drawing
on a related theme, two participants (3%) described feeling confused at the
time of their act, and two more said their ‘mind was racing’. In contrast, five
prisoners (8%) felt unable to comment on their thoughts and feelings during
planning and preparation because their mind ‘was totally blank’ at the time;
their act had ‘just happened’:

I don’t know when I got up and did something to myself. It’s just like [clicking
her fingers] a thing that is not, I don’t have to sit down and think about ‘oh
yeah I’m going to hurt myself’. No, it’s just [clicking her fingers] a second of, I
mean you know, it just happened. It happens. (Case 42)

Mental imagery: Two-thirds of participants (37/56, 66%) reported

experiencing one or more mental images prior to their act, often for a
considerable proportion of the time (Table 4). Amongst different types of
images, those of past traumatic events were both the most frequently
reported and most often identified as most significant. Whilst images said to
have made participants feel safe or better were also reported, the majority of
prisoners described their most significant image as upsetting or very
upsetting (24/37, 65%), with only two participants (5%) rating them as not
at all upsetting.
Planning the self-harm: Just over a third of participants (22/56, 39%)
said they had contemplated their act for more than three hours, and only a
fifth (11/56, 20%) had made a detailed plan. Many prisoners described their
act as impulsive (28/56, 50%), even though suicidal thoughts had often been
present for a much longer period, sometimes ‘constantly’:
That day was impulsive but I was, yeah, I was thinking about it the days
leading up to it. (Case 57)

Where any planning had taken place, it had mostly involved taking
precautions against discovery, rather than contemplating strategies to secure
the means to self-harm (6/56, 11%), making final arrangements in
anticipations of death (11/56, 20%), or writing or thinking about writing
a letter (26/56, 46%).
Timing and other precautions against discovery: By far the most
commonly cited precaution taken by the prisoners was to ‘wait for the right
Table 4. Mental imagery during the period around the near-lethal self-harm as stated by women prisoners.

Most significant
Image was of the images
experienced – experienced –
N ¼ 56, n (%) N ¼ 56, n (%)
Image of/that
A real event that happened to you (e.g. a traumatic event but not suicide or self-harm) 27 (48) 14 (25)
The things you were escaping from by attempting suicide 19 (34) 1 (2)
Yourself planning/preparing to harm yourself or make a suicide attempt 18 (32) 2 (4)
What might happen to you if you died 17 (30) 3 (5)
A memory of a time you tried to harm yourself in the past 14 (25) 4 (7)
What might happen to other people if you died 12 (21) 4 (7)
Made you feel safe or better 9 (16) 1 (2)
Any other type? 12 (21) 3 (5)
A family member 4 (7)
Colours 1 (2)
Unspecified 7 (13)
No image reported 19 (34)
No image most significant 23 (41)

For those reporting images (N ¼ 37) Mean (95% CI) Median SD Range
How much of the time did you experience these images? (from 1 ¼ none of the time 6.6 (5.8–7.4) 7.0 2.4 7
to 9 ¼ all of the time)
How much time did you experience verbal thoughts about the same types of things? 4.5 (3.5–5.5) 5.0 2.9 8
(from 1 ¼ none of the time to 9 ¼ all of the time)
How upsetting was your most significant image? (from 1 ¼ not at all upsetting 7.2 (6.3–8.0) 8.0 2.6 8
The Journal of Forensic Psychiatry & Psychology

to 9 ¼ very upsetting)

Note: Percentage 4 100 as some participants gave multiple responses.

