The Journal of Forensic Psychiatry & Psychology

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Self-harm among UK female prisoners: a cross-

sectional study

Birgit A. Völlm & Mairead C. Dolan

To cite this article: Birgit A. Völlm & Mairead C. Dolan (2009) Self-harm among UK female
prisoners: a cross-sectional study, The Journal of Forensic Psychiatry & Psychology, 20:5,
741-751, DOI: 10.1080/14789940903174030

To link to this article: https://doi.org/10.1080/14789940903174030

Published online: 18 Sep 2009.

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The Journal of Forensic Psychiatry & Psychology
Vol. 20, No. 5, October 2009, 741–751

RESEARCH ARTICLE
Self-harm among UK female prisoners: a cross-sectional study
Birgit A. Völlma* and Mairead C. Dolanb
a
Department of Forensic Mental Health, University of Nottingham, Nottingham, UK;
b
Monash University, Victoria, Australia
(Received 25 July 2005; final version received 18 December 2008)

Psychiatric morbidity and suicide rates in prisoners are high. The

detection of mental illness and its associated risks in prison are low. The
aim of this study was to ascertain the prevalence of psychiatric
symptomatology, needs and self-harming behaviour among UK female
prisoners and to identify differences between individuals with and
without a history of self-harm. We conducted a cross-sectional study
including 638 female prisoners from two prisons in the North-West of
England. Outcome measures used were the Prison Screening Ques-
tionnaire (PriSnQuest), a questionnaire on self-harming behaviour and
suicidal ideation and the Camberwell Assessment of Need – Forensic
Version (CANFOR). 241 women (37.8%) screened positive on the
PriSnQuest; 281 women (45.9%) had a history of self-harm. An average
of 8.5 needs was identified with more than half of those needs classified
as unmet. Differences between women with and without history of self-
harm were identified on offending history, PriSnQuest scores and the
CANFOR total and unmet needs. Previous contact with a psychiatrist,
total and symptoms of depression on the PriSnQuest were independently
associated with a history of self-harm. This study confirmed that the
prevalence of psychiatric symptomatology and self-harm in female UK
prisoners is high. Individuals at risk of self-harming behaviour may be
identified using screening questionnaires.
Keywords: prison; female; self-harm; mental health; CANFOR;
screening

Introduction
The high prevalence of psychiatric morbidity in prisoners is well established.
In a recent systematic review including 22,790 prisoners from 62 surveys in
12 countries, Fazel and Danesh (2002) reported a six-month prevalence of
3.7% for psychosis, 10% for major depression and 65% for personality
disorders. Axis I disorders in women were even more prevalent with 4% for
psychosis and 12% for major depression while personality disorders were

*Corresponding author. Email: birgit.vollm@nottingham.ac.uk

ISSN 1478-9949 print/ISSN 1478-9957 online

Ó 2009 Taylor & Francis
DOI: 10.1080/14789940903174030
http://www.informaworld.com
742 B.A. Völlm and M.C. Dolan
less common (42%). The prevalence of alcohol and substance abuse and
dependence has also been shown to be high in prison samples. Differences
between prisoners and the general population appear to be particularly
marked for women with a two- to four-fold excess in alcohol dependence
and at least a 13-fold increase in drug dependence (Fazel, Bains, & Doll,
2006). Some authors have observed a rise in the prevalence of psychiatric
morbidity in prisoners over time (e.g., Gunn, 2000). Nevertheless, the
detection of psychiatric morbidity and its associated risks by prison staff
remain poor (Blaauw, Roesch, & Kerkhof, 2000).
Suicide in prisoners is a major concern. A study by Fazel, Benning,
and Danesh (2005) has identified increasing numbers of suicides in
England and Wales from 1978 to 2003 with a five-fold excess of suicides
in prisoners compared to the general population. After a decline in
suicide numbers in 2005 and 2006, self-inflicted death figures in prisons
increased again in 2007 with 92 suicides in total, including eight women
(compared to three in 2006). Lohner and Konrad (2007) reviewed the
literature on self-injurious behaviour in prisoners in order to identify risk
factors for such behaviour. Findings were heterogeneous, often with a
similar number of studies confirming and contradicting a particular risk
factor. The authors attributed this inconsistency to different definitions of
the self-harm.
Identifying those prisoners at risk of self-harm or suicide is of utmost
importance in order to deliver appropriate interventions to prevent such
outcome. This study aimed to describe the prevalence of psychopathology,
self-harming behaviour and needs in women prisoners in two prisons in the
North-West. Furthermore, we sought to identify associations between
socio-demographic and psychopathological variables and self-harming
behaviour.

