‘You can have a bit of my pain, see how it feels’ – understanding male prisoners who engage in dual harm behaviours

ABSTRACT

Prison-based violence and self-harm are continuing to rise. Recent research is increasingly showing that for some prisoners, self-harm and violence co-occur, i.e. they engage in dual harm. This study contributes to the developing research and literature focusing on dual harm by presenting an analysis of the dual harm experiences of six men residing in a Category B English prison. Participants were interviewed and their narratives analysed using interpretative phenomenological analysis. Superordinate and subordinate themes were identified, and they shed further light on why men in prison dual harm and what influences their decision to engage in one type of harm over the other at any given time. The findings indicate that co-occurrence is not coincidental. Participants experienced a combination of interlinking factors and complex temporal and experiential relationships underpinning the two behaviours: experiencing difficult and unpredictable environments, an incoherence of sense of self and identity, painful psychological and emotional states, and connections to early adverse experiences. The findings are discussed in line with the growing dual harm research and wider psychological literature. Limitations of the study and future research directions are provided, and implications for policy and practice are suggested.

KEYWORDS:

• Dual harm
• prisoners
• prison
• violence
• self-harm

Introduction

Violence reduction and safe prisons remain a key priority for the UK government and HM Prison Service (HM Prison and Probation Service, 2018). However, statistics from the Ministry of Justice indicate that rates of self-harm and violence in prisons are generally continuing to rise (MoJ, 2019, 2020). Audits of prison data revealed some underreporting of both self-harm and violent incidents ; therefore, the aforementioned statistics are likely to be an underestimation of the prevalence of these behaviours (MoJ, 2018). Traditionally, self-harm and violence have been researched separately and viewed through separate theoretical frameworks. For example, violence can be considered in the context of the General Aggression Model (Allen & Anderson, 2018), whereas self-harm might be viewed through the Interpersonal Theory of Suicide (Joiner, 2005) or The Four Function Model of Non-Suicidal Self-Injury (Nock, 2009, 2010; Nock & Prinstein, 2004). There are currently no tested theories of dual harm, although attempts to draw together hypotheses based on the existing research are emerging, which require testing (e.g. Shafti et al., 2021). Furthermore, different studies, institutions and fields of study may vary in their conceptualisation of self-harm and violence and the models explored. Indeed, self-harm and violence have been thought to occur separately as a result of the ‘direction’ of aggression, with self-harm resulting from aggression being directed inwardly and violence resulting from aggression directed outwardly (Plutchik et al., 1989). In practice, HM Prison Service currently uses the ‘Assessment, Care in Custody and Teamwork’ (ACCT) procedures for people in prison who are at risk of harm to themselves (PSI 64/2011 revised in 2021, HM Prison & Probation Service (HMPPS)), and since 2018, ‘Challenge and Support Intervention Plans’ (CSIP) have been instructed for people in prison, who are violent, or are considered to be posing a risk of violence (Buckland, 2019). However, there is a small but growing body of quantitative research indicating that self-harm and violence are interlinked.

Smith (2015a) explored the perspectives of people in prison in South Carolina, USA, who repeatedly engaged in non-suicidal self-injurious (NSSI) behaviours. Themes relating to emotional experiences and a need for control and emotional relief were found, revealing that suppressed emotion could manifest into externalised violence. This suggests that a link between harmful behaviours to self and others may exist across geographically diverse prison populations. Power et al. (2016) interviewed both males and females serving sentences in a Canadian correctional facility and found that the infliction of NSSI removed the negative consequences that would occur as a result of perpetrating violence towards others. This alludes to a decision-making process that takes anticipated consequences into account, resulting in a different type of harm being inflicted. Given that self-harm tends to attract a ‘care-planning’ response (Slade, 2018), and violence is often managed with a challenging approach with action being taken against the perpetrator (PSI 64/2011 revised in 2021, HMPPS), the manifestation of self-harm in those who would typically engage in harm towards others is conceivable. Therefore, for some, dual harm may be a product of the responses, approaches and systems that exist within the prison system.