875
876 L. Marzano et al.
time’, when discovery might be less likely to occur (23/56, 41%). This
included waiting for staff to have done their ‘observations round’ before
self-harming or to be ‘checked’ at less regular intervals, reclassified as not
being ‘at-risk’ or moved from the healthcare centre to normal wing location.
In turn this could involve ‘making out that I was happy as Larry’ and
‘letting them think that I was alright’.
Waiting for a time when discovery would be unlikely, or less likely, was
also the most commonly cited reason for ‘delaying’ self-harm (when the act
had been contemplated for a period of hours or days). The majority of
prisoners (43/56, 77%) had carried out their act at a time when, in their
view, intervention was not likely or highly unlikely:
It’s difficult to do in here because you are on such high obs [observations] . . .
you’ve got to get a right slot. (Case 48)

Further precautions against discovery included pretending to be asleep,

covering the head when ligaturing, hiding out of view and playing loud
music to conceal any noise. In a minority of cases (12, 13%), more ‘active’
measures were also taken, such as barricading or jamming the cell door and
covering its viewing flap. Although this was seldom explicitly discussed as a
precaution, many prisoners also reported not disclosing their intention to
self-harm to avoid being ‘stopped’. Forty-five prisoners (75%) said they had
not communicated their intent to harm themselves, or discussed the
problems leading to their act, prior to their self-harm. It is notable that 11
prisoners (18%) said they had not spoken to anyone before their act because
they felt they had no one with whom they could speak or because the person
they would have confided in was not available at the time. In four cases
(7%), active attempts had been made to talk to someone but these had
failed. Of the 13 prisoners (22%) who had discussed their difficulties and/or
intentions before their act, eight (/13, 62%) described the response they had
received as unhelpful or dismissive.

2. Carrying out the near-lethal self-harm

Methods used: The majority of near-lethal incidents included in the study
involved hanging (28, 47%) or ligaturing (15, 25%), with nine involving
severe cuts and lacerations, seven overdoses, and one self-induced diabetic
coma (Figure 1). In five cases (8%), multiple methods were used.
Reasons for choosing methods used in self-harm: Forty-eight prisoners
(80%) spoke of their reasons for using a particular method in their attempts.
Of these, only five (10%) were unable to clearly explain their reasons for
their choice of method, citing feeling confused and using ‘anything that is
around, just for me to get peace of mind’. All others spoke of the method
they chose being the result of a rational decision-making process, albeit one
that was often constrained by limited choices and the necessity to go
 The Journal of Forensic Psychiatry & Psychology 877

Figure 1. Methods of near-lethal self-harm.

through a process of exclusion. Fifteen participants (/48, 31%) (of whom 13

had attempted hanging (10/48, 21%) or ligaturing (3/48, 6%)) said that the
method they employed was the only one available to them at the time of the
near-lethal act, at times adding that this was not necessarily their ‘preferred’
method or the one they would have used outside prison.
Twelve others (/48, 25%) explained that the method they used in their
attempts was chosen because of its potential lethality. Of these, only one
prisoner (2%) (who said she had not been suicidal at the time of her act)
reported having used the method she thought would be ‘the safest’
(cutting). All others spoke of having used the most lethal and ‘certain’
method, at least of the ones available to them at the time. In most cases,
hanging (6/48, 13%) and ligaturing (4/48, 8%) were the specific methods
being referred to:

[Hanging] is a more certain way to do it. Cut your wrists; if you don’t get deep
enough then that ain’t going to work. Plus if it doesn’t work people can see
what you’ve done it. And then I just thought if you hang yourself then it would
be pretty much instantaneous. (Case 32)

Even prisoners whose choice of self-harming method was not explicitly

motivated by concerns about lethality often said that the method used
exceeded or equalled what they considered to be lethal (41/56, 73%), and
thought it possible, probable or certain that they would die as a result of
their act (50/56, 89%). Other factors said to have motivated the choice of a
particular method were speed (4/48, 8%) and/or ease (4/48, 8%).
Suicidal intent: The mean SIS score was relatively high (18.9, SD ¼ 5.5).
Ninety-one per cent (51/56) of prisoners who had engaged in near-lethal self-
harm stated that they had carried out their act with the intent to die. Five
prisoners (8%) reported having self-harmed for temporary escape (4, 7%) or
to influence their environment (1, 2%). Of these, three (5%) said they had
not wanted to die, with five others (8%) having ambivalent feelings about
878 L. Marzano et al.
whether they lived or died (this included four prisoners (7%) who reported
they had originally intended to die, but had changed their mind soon after
carrying out their act).
Location: All but two incidents (97%) had taken place in the prisoners’
own cells, most of which were on normal wing location (47, 78%); eight
(13%) were on intensive residential units, four (7%) on segregation units
and one (2%) in a prison’s healthcare centre. Only two incidents (3%) took
place in the presence of a cell mate (both were overdose attempts), with all
other acts occurring in isolation.
Prisoners’ feelings during the near-lethal act: Just under half the
prisoners interviewed (28, 47%) spoke about their thoughts and feelings
whilst self-harming. A considerable proportion (14/28, 50%) described
positive thoughts and emotions, including a sense of calm (4/28, 14%),
release (at least initially) (3/38, 11%) and control (1/28, 4%), a ‘rush’ (2/28,
7%), a feeling of anticipation at being reunited with late family and friends
(2/28, 7%) and even happiness (1/28, 4%):
When you initially have it around your neck and your breathing goes, you
struggle for a bit but then if you just close your eyes and just, and knowing
that’s what you want . . . and then it just goes black; you get a rush, like a head
rush . . . it is probably one of the best feelings in the world. (Case 31)