Methods
Setting and participants
Three prisons housing adult women were identified in the North-West of
England. The management of one prison declined participation in the study.
Prisons included therefore were HMP Styal and HMP Buckley Hall. HMP
Styal accepts adult female remand and sentenced prisoners. HMP Buckley
Hall is a privately managed Category C prison that operated as a closed
female training prison between April 2002 and December 2005 but currently
only accepts male sentenced prisoners.
Study participants were women over the age of 18 years residing in these
two institutions on a given census date. For HMP Styal, there were two
census dates, 3 December 2001 for sentenced women and 17 December 2001
for women on remand. Over the two census dates, 426 women were resident
at HMP Styal of whom 399 were approached to participate in the study;
 The Journal of Forensic Psychiatry & Psychology 743
27 women had left the prison before they could be approached. 376 (94.2%)
women consented to participate in an initial screening interview (see below).
At HMP Buckley Hall, 302 women were resident on the census date, 26
November 2003. Of those, 20 declined participation, 17 had left the prison
before being approached and three women had already completed the screen
at HMP Styal. Therefore, 262 women were included in the screening
interview.

Assessment instruments
Socio-demographic details collected from participants and/or case notes
included: age, status, current charge and length of sentence. For status,
prisoners were dichotomised into those who had been convicted (including
those awaiting sentencing) and remanded prisoners. For current charge, the
offence leading to the current period of imprisonment was recorded using
seven categories: homicide or attempted homicide, including conspiracy to
commit murder; other violent offences including threats of violence; arson;
acquisitive offences; breach offences; drug-related offences and miscella-
neous offences.
The Prison Screening Questionnaire (PriSnQuest; Shaw, Tomenson, &
Creed, 2003) was used to identify mental health problems. The PriSnQuest
consists of eight questions; four are designed to identify depressive
symptoms, three to identify symptoms of psychosis and one question
inquires about previous psychiatric contact. A cut-off of three or more
questions was used to indicate a positive mental health screening.
The questionnaire on suicidal intent and self-harm (adapted from
Singleton, Meltzer, Gatward, Coid, & Deasy, 1998) consisted of questions
about thoughts of suicide and self-harm, actual suicidal attempts and acts of
self-harm, methods of self-harm and timing of these thoughts and
behaviours.
The Camberwell Assessment of Need-Forensic Version (CANFOR;
Thomas et al., 2003) was implemented for use in those women who screened
positive on the PriSnQuest. This tool consists of 20 questions around
current met and unmet needs in relation to the present setting.
Interviews took 10 to 30 minutes.

Statistical analysis
Analysis was conducted using SPSS 15.0. Descriptive statistics were
performed using frequencies, proportions or means as appropriate. Two
sample t-tests and w2 tests were used to identify differences between
individuals by history of self-harm or suicide attempts. Backward logistic
regression was conducted entering all variables with a statistically significant
difference in this comparison in the model.
744 B.A. Völlm and M.C. Dolan

Results
Sample characteristics
Six hundred and thirty-eight women were included in the study. The mean
age of women was 30 years (range 18–68). Five hundred and fifty-two
(86.5%) were convicted while the remainder were on remand. Of those
women for whom this information was available (603), 45 (7.5%) were
charged with homicide or attempted homicide (including conspiracy to
commit murder), 133 (22.1%) with other violent offences, 15 (2.5%) with
arson, 156 (25.9%) with acquisitive offences, 28 (4.6%) with breach offences,
168 (27.9%) with drug-related offences and 58 (9.6%) with other offences.

Prison Screening Questionnaire

Of the 638 women screened, one-third (32.4%) reported they had previously
seen a psychiatrist. Six hundred and four (94.7%) reported at least one
symptom of depressed mood, 163 (25.5%) screened positive on at least one
question on psychosis. Two hundred and forty-one (37.8%) of the women
screened positive on the PriSnQuest based on a cut-off of three questions
and 363 (56.9%) had answered ‘yes’ to two or more questions.