O’Donnell et al. (2015) concluded that those who engage in both types of harm are likely to use different methods of harm and engage in more severe harmful behaviours than those who engage in sole harm. These tentative conclusions were empirically supported by Slade (2018) and Slade et al. (2020), who found that in comparison to male sole harm prisoners (either violence or self-harm), those who engaged in both types of harm, i.e. dual harm (Slade, 2019), also engaged in: significantly more incidents in custody; a significantly higher rate of incidents; a more diverse range of incidents in custody, including fire-setting and damage to property; statistically greater lethality of self-harm methods (i.e. ligatures and overdose); a wider range of self-harm methods. Slade (2018) found that dual harm prisoners would likely experience more punishment and longer periods of time in segregation than their peers. Whilst no differences have been found within the male prisoner population between sole and dual harm groups in relation to current age or offence type, dual harm prisoners had spent 40% longer in prison than all other groups (Slade et al., 2020).

Dual harm has been researched amongst a female prison population and the findings support those of Slade (2018). For example, Kottler et al. (2018) found that almost 40% of women who self-harmed were also violent. In comparison to females who sole harmed, females who engaged in dual harm were significantly more likely to use methods to self-strangulate, i.e. hanging/ligaturing, as well as swallowing foreign objects and engaging in fire-setting. It was also concluded that the more violent the female prisoner, the more likely they were to self-harm. This corroborates the conclusions of Jordan and Samuelson (2016), who reported that repeated acts of violence were associated with high suicide intent.

Research on dual harm within adolescent populations has also gained traction recently. For example, Richmond-Rakerd et al. (2019) found that self-harm was associated with violent crime and that dual harm adolescents were characterised by interpersonal and emotional lability, as well as a resistance to change. This could suggest that dual harm found in adult prison populations may be a continuation of a longstanding co-occurrence and relationship between harmful behaviours since adolescence.

Recently, research has explored how experiences of alexithymia may be related to suicidal and violent thoughts and behaviours in a sample of male prisoners (Hemming, Bhatti, et al., 2020). Whilst the focus of this study is narrow in scope, they found that the 15 men in prison tended to not discuss their emotions. Subsequently, their emotions built up, resulting in either an overload or feeling no emotions, which, it was suggested, led them to harm themselves or others.

The aforementioned findings give strong support to the notion that those who engage in both types of harm are likely to be a distinct group and that effective intervention and management of dual harm is of clinical importance to the safe running of prisons (Slade, 2018). This calls for developing a greater understanding of the connection between these behaviours (O’Donnell et al., 2015). There is recent research that qualitatively explores dual harm (e.g. Hemming, Bhatti, et al., 2020; Hemming, Pratt, et al., 2020). These studies do not specifically explore or seek to understand the behaviour development, salient experience or the meaning ascribed by those in prison who dual harm. Without additional evidence base, theory development and subsequent effective intervention and management plans for dual harm is considered unlikely. Frequent self-harm, violence and disruption within prisons will, therefore, likely continue with the associated psychological, physical and financial costs. In light of this, the current study is considered novel in focus as it aims to address some of the deficits in the dual harm literature using qualitative methodology.

Aims

Based on the existing literature and current gaps in empirical evidence, the overarching aims of the current study are to hear the stories of men in prison relating to the experience and sense-making of their dual harm behaviours. Due to the limited qualitative research on dual harm, this study is largely explorative and aims to uncover why men in prison who dual harm engage in this behaviour, what influences their decisions to engage in one type of behaviour or the other at any given time, and what may have contributed to the onset of and (if applicable) cessation of their dual harm. It is hoped that by documenting their experiences in their own words, an understanding of why men in prison engage in dual harm behaviours can be further developed.

Method

Study establishment

This study was conducted in an English Category B¹ male training prison² for those who had been convicted of a previous or current sexual offence. The prison held those who were over 21 years of age and had a sentence of four years or more.

Participants

Six male prisoners were interviewed. To select participants, all incidents logged by the local Safer Custody Team between 1 January 2016 and 1 November 2018 (as dictated by prison service instructions and incident reporting and management processes) were reviewed and filtered by an incident of violence or self-harm. This generated a list of men in prison engaged in violence or self-harm between the aforementioned dates. This study used the definitions of self-harm and violence (assault, including fights between people in prison), which were adopted by Slade (2018) and Slade et al. (2020). Direct bodily contact is included in both definitions. Non-physical harm and threats of harm were not included in the definitions.

These lists were then cross-referenced to identify men in prison who had engaged in both behaviours during the stipulated timeframe. A list of 25 potential participants was subsequently generated who still remained in the establishment. These individuals were contacted through the Custodial Management System (CMS³) with a message outlining the research and requesting that they respond if they would like to express interest in taking part. Nine potential participants responded. However, three later declined to take part prior to the information and consent stage (reasons not provided).