A further four prisoners (/28, 14%) discussed having thought of their

families immediately after carrying out their act, which in three cases
resulted in them calling for help as they ‘could not put my family through
this’.
In contrast, four others (/28, 14%) spoke of being focused on their act
and the thought – in some cases hope – of their imminent death:
I was scared but I just wanted to go. I just kept thinking ‘no, any minute now’.
(Case 30)

Being scared was a relatively recurrent feeling, with eight prisoners (/28,
29%) speaking of their fear and shock as the severity of their self-harm
became apparent. Other prisoners reported that during their act they felt
angry and upset (2/28, 7%), emotionless and remorseless (1/28, 4%),
concerned about the welfare of the staff who would discover their body (1/
28, 4%), or like their ‘heart was pumping’ (1/28, 4%).

3. After the near-lethal self-harm

Discovery: Only eight prisoners (13%) had called for help following their
near-lethal suicide attempts. In many cases, the ‘discovery’ was said to have
happened shortly after the act, mostly during routine staff checks. In seven
cases (12%), intervention had been possible thanks to other prisoners
alerting staff to what had happened.
 The Journal of Forensic Psychiatry & Psychology 879
Three quarters of prisoners described anger, disappointment and
frustration at having been ‘found’ and not having ‘succeeded’ (38/51,
74%). It was not uncommon for these feelings to be directed at staff, in two
cases resulting in physical and/or verbal assaults:
I was angry, I was upset. I was angry that they’d cut me down in time; I was
upset because I’d allowed somebody to find me like that. (Case 1)

Consequences of the near-lethal self-harm: Only a quarter of prisoners

(11/45, 24%) said that their self-harm had in some way helped to alleviate
their problems, with some commenting that their situation had worsened
since their act. Amongst the positive consequences of the acts were: the
realisation of not wanting to repeat the act or leave their loved ones (5/45,
11%), staff listening and talking to them more (2/45, 4%), having more
attention from and communication with family members (2/45, 4%), being
given more medication (2/45, 4%), having learnt the importance of
discussing rather than acting on difficult feelings (1/45, 2%), a temporary
feeling of release (1/45, 2%), and knowing ‘how to do it next time’ (1/45,
2%). Adverse effects were more commonly reported and included: being
‘moved around’ the prison or transferred to another establishment (7/45,
16%), placed on more regular or constant observations (5/45, 11%) or in a
bare cell (3/45, 7%), being denied medication (2/45, 4%) or the opportunity
to join a therapeutic community (1/45, 2%) and realising the traumatising
effect of their self-harming behaviour on staff (2/45, 4%). Feeling
embarrassed about having self-harmed (1/45, 2%), angry at themselves for
having carried out the act or for being found (2/45, 4%) and worried about
the implications this may have for their sentence (1/45, 2%), were also
reported.
A fifth of participants (10/50, 20%) stated relief at having survived their
near-lethal act, and others said they felt better (if only slightly) than they did
at the time (7/50, 14%), or at least more ambivalent about wanting to die (5/
50, 10%). Nevertheless, the majority of participants thought it probable or
certain that they would attempt suicide again (37/54, 69%), with only a fifth
(12, 22%) saying they knew or hoped they would not do so, and five (9%)
being unsure.
Preventive factors: Twenty-five (42%) prisoners reported that the act
could not have been prevented, and three prisoners (5%) were unsure as to
whether anything or anyone might have prevented it. Amongst those who
described their self-harm as preventable, the most frequently mentioned
factor was being able to talk to someone (11, 18%), be they a particular
member of staff (3, 5%), a friend in prison (2, 3%), a relative or friend from
outside prison (2, 3%), a ‘prison listener’ (prisoners trained by the
Samaritans to listen in confidence to fellow prisoners in distress) (1, 2%),
or anyone available (3, 5%). Other factors that might have prevented their
behaviour were: being treated better by prison officers and healthcare staff
880 L. Marzano et al.
(especially in relation to the administration of medication) (5, 8%), not
being in prison (2, 3%), having more distractions and time out of cell (2,
3%) or reduced access to means to self-harm (1, 2%), being in a shared cell
(1, 2%), having received counselling (1, 2%), and more help with their
mental health problems (2, 3%).