Prevalence of self-harm and suicidal ideation

Table 1 shows the frequency of suicidal thoughts and behaviour in the
women screened. Over 40% of prisoners had felt their life was not worth
living, had wished they were dead or had thoughts about taking their life at
some point in their life, for about 10% of women this was the case in the
week preceding the interview.
About 45.9% (281 women) had ever self-harmed or attempted suicide,
some recently. Many women had engaged in self-harm without suicidal
intent and had made a suicide attempt, but 55 women had deliberately self-
harm only (without intent of killing themselves) and 105 had tried to take
their own life but not ever self-harmed without suicidal intent.
Of those who had ever harmed themselves or made a suicide attempt,
just over half (54.1%) did so before coming to prison. The majority of
women (75%) used cutting as method of self-harm and reported they did
this to relieve unpleasant feelings of anger, tension, anxiety or depression
rather than to attract attention.
Two hundred and nineteen (28.1%) women had been on a Form
2052SH1 during their current imprisonment and for 48 women (7.8%) this
procedure was active at the time of interview. Of those women who had self-
harmed or had made a suicide attempt in the past month (60), 26 (43.3%)
were on an open Form 2052SH, of those who had shown such behaviour in
the past week (32), the percentage was 71.9%.
 The Journal of Forensic Psychiatry & Psychology 745
Table 1. Frequency of suicidal thoughts and behaviour.

Thoughts and behaviours Yes, ever* Yes, within the last week
Ever thought life was not worth living 290 (46.6%) 84 (13.2%)
Ever wished they were dead 280 (44.0%) 80 (12.6%)
Ever thought of taking own life 259 (40.9%) 62 (9.8%)
Suicide attempt 220 (34.6%) 12 (1.9%)
Self-harm without suicidal intent 171 (27.9%) 28 (4.4%)

Note: *Total numbers vary from 613 to 636.

Needs assessment
A high number of needs were identified in those women for whom
CANFOR data were available (250). On average 8.5 needs were identified
(range 2–16); a mean of 4.6 needs were classified as unmet (range 0–14). The
largest areas of need were psychological distress, daytime activities,
treatment and information about treatment. The largest unmet need was
for psychological distress which was rated as unmet by over half of the
women.

Associations with self-harming behaviour

Associations between socio-demographic and clinical variables and self-
harming behaviour were explored by comparing those women who had ever
self-harmed or attempted suicide (281) with those without such history (331)
on a number of variables (see Table 2). No significant differences were found
in conviction status or length of sentence; age approached significance
(p ¼ .08) with those women with a relevant history being slightly younger.
Differences were also found in offending history ( p 5 .001) with those with
a history of self-harm or attempted suicide being overrepresented in
prisoners with a history of violent offences (56.3% of women within this
offence category had self-harmed), homicide or attempted homicide (58.1%)
and arson (86.7%).
Significant associations were found for previous psychiatric contact
(p 5 .001), for all individual items of the PriSnQuest, rates of positive
screens using two or three as cut-off (p 5 .001 for all of these comparisons),
total number of items screening positive on the questionnaire (3.5 vs 1.7;
p 5 .001), total number of items of depression (2.2 vs 1.3; p 5 .001) and
total number of items of psychosis (0.8 vs 0.2; p 5 .001). Furthermore,
those women with a history of self-harm or suicide attempts had
significantly more total (8.9 vs 7.3; p 5 .001) and unmet (4.9 vs 3.5;
p 5 .002) needs on the CANFOR and were more likely to have ever been
on a Form 2052SH ( p 5 .001).
746 B.A. Völlm and M.C. Dolan
Table 2. Socio-demographic and risk factors in prisoners with and without history
of self-harm or attempted suicide.

Prisoners with Prisoners without

Variable self-harm (n ¼ 281)* self-harm (n ¼ 331)
Age (mean) 29.0 30.7
Conviction status
Remand n (%) 39 (13.9) 41 (12.4)
Sentenced n (%) 242 (86.1) 290 (87.6)
Current charge n (%)
homicide** 25 (9.5) 18 (5.7)
other violence 72 (27.3) 56 (17.7)
arson 13 (4.9) 2 (0.6)
acquisitive 65 (24.6) 87 (27.6)
breach 9 (3.4) 17 (5.4)
drug-related 55 (20.8) 106 (33.7)
miscellaneous 25 (9.5) 29 (9.2)
Length of sentence (mean in months) 66.5 56.9
PriSnQuest positive n (%)
cut-off three 178 (63.3) 58 (17.5)
cut-off two 225 (80.1) 128 (38.7)
PriSnQuest (mean)
total positive items 3.5 1.7
depression items 2.2 1.3
psychosis items 0.8 0.2
CANFOR needs (mean)
total 8.9 7.3
unmet 4.9 3.5
Previously seen by psychiatrist n (%)
yes 145 (51.6) 59 (17.8)
no 136 (48.4) 272 (82.2)
Form 2052SH ever n (%)
yes 166 (60.4) 49 (15.5)
no 109 (39.6) 268 (84.5)

Note: *Due to missing items actual n might be lower for some variables; **Including attempted
homicide and conspiracy to commit murder.