Procedure

Six participants were interviewed individually using a semi-structured interview schedule. As part of the study information and consent process, the concept of dual harm was briefly described to participants as having engaged in both self-harming and violent behaviours.

The interviews began with a broad question, asking the participants to talk about the first time they had either self-harmed or engaged in violence towards someone else. This offered participants a choice to speak about which behaviour or experience was most important to them. The interview used open-ended, non-directive questions, enabling participants to describe their experiences in their own words and to support the development and maintenance of a positive rapport (Knight et al., 2003; Reid et al., 2005). Selected examples of the topic guide used in this study included ‘can you tell me about the first time you remember either harming yourself, or harming somebody else?’, ‘what is your understanding of what determines which behaviour?’, ‘how do you see the self-harm and the violence being similar to each other?’, ‘how do you see the self-harm and the violent being different from each other?’, ‘have there been times where you haven’t had to use either of those behaviours and you’ve not self-harm or been violent? Tell me about those situations’. All interviews, lasting between 40 and 72 min, were audio-recorded and transcribed verbatim. Research and ethical clearance were gained. HMPPS National Research Committee (NRC) reference was 2018-241.

Analysis

Given the overarching aims of this study, the data were analysed using interpretative phenomenological analysis (IPA), the implementation of which was guided by Smith et al. (2009). IPA is ‘concerned with the detailed examination of human lived experience’ (Smith et al., 2009, p. 32) and takes the view that the individual makes sense and takes meaning from their experience in a discursive way (Eatough & Smith, 2006). The analyst is concerned with the participant’s perspective and facilitates understanding and making sense of the participant’s lived experiences of phenomena in a dynamic, hermeneutic loop (Smith et al., 2009). IPA, therefore, produces a more abstract, interpreted and theoretical understanding of the topic (Nulty et al., 2019). IPA coding was approached using the same procedure across all interviews. Firstly, the data were coded descriptively; then the analysis moved towards linguistic coding focusing on the function of the language and how it was conveyed. Conceptual coding was then used, allowing for a more interpretative analysis, focusing on overarching psychological understandings of the topic (Gajwani et al., 2018). The final phases included reviewing themes, ensuring that they were consistent with the coding and grounded in the qualitative data (Braun & Clarke, 2021; Smith, 2015b). The final themes were representative of the sample. A form of inter-coder agreement was used as a verification procedure to check the coding of qualitative data (see De Wet & Erasmus, 2005; Miles & Huberman, 1994). In qualitative research, this occurs when two or more researchers’ code aspects of the same data independently and check for consistency across coders (De Wet & Erasmus, 2005). The authors of this paper independently analysed transcripts, shared coding and themes and discussed emerging codes and themes, as well as similarities and differences in data analysis. Where any differences existed, the authors discussed the different interpretations to come to a consensus regarding the interpretation of the data. As De Wet and Erasmus (2005) argue, this dialogical process can help to produce safeguards against bias, and in this study, it assisted the researchers towards inter-coder agreement.

Results and discussion

All participants were over 21 years old, residing in a male prison. Information relating to the age at which harmful behaviours first started was reported by some of the participants via the interview schedule. Three of the six participants first engaged in dual harm during childhood or adolescence. One participant out of the remaining three first engaged in dual harm whilst residing in a Young Offenders Institute (specific age not provided) and another during adulthood. From the narrative provided, it was unclear what age the remaining participant first engaged in dual harm.

The themes identified following the analysis are presented in Table 1, including two superordinate themes, each comprising subordinate themes. This section presents and unpacks each theme to provide insight and understanding of the participants’ dual harm experiences. The themes are discussed in line with the existing psychological literature.

Table 1. Superordinate and Subordinate themes.

