Managing Self Harm by Standardizing the Definition, Tracking its ...

Managing Self Harm by Standardizingthe Definition, Tracking itsPrevalence, and Using a BehavioralPlanMHM Services, Inc.Carole Seegert, Ph.D.Senior Clinical DirectorJim DeGroot, Ph.D. Marina Cadreche, Psy.D Sharen Barboza, Ph.D.Director of Mental Health Director of Mental Health Director Clinical OperationsGeorgia Dept. of Corrections Tennessee Dept. of Corrections MHM Services, Inc.

Learning ObjectivesParticipants will:1. Perceive self-injurious behavior as one of themost demanding challenged facing mentalhealth.2. Compare your own system’s definition,surveillance, and management o delf-injuriousbehavior to other state DOCs.3. Collaborate with the other participants indefining self-injurious behavior, developingsurveillance tools, and sharing effectivetreatment/management strategies.

AgendaI. Introduction (5 minutes)II. Definition (15 minutes)• Core Elements• Surveillance• PrevalenceIII. Management• Georgia (15 minutes)• Tennessee (15 minutes)• MHM (30 minutes)IV. Collaboration (10 minutes)

I. Introduction:‣The Magnitude of the SIB Issue‣Underlying Assumptions‣Next Steps: The Goal of this Seminar

The Big QuestionWhy is self-injuriousbehavior (SIB) aproblem in correctionalsettings when itsbase-rate is apparentlyso low?

Major Research StudiesAppelbaum, Kenneth L., et. al., A National Survey of SIB inAmerican Prisons: Psychiatric Services: Vol. 62 No. 3,285-290, March 2011.Fagan, Thomas J., etc. al., Self-Injurious Behavior in CorrectionalSettings: Journal of Correctional Health Care: 16(1) 48-66,2010.Nock, Matthew K. Why Do People Hurt Themselves?: CurrentDirections in Psychological Science: Volume 18, November 2,2009.Smith, Hayden P., et. al., Self-Injurious Behavior in State Prisons:Findings from a National Survey: Criminal Justice andBehavior: Vol. 38 No. 1, February 15, 2011.

The Magnitude of the SIB IssueIt’s one of mental health’s most challengingproblems because:1.It’s a public health and a public safety problem.2.It’s an interdisciplinary problem.3.It’s a problem that’s poorly understood andmanaged.4.It’s a complicated problem made controversialby intense emotions, agency politics, and adearth of scientific research.

Underlying Assumptions‣We have the technology to prevent and reducethe prevalence of SIB in corrections.‣We have a responsibility to ensure public safetyand public health by collaboratively defining,tracking, treating, and managing SIB.

Next Steps: The Goal of this SeminarCollaboratively develop a position paper on thecore elements which define SIB in order to assistDOCs develop SIB Classification Systems, anomenclature, policies, procedures, directives,surveillance tools, risk assessment tools,prevention programs, and managementstrategies.Share best practices in managing SIB.

II. Definitions‣Core Elements‣Surveillance‣Prevalence

Definitions of SIBCore Elements:‣Motivation‣Intention‣Severity‣Method‣Lethality

Definitions of SIBMotivation:‣Unconscious/Conscious‣Antecedents/Consequences

Definitions of SIBConscious Intent:‣Intent to die‣Intent to regulate the environment‣Intent to regulate emotions‣Intent to obey command hallucinations/delusions

Definitions of SIBSeverity:‣Superficial/Mild‣Moderate‣Severe

Definitions of SIBMethod:‣Scratching‣Cutting‣Opening Wounds‣Swallowing‣Hanging‣Inserting‣Banging‣Amputating‣Castrating‣Enuculating‣Piercing‣Tattooing‣Hunger Strike‣Medication Non-Compliance

Definitions of SIB Lethality• Low• Moderate• High

Surveillance of SIB‣Tracking‣Training‣Auditing

Prevalence of SIB‣Massachusetts‣Wisconsin‣Georgia‣Tennessee‣National

Prevalence of SIBMassachusetts (Prison + Bridgewater State Hospital)‣2008• SIB – Total = 440• Suicide attempts = 69 (1 completed suicide)‣2009• SIB – Total = 711• Suicide attempts = 75 (5 completed suicides)‣2010 (through June 1)• SIB – Total = 262• Suicide attempts = 42 (8 completed suicides)

Prevalence of SIBWisconsin (2009)• 1366 total placements in observation cells• Of these, 316 were for SIB• Cut 119• Overdose/ingestion 57• Hanging/ligature 46• Head banging 45• Making a noose 23• Refusing food/fluids 9• Cut throat 6• Inserting foreign object 6• Jumping 5