Discussion
A mixed qualitative and quantitative approach was used to investigate the
circumstances and psychological processes involved in the near-lethal self-
harm acts of 60 female prisoners. The women in this study had high levels of
previous attempted suicide and self-harm, both inside and outside prison,
and most were multiple repeaters. In most cases, their high level of suicide
risk had been recognised by prison staff, as indicated by 88% of them being
on ‘ACCT’ at the time of the near-lethal self-harm.
Consistent with the notion of suicide as a ‘process’ (Buchanan, 1991),
we investigated the sequence of events, thoughts, feelings and images
leading up to the near-fatal acts. As we aimed to explore the nature and
development of suicidal thinking in the prison context, we focused on the
period shortly preceding the near-lethal self-harm. However, the results
indicate the extent to which the thoughts, attitudes and mental state of
prisoners are often related to traumatic experiences much earlier in their
lives. This supports a life-course model of the aetiology of suicidal
behaviour in which risk depends on cumulative exposure to social,
environmental, personality and mental health factors (Mann, Waternaux,
Haas, & Malone, 1999).
The primary self-reported reasons for carrying out suicidal acts were
various and often multiple. They included prison-related factors, especially
problems with prison staff or other prisoners, and the influence of events
and difficulties outside prison, especially bereavement and abuse. They were
also often related to some aspects of the prisoners’ mental state, reflecting
the high prevalence of psychiatric disorders found in female prisoners
engaging in non-lethal self-harming behaviour (Marzano et al., 2010;
Meltzer et al., 1999).
The triggers or precipitants for the near-lethal self-harm were typically
events in prison, especially interpersonal disputes, mental health phenomena
and distressing news from outside prison. Additional fairly common
contributory factors were difficulty in coping with being in prison,
withdrawal of drugs or medication and individuals missing their family
and friends outside prison.
Half the prisoners described their near-lethal act as impulsive. However,
this often occurred against a background of longer-term suicidal thoughts.
Much of the content of many of the prisoners’ thoughts once they had
decided on suicidal acts were often focused on wanting to die and avoiding
being caught. However, there was ambivalence in some, including thinking
 The Journal of Forensic Psychiatry & Psychology 881
that the act would fail. A sense of hopelessness often preceded the act,
including in some cases thoughts that other people would be better off if the
individual died. These phenomena are in keeping with Joiner’s theory that
the feeling of being a burden on loved ones is a major factor in suicide
(Joiner et al., 2002).
Some of the prisoners appeared unable to recall what they were thinking
and feeling before their suicide attempts. This may indicate a subgroup of
prisoners for whom prevention in terms of reaching out or encouraging
help-seeking may be particularly difficult.
Rarely has mental imagery been investigated in research of this kind.
Two-thirds of the prisoners described images preceding their self-harm,
which were often multiple experiences. These particularly involved images of
previous traumatic experiences, in keeping with the frequent experience of
abuse and violence in the histories of these women (Marzano, Hawton,
Rivlin, & Fazel, 2011). Other images related to the suicidal act and the
impact it might have on others, which is consistent with the notion of flash-
forward images associated with suicidal behaviour (Holmes et al., 2007).
The images were usually particularly upsetting. Such images may play an
important role in the genesis of suicidal behaviour, by intensifying
emotionality and increasing the likelihood of action (Holmes et al., 2007;
Libby, Shaeffer, Eibach, & Slemmer, 2007).
Many of the prisoners took care to avoid discovery, particularly not
disclosing their thoughts and plans, and by timing the act when intervention
was least likely. Some also took active steps to prevent other individuals
gaining access to their cell. Their self-harm methods reflected those most
readily available in prison, with hanging or ligaturing being particularly
common. These are methods with relatively high case fatality (Gunnell,
Bennewith, Hawton, Simkin, & Kapur, 2005). Three-quarters of the
prisoners described feeling angry when they realised they were going to
survive their suicide attempts, another indication of the high suicidal intent
usually involved.