Superordinate theme	Subordinate theme
1. The looking glass	1.1 Navigating unpredictability 1.2 My reflected identity 1.3 Public and private expression
2. Making and rejecting meaning	2.1 The here and then … and back again 2.2 Pain, pleasure and escape

The looking glass

Drawing on Cooley’s theory of self (1902), the concept of this superordinate theme conveys the participants’ experiences of discrepancy or incompatibility between what they understood or expected versus what they perceived to be happening in their reality. This strange and bizarre world and the associated expectations that were in contrast to their own made navigating unpredictability difficult for the participants. Similarly, participants experienced incompatibility between their own conceptualisation of their identity and their identity, which they anticipated or experienced others to reflect to them (‘my reflected identity’). Dual harm often occurred to resolve this conflict between their ‘good’ and ‘bad’ identities. Participants would forcefully include or exclude the outside world from their emotional pain, dictating whether harm was perpetrated overtly or covertly.

Navigating unpredictability

This theme relates to participants engaging in dual harm when they experienced a discrepancy between their expectations and reality. As a result of the discrepancy, they experienced a subsequent lack of predictability which left participants being ‘lost’ and unable to identify possible options and ways to navigate the novel and unexpected situations they are being faced with. Dual harm was a known constant that the participants could do when living in a world that was fundamentally unpredictable and strange to them. Within an institutional context, carrying out their known and predictable behaviour enabled participants to regain a sense of control.

I think last time I self-harmed, ermmm, my pad mate changed cells and he moved to a different wing and I had no idea who I was gunna get, [inaudible] I asked who am I gunna get and oh we don’t know and I mean then that’s a different worry because that was my whole routine was like shattered so every day I put in to it, it would just seem to unravel. (P5)

Participants expressed that having a sense of predictability and routine reduced the tendency for them to engage in dual harm behaviours as demonstrated by P6:

Purpose and structure and things to work towards. I never used to do any of these plans, everything was always just all chaotic and mixed up. (P6)

For P6, having a sense of external predictability was really important for him to regulate his emotions and maintain his self-determination. He reflected on how as a child, he experienced ‘a lot, like confusion and, all mixed up, I didn’t know where I fitted into the world’ and that when his emotions get ‘a bit fuzzy’ that’s when he would ‘normally do this dual harm business’. P6 expressed feeling rejected or overlooked by people around him and this would often trigger his mixed-up emotions. To avoid this, he had learnt over time who in his world would trigger his dual harm:

I’m careful about who I approach because I think to myself yea that person won’t have time for me, or that person won’t have time for me. (P6)

Building on this theme further, for P4, his experience of dual harm was a consistently known entity within a life characterised by unpredictability, inconsistency and his expectations not being met. He likened his dual harm to a predictable, known object:

 … when I put someone on a pedestal and obviously when that pedestal crumbles and the person turns out to be not the person I thought he was, it’s (pause) it’s like going back to old things that you know, like you know when you have an old chair … You go and sit in that chair coz you know it’s comfortable you know it’s, it’s what you know. (P4)

Living in a world that is frequently unpredictable or having predictability and routine followed by the subsequent removal or change to this may contribute to the perpetration of both forms of harm. Carleton (2016) provided a literature review relating to the fear of the unknown and related concepts, such as intolerance of uncertainty and models of emotion and attachment. Carleton (2016) suggested that intolerance of uncertainty is the inability to tolerate the response (e.g. fear) triggered by the individual’s perception of an unknown and the experience of uncertainty. Intolerance of uncertainty influences the individual’s perception and desire for control and predictability. Given the findings outlined in 1.2, it is plausible that dual harm provides the participants with their sought-after sense of control and predictability. Therefore, developing the capacity to navigate and cope with uncertainty or ambiguity would logically be a skill that may help to protect against dual harm behaviours. Dual harm could also be a response to regulate an aversive response when faced with unknowns. This is a tentative suggestion and would require further exploration.

My reflected identity

This theme is related to all six participants and the complexity in achieving a coherent self-identity in those who engage in dual harm. There was an apparent incongruence in their identity between how they perceived themselves and how they believed others perceived them. One aspect was their own conceptualisation of the self as being multifaceted and comprising inherently ‘good’ traits, and the other part was the perception of others only recognising their undesirable traits. The analysis indicated that participants would outwardly portray their ‘good’ identities whilst simultaneously refuting all of their undesirable traits. However, they anticipated that the people in their world would only see their undesirable traits; thus, they experienced their external world as powerfully reflecting only their undesirable traits to them. For some, the reflection of their undesirable traits was directly linked to the nature of their offences or being a prisoner. They felt that they received no recognition of their pre-prison identities.