Logistic regression model

All variables for which significant group differences were observed, were
entered in a backward logistic regression model. The following variables
were independently associated with a history of self-harm or attempted
suicide: previous contact with psychiatrist ( p 5 .001; b ¼ 71.108), total
symptoms on PriSnQuest (p 5 .001; b ¼ .787), symptom ‘taking longer
over things than usual’ (p ¼ .04; b ¼ 70.654) and symptom ‘recently
wished they were dead’ (p 5 .001: b ¼ 71.263). The rate for predicting
status of self-harm/attempted suicide of the final model was 74.5%.
 The Journal of Forensic Psychiatry & Psychology 747

Discussion
In this cross-sectional study of female prisoners, we found high prevalence
rates of previous psychiatric contact and current psychopathology,
particularly symptoms of depression. Nearly half of the women had a
history of self-harm or suicide attempts and for about half of those the onset
of these behaviours post-dated their imprisonment. Women with a history of
self-harm had significantly higher rates of violent offending, psychopathol-
ogy and needs, but a large proportion of self-harming prisoners had not
been identified by the prison service’s risk assessment procedures.
Strengths of this study are the large sample size and high consent rates. It
is to our knowledge the first study to look at psychopathology, self-harm
and needs within the same sample in a female UK prison population.
In order to obtain a large sample of consenting women, assessments had
to be brief. Consequently, we were not able to conduct structured interviews
to provide psychiatric diagnoses, including assessment of personality
factors, or obtain independent verification of the information given by the
women on their mental health. Although this appears to be a weakness, one
should bear in mind that, considering the limited resources within the prison
system, the use of comprehensive assessment instruments would not be
feasible in day-to-day practise. The use of brief, easy to administer tools
could therefore be seen as an advantage as it potentially allows their
introduction into routine care. However, the brevity of the assessment
procedure in this study precluded a more detailed assessment of potentially
informative parameters, such as precipitants and circumstances of self-harm
and suicidality and details of current treatment.
Previous UK studies looking at the mental health of prisoners have
found high rates of psychiatric disorders, ranging from 10% to 30% for
serious mental illness using established diagnostic instruments (Birmingham,
Mason, & Grubin, 1991; Brooke, Mason, & Grubin, 1996; Fazel & Danesh,
2002; Gunn, Maden, & Swinton, 1991; Gunn, Robertson, Dell, & Way,
1978; Singleton et al., 1998). Few studies have specifically focussed on
female prisoners. Parsons, Walker, and Grubin (2001) found that 59% of
remand woman prisoners had at least one mental disorder with 11%
suffering psychotic symptoms. The authors noted that reception screening
did not identify the majority of these cases. Lower rates, particularly for
severe mental illness, had been reported by Maden, Swinton, and Gunn
(1994) in sentenced prisoners. Studies including both genders have reported
higher rates of psychiatric morbidity in women compared to men (Fazel &
Danesh, 2002). Fazel et al. (2006) commented specifically on the
disproportionately high rate of substance abuse in women which has been
found to be a risk factor for completed suicide in prison. Our study assessed
symptomatology using a brief check list as reported by Shaw et al. (2003) for
use in Magistrates’ Courts rather than more elaborate diagnostic schedules.
748 B.A. Völlm and M.C. Dolan
Shaw et al. (2003) reported good sensitivity and specificity of this instrument
in their sample, detecting the majority of cases with serious affective or
psychotic illness; however, their study did not investigate associations with
self-harming behaviours.
Studies on completed suicides in prisoners have identified a three- to ten-
fold increase compared to the general population (Crighton & Towl, 1997;
Dooley, 1990; Topp, 1979). More recent reports (Konrad et al., 2007; Shaw,
Baker, Hunt, Moloney, & Appleby, 2004) suggest that age-standardised
rates for suicide in female prisoners are higher than for their male
counterparts and that the difference to suicide rates in the general
population is also more prominent in women. In our study, a large
proportion of women, nearly half of the sample, reported a history of self-
harm or suicide attempts. Given the association between suicide attempts
and completed suicide (Hawton et al., 1998), one has to assume that the risk
of suicide in this sample was also high. Power and Moodie (1997), in a
Scottish mixed gender prison sample, found that just over 1% of their
sample openly talked about suicide on reception and about 0.5% did so at a
later time during their imprisonment. Shaw et al. (2004) reported that 16%
of prisoners who later committed suicide had disclosed thoughts of self-
harm or suicide at the reception screening. The lower figures in these studies