Strengths and limitations of the study

We used a novel approach to study suicidal behaviour in prisoners
(Marzano et al., 2009). Our objective in using the near-lethal self-harm
methodology was to further understand the suicidal process in this high risk
population by going beyond what can be achieved through psychological
autopsy studies of completed suicides, in which access to psychological
processes is usually impossible (Hawton et al., 1998). Although self-report
data are susceptible to poor and distorted recall, it provides important
insights into the pathways to severe self-harm and possibly suicide.
Interviewing survivors of a near-lethal attempt shortly after the act about
the events immediately preceding and following it may have reduced the
likelihood of recall problems.
882 L. Marzano et al.
While we chose not to use suicidal intent as a criterion for inclusion of
prisoners in the study, the relatively high suicide intent scores of most of the
acts suggests that we achieved our aim of studying processes likely to lead up
to suicide. Also, our approach is in keeping with the criteria used for
identification of self-inflicted deaths by UK prison authorities (McHugh &
Towl, 1997), which are somewhat broader than those used by UK coroners.
The Prison Service in England and Wales uses the term ‘self-inflicted death’
to describe all apparent suicides, regardless of suicidal intent.
Although we collected data on prisoners’ history of self-harm and
attempted suicide, it was not possible to investigate in depth the trajectory of
participants’ suicidal behaviour over their lifespan, mostly due to time
constraints. Further research is warranted in this area, and may help to
better understand the differences and similarities between suicidal behaviour
in prison and other settings, and the link between past and future suicidal
behaviour (Joiner, 2002).

Implications
The results of this study underscore the considerable therapeutic needs
many of these women have in terms of addressing their early experiences
of abuse and violence (Marzano et al., 2011). Further research could chart
the range, use and effectiveness of interventions available to women
prisoners, and randomised control trials for the treatment of depression
and posttraumatic stress disorder (PTSD) may be warranted. There is
encouraging evidence from hospital and community based studies of the
effectiveness of psychological treatments in tackling the cognitive and
imagery processes that may be involved in suicidal behaviour (Bisson
et al., 2007; Cuijpers, van Straten, Warmerdam, & Andersson, 2008;
Holmes et al., 2007). However, the extent to which these interventions may
lend themselves to use in a prison setting, and the resource implications,
require some consideration. Also, as several other contributory factors
were prison related, disposals for alternative places to prison should be
considered, especially locations where appropriate psychological therapy
can be provided.
While the apparent impulsivity of many of the acts might suggest that
preventive interventions are difficult, many reported long-term suicidal
thoughts and most had been identified as at risk. At a practical level, checks
on prisoners are often carried out on a predictable time schedule. Varying
the schedule might help detect some prisoners engaging or just prior to
engaging in self-harm. Attention to availability of means for suicidal acts is
essential, especially clothing and bedding that might be used for hanging or
ligaturing. Finally, increasing the availability of people with whom prisoners
can discuss their problems and confide in is likely to reduce suicide risk
(Borrill, Snow, Medlicott, Teers, & Paton, 2005).
 The Journal of Forensic Psychiatry & Psychology 883

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