you know, they [Officers] push you to one side and think you know, you’re a sex offender, you’re in here … but at the end of the day, we are still humans … you think I’m here doing time and I’ve lost my family, my home, my freedom, you know I should not be treated like I’m being treated. I’m a human, I was a husband, I was a dad, you know. Now I’m in here … . (P1)

P1 highlights how only his offending self is recognised in prison, aspects of his core identity before prison are neglected or ignored. For others, their reflected undesirable traits and identities involved being conceptualised as weak, unimportant, violent or not worthy of being listened to or heard. P3 would engage in dual harm to offset his perceived externally reflected identity of him being weak or undeserving of respect:

Sometime, sometime, when you self-harm, you try to show up you’re strong man, you try to show up you can lose lots of blood, you can, you can cut yourself, big cut. (P3)

 … with the violence as well, the fight you know, sometimes you feel like the person want to make you weak, the person want, you never want someone to make you weak, you never want someone, you never want to hurt someone, like me, I never want to control someone, I never want to, I just want to have respect, to talk to people, to respect you. (P3)

For P3 his harm to self and others was to demonstrate to those around him that he was fundamentally strong. It was a way to control how others would perceive him. Through showing he can lose blood, he is displaying, for him, a strong identity and rejecting being weak.

Similarly, engaging in harmful behaviours, offset P2’s experience of his external world reflecting him as weak, which was incongruent with what he associated with being a man. He would cause harm to avoid his external identity reflecting him as being ‘unmanly’.

Ummmm, I wouldn’t ask anybody for help or anything, whether I was in prison or out of prison, I just wouldn’t approach anybody and ask for stuff like that … it’s like, to me I’m a man, why should, why should a man have to ask for help. Why not deal with it myself? (P2)

This extract parallels the finding of ‘toxic masculinity’ by Hemming, Pratt, et al. (2020), where staff perceived that prisoners avoided discussing their feelings to not appear weak.

The discrepancy that participants experienced between their ‘good’ identity and the reflected undesirable identities brought about a sense of internal conflict. To resolve this conflict, participants would use dual harm to succumb to their externally reflected identities or actively challenge the reflected identity. However, this often caused a paradox. The seemingly inevitable perpetration of harm would reinforce the externally reflected identities and the intensity in which these traits were reflected to them by others, creating and maintaining a vicious cycle.

I ended up being violent because everybody saw me as a worthless piece of shite, so why not act like a worthless piece of shite? (P4)

For P4 his violent behaviour was a reflection of internalised labels and the associated characteristics that were assigned to him. This process is akin to Maruna et al. (2004) reworking of Cooley’s ‘looking glass self’, where individuals not only gain a sense of self from the appraisals of others but also from the consequences and products of behaviour. Thus, those who are labelled negatively, act negatively are then not only condemned for their acts, but given an aberrant identity, where their offending characteristics are viewed as a central part of who they are (Goffman, 1963). This narrative has symmetry with Maruna’s (2001) ‘doomed to deviance’.

I’m here you know, I’m I’m alive as well you know … you know I’ve had a bad life as well. I mean (inaudible) I was called psycho. Imagine when I was in prison … reading a psychiatrist’s report saying I’m a psychopath, fucking (inaudible) when I was a kid, might as well act like one. (P4)

P4 discusses a similar experience and demonstrates how negative life events, coupled with poor expectations from others, brings about poor outcomes (Babad et al., 1982; Maruna et al., 2009). People define themselves not only through pre-existing views of self but also through a reflection and reaction to how they imagine or believe others perceive them (Cooley, 1902). This appeared highly salient for the participants in this study and is an important consideration as this ‘golem’ effect (low expectation of people, leads to a poor outcome) has been linked to offending behaviour and an impaired ability to find a place in society (Maruna et al., 2009). As Cioffi (2003) argues, ‘the looking-glass stands not before a single social reflection, but in a veritable hall of mirrors’ (p. 211). Such perceptions were having or have had profound impacts on the participants.

By examining P4’s story, this subordinate theme was prevalent throughout his narrative and his dual harm was expressed as being integral to his identity from a young age. As a child, P4 was compelled to hide the parts of himself that were consistent with the reflection of how others perceived him, i.e. vulnerable, weak, easy to hurt. By putting on an ‘overcoat’ of violence, he would counteract how he experienced others viewing him and he would transition or morph into this ‘fucking hard guy’. When P4 took off his overcoat, he would ‘feel vulnerable, I feel unsafe, so then I have to put that overcoat back on’. Over time, his overcoat extended to include his self-harm which became intertwined with his violence:

 … to marry with the violence yea ermmmm and I’m violent so I cut up, I cut up so I’m violent. (P4)

Harm and the potential for causing harm became an essential and an ‘ingrained’ characteristic of who he was to the point that it was ‘automatic’ for him to put his overcoat on and experience a powerful shift in identity from weak to strong. In addition, causing harm served to counteract the world, reflecting him that he did not matter; perpetrating harm forced people to notice him.

