Caring for Women in Prison: Mental Illness and Self-Harm

The mindThe disturbing story of 19 year old Ashley Smith’s witnessed suicide in a Canadian prison highlights the complex issue of mental illness and self-harming behaviors among incarcerated women. Ashley Smith attempted self-harm over 150 times during a three year period as outlined in this report of her treatment and in-custody death. She was a very troubled young women, as so many of our patients are.

Women in the criminal justice system have higher rates of serious mental illness than male counterparts; including higher rates of depression, bipolar disorders, antisocial personality disorder, and post-traumatic stress disorder. This can be attributed to many factors including histories of childhood abuse, adult victimization, substance abuse, and traumatization.

Social problems add to emotional stress; intensifying mental and behavioral disorders. Financial hardship, parental stress, and inadequate relational support make dealing with mental illness more difficult. Higher rates of chronic illness among female inmates compound the burden of mental illness.

Deliberate Self-Harm

Some women turn their distress inward and engage in deliberate self-harm (DSH) also called self-injurious behavior (SIH). In fact, as many as 30-50% of incarcerated women may harm themselves intentionally; most often by cutting or scratching with an object. This behavior can be perplexing and frustrating for healthcare and custody staff, alike. Conflicting interpretations cloud objectivity. Healthcare staff are more likely to see self-injury as a condition in need of treatment while custody staff are more likely to see it as a behavior issue requiring control.  Although Ashley Smith received anger management interventions and participated in group activities early in her incarceration, increasingly frustrated custody staff resorted to isolation, restraint, and pepper spray to compel her to comply with security requirements.

Mental health professionals, however, see self-harm as a coping mechanism brought on by distress, like the stress of incarceration. Therefore, a therapeutic response involving a non-judgmental attitude and interventions to decrease injury events is advocated over punitive measures. Phased-in behavior management plans, for example, have been effective for self-injury reduction. In this program, individualized incentives are developed and awarded when self-injury is avoided for periods of time. Patients move into advanced phases of the program with positive behavior change or back into earlier, more restrictive, phases if self-injury returns.


Deliberate self-harm when used as a coping mechanism rarely moves to suicide. Ashley Smith, however, began attempting suicide soon after she was transferred to an adult facility at age 18. Women inmates attempt suicide more frequently than men; although men have more completed suicides. Frequent, unsuccessful suicide attempts are viewed by staff as attention-seeking behavior and can soon be disregarded. It appears that Ashley Smith was allowed to kill herself while being watched by security officers. By that time she had been transferred 17 times through 9 different institutions. She entered the system as a youth on a 30 day sentence and accrued additional time for various charges resulting in a total of 2,239 days cumulative sentence.

As noted in the ombudsman report, there is no record of a psychiatric evaluation once Ms. Smith was transferred to the adult facilities; even after beginning a string of suicide attempts. Could a concerted program of therapy and behavioral management have avoided this fatal outcome? It is hoped that something positive will come from the death of Ashley Smith. The inquest jury has made 104 recommendations for improvements in mental health care and inmate treatment. The case highlights the challenges of working with mentally ill female offenders and the need for a coordinated program of care.

What has been your experience working with incarcerated women with mental illness? Share your thoughts in the comments section.

To read more about the unique aspects of women’s health care in the correctional setting see Chapter 9 in the Essentials of Correctional Nursing. The text can be ordered directly from the publisher and if you use Promo Code AF1402 the price is discounted by $15 and shipping is free.

Photo Credit: © Rob hyrons –

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