Prevalence of SIBGeorgiaNumber of Incidents

Prevalence of SIBGeorgia

Prevalence of SIBTennessee

Prevalence of SIBTennessee (2011)• Cut 65• Overdose/ingestion 15• Hanging/ligature 19• Head banging 5• Making a noose 2• Cut throat 4• Inserting foreign object 22• Jumping 1• Miscellaneous 8

Prevalence of SIBNational:‣Data – Literature• A national survey of SIB in American Prisons(March 2011)• 50% of female inmates have a SIB history• 75% of DOC SIB is cutting• 50% of SIB occurs in restricted housing• < 2% of inmates in 2009 self-injured• SIB Frequency:• 5 of 39 less than once a month• 29 of 39 at least once a week• 5 of 39 more than once a day

III. Management of SIB‣Georgia‣Tennessee‣Research

Management of SIB• Georgia:Carole Seegert

Management of SIB• GeorgiaSuicide Precautions 2SP2• For severe risk of suicide or life-threatening selfinjury• Protective approach – short-term until risk decreases• Requires placement in crisis cell (ACU/CSU) andproperty restriction

Management of SIB• GeorgiaSuicide Precautions 1SP1For moderate risk of suicide or serious self-injury.May be initial status of step-down from SP2No housing changeTherapeutic approachRequires twice-weekly treatment contacts from MH staff(Phd/MD/AT/MHC)Chronic self-injurers may require ongoing SP1 statusImportance and power of therapeutic relationship

Management of SIB• GeorgiaModel of SP1 Treatment Program: Valdosta State PrisonSP1 group run by Psychologist and Mental Health counselorOngoing, twice-weekly sessionsOne process-oriented (psychologist)One psycho-educational ((Mental Health counselor)MHM’s Hoping and Coping module

Management of SIB• GeorgiaInitial Data3/2011 – 3/2012Inmates treated in SP1 group = 49 with history of selfinjury/threatsGraduates = 17Participants requiring SP2 while in group = 10Inmates placed on SP2 since graduation = 2

Management of SIB• TennesseeMarina Cadreche

Management of SIB• ResearchSharen Barboza

Management of SIBResearch:‣The Pitfalls‣The Solution‣The Question‣The Results‣The Implications

Management of SIBThe Pitfalls: Responses that Don’t Work

Management of SIB‣Heroic, desperate psychiatric efforts‣Verbal therapy‣Mental Health / Suicide Watches‣Fire Fighter Work‣Punishment‣Evidence Base?

Management of SIBThrow the Inmate Over the Wall– “Not my job!”– “You touched him last!”– “He’s custody’s”– “He’s mental health’s”– “He’s medical’s”

Management of SIBThe Solution:Behavior Management

Management of SIBBehavior ManagementGoals:• Decrease SIB• Increase staff, inmate safetyMethods:• Incentivize desired behaviors• Teach skills

Management of SIBBehavior ManagementDoes• Increase safety• Improve functioning• Increase inmate’sautonomy• Increase inmate’s qualityof lifeDoes Not• Control inmate• Punish SIB• “Trick” inmate intoacting better• Minimize mental healthservices

Management of SIBGuidelines• Informed consent• Evidence-based practices• No advance or “prn” prescription or emergencyinterventions• No use of punishment• No coercion, no fear induction, no aversive stimuli• No deprivation of basic needs

Management of SIBFunctional Assessment• What is the nature of the SIB?• Suicide? Psychosis? Self-regulation?• Control of the environment?• What is the inmate getting out of the SIB?• Driven by antecedent? By consequence?• How dangerous is the SIB?• What incentives will work with the inmate?

Management of SIBIncentives• Out of cell time• One-to-one face time• Meetings with treatment team• Access to group interactions• Time-limited access to television,radio, reading materials, telephone, video games• Reduction in segregation time

Management of SIBIncentives• Start small and safe• Use shorter time intervals to earn• Build to bigger and more risky – slowly!• Use longer time intervals to earn• Don’t just reward absence of bad behavior• Also reward emergence of good behaviors

Management of SIBFour Steps1. Identify and measure problem behavior2. Identify function of behavior3. Build and implement plan4. Repeat Step #1

Management of SIBFact Gathering• Staff consultations• Mental Health staff• Correctional staff• Substance abuse treatment staff• Medical staff• Facility Administration• Develop treatment data• Prior responses and current options

Management of SIBFact Gathering (cont.)• Record review:• Mental Health and medical records• Disciplinary reports• Incident reports• Telephone and visitation logs• Develop behavioral data• Antecedents, behaviors, consequences• Location, timing, context, method• What this looks like in practice