And violence used to get that world to revolve around me. Coz once I, because I, my violence used to be so so so extreme, everything would stop. I could bring this prison to a standstill. (P4)

When faced with the prospect of further identity change, P4 was ‘scared of losing the old me’ and that he was not going to change straight away. Similarly to how his old self had been created by what traits and identity people reflected to him, his current and non-harming self was created by what people reflected him to be now (the looking glass self, Cooley, 1902; labelling theory Becker, 1963; Lemert, 1967; the Galatea effect whereby high expectations enhance achievement and outcomes, Babad et al., 1982). This was facilitated by therapeutic relationships and reflects what is highlighted in the existing psychological literature regarding the link between therapeutic relationships and treatment outcomes (e.g. Lambert & Barley, 2001); experiencing trust in his relationships with staff and being confident in the relationship was paramount to help P4 change his identity to a non-harming one.

Finally, the analysis suggested that attribution may also be a contributing factor to the process of dual harm. For example, P6’s experiences demonstrate that different states of emotion drove self-harm or violence.

Well for self-harm I’d say sadness ermmmm, guilt, shame and for violence, I’d say anger, frustration or can be sometimes when I feel like someone is being dismissive of you. (P6)

Drawing on Baumeister (1990), it may be that when P6 attributed his circumstances and subsequent adverse states to be due to his own failings, this resulted in distinct emotions, such as shame and his subsequent self-harm. In contrast, when the cause of his situation and adverse states were attributed to the fault of others, this resulted in violence. However, this is an initial observation and would require further exploration and evidence.

Public and private expression

The essence of this theme reflects a pattern whereby participants felt and or expressed their distress publicly or privately. Interestingly, there appeared to be no clear pattern across the data of whether one harmful behaviour would consistently correspond to either a public or private expression of pain. There were variables that appeared to influence whether the participant would forcefully include or exclude the outside world from their pain, such as the individual participant and the specific situation. This alluded to complex and subtle interactions of internal and situational processes which would dictate whether harmful behaviour would be overtly or covertly carried out. This theme also captured the participants’ sense of control and ownership over their dual harm. This was a particularly salient point given that the participants resided in prison. For example, P1 talked about how ‘all prisoners want, is to be taken notice. Want Officers to have more … how can I say it, respect for prisoners’. Interestingly, P1 reported that his self-harming started only when he came to prison for his current offence(s) and was a public act that forced Officers to take notice of him:

Well, it [self-harm] does help to ease the tension, you know, and show the Officers, you know, you’re not going to you know, put up with it, how you are being treated. It gives them something to think about … Ooo make the prison take notice of me, you know, realise that what I am going through, how I feel. You know, I find it’s the only way of making them realise you know.(P1)

The self-harm for P5 would also be a mixture of a public and private expression of distress and this would seem to hinge on whether he wanted help then or not.

 … with the self-harm the pulling is like I need help, I mean I might’ve not said it but … I need somebody to talk to …  (P5)

This was in stark contrast to how publicly known P5 anticipated his distress would be if he were violent. P5 held a level of ambivalence towards wanting others to acknowledge and provide offers of support in response to his violence. Therefore, P5’s consideration and subsequent self-harm was fuelled by avoidance of hurting others and thus endeavouring to hide his distress from others. As P5’s self-harm was both public and private, this again suggests an experience of choice and control over eliciting help:

if I hide the self-harm so obviously nobody can see it ermmmm, I can … it’s [self-harm] easier to hide really than obviously the violence coz obviously with violence, obviously someone is always going to be injured and someone is always going to know aint they? (P5)

Similarly, when P3 was in distress, his decision to engage in harm either privately (self-harm) or publicly (violence) was at times more considered. He recognised that he wanted to be violent to Officers but anticipated the consequence of potentially receiving an additional custodial sentence. Instead, he would self-harm or expel his distress, which was often experienced as anger, on objects:

Sometimes I will self-harm when I, when someone upset me and I don’t want to hurt no one and I choose to hurt myself. (P3)

A public consequence of prison staff knowing that a prisoner had self-harmed the ACCT document. For some, this acted as a powerful public symbol of the prisoner’s distress which was consequently known by everyone.