may reflect a reluctance of prisoners to disclose such thoughts to prison staff
and the different gender composition of the samples. Furthermore, Power
and Moodie (1997) focussed specifically on suicidal thoughts rather than
any self-harming behaviour. Other studies (Dooley, 1990; Power & Moodie,
1997; Singleton et al., 1998) using the broader concept of self-harm have
found similarly high figures as our study with some suggestion of higher
rates of such behaviours in women compared to men.
Of particular concern in our study was the large number of prisoners
who only started self-harming following imprisonment, possibly indicating
difficulties in adjusting to prison life. Shaw et al. (2004), in a sample of
prison suicides in men and women, found that only just over half of the
prisoners who eventually committed suicide had a previous history of self-
harm. This suggests that additional indicators have to be taken into account
in order to identify those at risk of suicide.
Our study showed that a higher percentage of women with than without
a history of self-harming behaviour were on an ‘open’ Form 2052SH. While
this is encouraging, it is also of note that nearly 30% of women with self-
harming or suicidal behaviour in the previous week were not identified by
this procedure. Furthermore, Shaw et al. (2004) reported that a quarter of
suicide completers were on an ‘open’ F2052SH at the time of death,
suggesting short falls in this procedure even if individuals were identified as
at risk.
Age, being on remand, recent incarceration, long sentence, foreign
nationality, violent offending, history of substance abuse, use of
 The Journal of Forensic Psychiatry & Psychology 749
psychotropic medication, psychiatric history and morbidity and history of
suicidality have been identified as risk factors for completed suicide in
prisoners (Daniel, 2006; Fruehwald, Matschnig, Koenig, Bauer, & Frottier,
2004; Lohner & Konrad, 2007; Topp, 1979; Way, Miraglia, Sawyer, Berr, &
Eddy, 2005). However, none of these studies have specifically focussed on
women and few have investigated self-harming or suicidal behaviour as
opposed to completed suicide or have compared those with such behaviour
to those without. We found a trend for age with those women of a younger
age being more at risk of self-harming behaviour; a similar effect has been
described in the general population (Schmidtke et al., 1996). Our results
further suggest that index offences involving violence or arson are risk
factors for self-harming or suicidal behaviour. Impulsivity might be the
common factor in these behaviours but this would need further investiga-
tion. We found higher rates of psychiatric symptomatology and previous
psychiatric contact in women with a history of self-harming behaviour
compared to those without such history. Our results further suggest that
depressive symptomatology is particularly pertinent in this respect as our
logistic regression model did not show any independent effect of psychotic
phenomena.
We are not aware of any research looking at met and unmet needs in
prisoners. Brooke et al. (1996) have specifically explored treatment needs
reporting 55% of their male samples were in need of some form of
psychiatric treatment. Studies using the CANFOR in non-prison population
samples suggest considerable lower levels of needs than in our population;
for example, mean needs of 6.8, of which 2.2 were unmet, have been
reported in a high-security sample (Leese et al., 2006) although data are not
reported by gender. This suggests that female prisoners may present a
similarly or even more complex patient group compared to those in
forensic-psychiatric hospitals; yet the level of input they receive is
considerably less.

Conclusions
Our results suggest that female prisoners are characterised by significant
psychopathology, high levels of self-harming behaviour and risk as well as
a high levels of complex needs. While historical factors associated with risk
of self-harm cannot be changed, psychopathological indicators can and
should be targeted in order to reduce the risk of the most vulnerable
prisoners. Our study suggests that simple check lists may be useful to
identify those at risk of self-harm. However, this risk is not static;
therefore risk assessment has to be a continuous process and should not be
restricted to reception screening. Even those with no previous history of
self-harm may develop such behaviour during their incarceration. Given
the high levels of disturbance and need in this population, it is unlikely
750 B.A. Völlm and M.C. Dolan
that any significant impact is going to be made without the allocation of
additional resources. Future research should focus on the characteristics
and precipitants of self-harming behaviour in order to increase our
understanding of those indicators not readily identified by current
screening procedures.

Note
1. A prison service form which was filled out for regular monitoring when an
individual was deemed to be at risk of suicide. This has since been replaced by
the ACCT (Assessment and Care in Custody Teamwork) form.

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