Management of SIBBuild the Plan• Identify:• Housing location(s)• Skills that need strengthening• Staff responsibilities• Expanding menu of incentives• Develop phases for the plan

Management of SIBPhases of a Behavior PlanPhase IPhase IISafety PhaseMost restrictiveBegin earning smallincentivesMay be onwatch/observation statusFreedom from problembehaviorsPresence of desiredbehaviorsPhase III Earn larger incentives All Phase IIrequirements plusadditional behavioralgoals

Management of SIBPhases‣Map out phases in advance‣Resetting to Phase I is not a failure• Phases are not surrogate disciplinary procedures‣Final phase = consistent with milieu‣Plan discontinued when inmate functions aswell as peers

Number of Incidents/MonthManagement of SIB15IdealRealitySuccess = Longerperiods free fromproblem behaviors10500 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24Time in Months

Management of SIBThe Question:Does it Work?

Management of SIBData Collected‣Incidents of SIB• Method‣On-site medical care• Medical interventions• Security interventions‣Outside hospital medical care• Medical interventions• Security interventions

Management of SIBThe Results:Effective Reduction of SIB

Management of SIBThe Process‣Consultations provided between August 2008and September 2010• Two licensed doctoral level clinicians• One licensed psychologist• Three days on-site‣Multidisciplinary collaboration• Identify function of SIB for each inmate• Develop behavior management plan for eachinmate

Management of SIBThe Sample‣Demographics of sample• Prison inmates = 9; Jail detainees = 2• Males = 6; Females = 5• Five states‣Data collection• 6 months prior to consult• 6 months post consult

Management of SIBLimitations of Data and Results‣Small sample size‣Limited follow-up period‣No comparison group‣Some self-injurious behavior may not bedetected‣Fidelity to behavior management plan notassessed

Management of SIBDataPre-ConsultPost-ConsultRange of Total SIB 3 to 47 1 to 48Range of On-Site Medical 0 to 47 0 to 45Range of Off-Site Medical 0 to 9 0 to 3

Management of SIBTotal number of SIBincidentsAverage SIBincidents per inmateResults – Self-InjuryPre-Consult201 10120.1 10Change (pre to post) t(9) = 2.70; p = .025Post-Consult

6-month pre5-month pre4-month pre3-month pre2-month pre1-month pre1-month post2-month post3-month post4-month post5-month post6-month postManagement of SIB4.543.532.521.510.50Average SIB Incidents

Management of SIBResults – On-Site MedicalTotal number ofinterventionsAverage interventionsper inmatePre-Consult Post-Consult94 6410.44 5.82Change (pre to post) t(8) = 1.56; p = .157

6-month pre5-month pre4-month pre3-month pre2-month pre1-month pre1-month post2-month post3-month post4-month post5-month post6-month postManagement of SIBAverage On-site Medical2.521.510.50

Management of SIBResults – Off-Site MedicalPre-ConsultPost-ConsultTotal number of trips 48 12Average trips perinmate4.36 1.09Change (pre to post) t(10) = 4.579; p = .001

6-month pre5-month pre4-month pre3-month pre2-month pre1-month pre1-month post2-month post3-month post4-month post5-month post6-month postManagement of SIBAverage Off-Site Medical10.90.80.70.60.50.40.30.20.10

Management of SIBThe Implications:Practical Guidelines for Implementation

Pre-Post OutcomesManagement of SIBBehavior Management Works!Reduction in SIB50%Reduction inOn-Site Medical32%Reduction in Off-Site Medical75%

Management of SIBBehavior Management Takes Work!‣Need expertise of psychologist/QMHP‣Need multidisciplinary input and buy-in• Supported through training (formal & informal)‣Need tracking• Requires documentation‣Need to review and revamp• Give the plan enough time to work

Management of SIB• Inclusion of the inmate isessential• Gather inmate’s insights intobehavior• Get input into incentives• Provide rationale for plan• Get consent• Without the inmate, the plan won’t work• Change is an inside job

Management of SIBCommunication‣Talk frequently‣Get feedback and input‣Put changes in writing(e.g., phase)• Copy to custody• Copy to Mental Health• Copy to inmate

Management of SIBDocumentation‣Essential to process• Track success and change• Understand behavior• Get staff to think about behavior (A-B-C)‣All staff are responsible for documentation!

Management of SIBPrevention is the Best Intervention• We can pay at thefront end or the backend• Cheaper, moreeffective and moreethical at the frontend• Once the train leavesthe station…

IV. Collaboration: A Consensual andCoherent Approach‣Barriers‣Definitions‣Surveillance‣Management