In response to my previous post, I received a number of comments and feedback which included assertions that individuals who engage in repetitive self-injury in correctional settings are “doing it for attention.”  That got me thinking.  And the more thinking I did, the more I realized that these statements are likely true.  But, not necessarily in the way one would think.  Let me explain.

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Often, when healthcare providers and correctional staff make statements about “secondary gain” or “doing it for attention,” they mean that the self-injurious behavior is completely within the control of the individual patient, rooted in antisocial traits (not serious mental illness) and done with clear intention toward a goal other than the goal of self-harm.  The belief is that these patients are willing to hurt themselves in order to get something.  Sometimes, staff say, the patients even tell us this is why they do what they do.  There is an implicit underlying belief that patients have it within their power to stop hurting themselves; they just don’t want to stop. 

I believe that a number of incarcerated patients who engage in non-suicidal self-injury do so in the service of something beyond the self-injury itself.  I also believe that for some patients, the goal is attention, but not in the pejorative way it is sometimes described.  I do not believe that the patients fully understand their motives nor do I believe that they can “just stop” when they want. 

Back in the 1950s and 1960s, a psychologist named Harry F. Harlow studied the impact of maternal deprivation and social isolation on the development of rhesus monkeys.  As you may recall from your basic psychology courses, Harlow found a number of amazing things.  He found that monkeys, deprived of mothering, actually favored a cloth-covered “mother” that supplied no nutrition over a bare wire “mother” which supplied nutrition.  This was not expected.  At the time, the prevailing belief was that baby monkeys only bonded with their moms because the moms gave them food.  It turns out, this is not the case.  In fact, Harlow found that the mere presence of a comforting contact object (cloth mother) reduced the death rate among baby monkeys. He also found that the presence of this cloth-covered “mother” allowed monkeys to socialize more freely and react to anxiety-provoking stimuli more adaptively.  Affection/attention/comfort is pretty important to survival it turns out.

In other studies, Harlow found that when baby monkeys were separated from their peers, the social isolation resulted in the following:

• Repetitive stereotyped movements
• Detachment from the environment
• Hostility directed outwardly toward others and inwardly toward the animal’s own body
• Inability to form adequate social attachments

Sound familiar?

I doubt very much that these baby monkeys were engaging in these behaviors based on volitional and conscious desires to simply gain the attention of the scientists who worked with them. 

All too often, patients who engage in repetitive and intractable non-suicidal self-injury in correctional settings are placed in isolated environments, in single cells, without items of comfort and with minimal interactions with peers and staff.  We expect, however, that they will socialize appropriately and engage in behavior that is not provocative or harmful despite their isolation.  This makes no sense. 

First, we know that people need human connection and social interaction.  When deprived of those things, abnormal behaviors manifest including aggression toward self and others.  Even death can occur.  It should be no surprise that individuals in a prison setting who are already deprived of attention, comfort and socialization would engage in behaviors that increase the likelihood for attention, comfort and socialization – not based on pathology – but basic human needs.   Now, I am not so naïve as to believe that there are not antisocial traits among our patient populations.  There certainly are.  But I believe that every human has a multitude of traits and that no one is purely pathological.

Attention, love, affection, comfort and socialization are NEEDS, beyond simple wants.  We need the attention of and connection to others to thrive and be healthy.  All of us.  So why do we think that our inmate/patients are any different?  And why do we think our patients can simply stop a behavior that may be the only means to get what they need?

I invite you to think about how these patients can access attention and socialization.  Does your team provide attention and socialization during times when patients are free from self-injury rather than only following acts of self-injury?  I believe we have a responsibility to provide our patients with alternative means of getting their needs met and in ways that do not include further isolation and alienation.  We need to explore ways to provide attention and socialization in a thoughtful, planned manner that supports the health and well-being of our patients rather than only providing them with attention that most likely reinforces and support further self-harm. 

What I have shared here is my opinion, based on my training, research and experience.  I could have missed something or just be plain wrong.  If you think I’ve got it wrong, please let me know why in the Comments.

Do you have any experiences with providing planned attention to support behavior change? 

Please feel free to share.