I feel guilt after self-harming, I feel like I’ve let myself down, I’ve let others down … I feel that people will think I’ve taken a step back if they see me on an ACCT. So I don’t like being on an ACCT. (P6)

Interestingly for P6, a similar experience did not occur when he was on a CSIP (Challenge and Support Intervention Plan), suggesting possible differences in the function of the two documents and of what they publicly symbolised to others.

Well you have meetings every 2 weeks and they discuss your progress and goals and what been happening and how you can improve things. So, that’s that’s a good thing … It [CSIP] gives you a chance to offload. (P6)

Similar to the theme of ‘talking about emotions’ found by Hemming, Bhatti, et al. (2020), the above suggests that being supported to talk about their current situation and experiences within the right environment can be beneficial. From P6’s narrative, this may be a CSIP review. This raises a further question regarding prisoners who have dual harm and their experiences of ACCT reviews compared to their CSIP reviews and the connection to behaviour outcomes.

A further element of this theme and more specifically in relation to the private expressions of pain included participants having a strong sense of ownership over their dual harm. It was theirs and could not be taken away from them. For example, P2 conveyed his self-harm as largely being something that was private to him. His sense of possession of his self-harm was implicit, where he was reluctant to discuss and share his experiences of self-harm in any depth other than towards the latter stages of the discussion. It became apparent that P2’s ownership over his self-harm was almost territorial in that he was not going to let others into his self-harming behaviour; they were not welcome or privy to this unless he chose to allow you in.

 … self-harm is something I turn to and once I’ve done it … I hide it away from people by covering up my arms. (P2)

Furthermore, P2’s private self-harm appeared also to represent his avoidance of the processes and protocols that are activated in response to self-harm, i.e. ACCTs, which he has experienced as unhelpful:

Ummm, when I was asking for the help and stuff, all they did was put me on the ACCT document, constantly looking through the door. To me that made it worse, coz now I am being watched six times an hour and I thought well, why? They aren’t fussed anyway. (P2)

Over time, his avoidance of ACCTs following self-harm seemed to transform into him experiencing control and pleasure in knowing that he was actively resisting the ACCT processes by keeping his self-harm private.

Ummmm, I usually walk round in T shirts and stuff but when I do cut up, I do cover it up by wearing jumpers and stuff like that. So, it’s only me who knows what’s going on. (P2)

In summary, dual harm was linked to public and private expressions of their distress which afforded the participants opportunities to either alert others to their need for help or regulate and have control over themselves, the prison establishment and those within it. As prisons are often environments that offer little opportunity for prisoners to have autonomy and self-determination, the act of private self-harm adds a further level of control and satisfaction as it circumvents prison systems and processes, i.e. ACCT documents. Given that dual harm populations are likely to spend longer and more frequent periods in further restricted areas of the prison, i.e. segregation (Slade, 2018; Slade et al., 2020), the act of private self-harm and subsequently resisting/opposing the system is likely to be a powerful experience for some prisoners as it enables them to take power back.

Making and rejecting meaning

This superordinate theme focuses on the participants’ stories and the meaning of their current lived experiences. Within the first subordinate theme, participants’ stories highlighted connections being made between their past and present. Their interpretations of their present and lived experiences were implicitly and explicitly influenced by their past adversarial experiences, leading to a sense of them being bound to their past, the outcome of which was dual harm. Furthermore, participants’ narratives highlighted their (often extreme) psychological distress and uncovered links between pain, pleasure and escaping from their self-awareness and cognitive constructs. These themes shed some light on why dual harm is a recurring and often an embedded phenomenon for these men and the possible function of their dual harm.

Here and then … and back again

This subordinate theme explores how participants are trapped by connecting their adverse past experiences to their present situations. Their interpretations of their present were thoroughly anchored in their past and this past-present relationship heavily contributed to their lived state and dual harm. The connection between past and present was explicit and implicit and highly dynamic, with a quick and chaotic movement between past and present, or, ‘here and then … and back again’.

P2’s story demonstrates the complex experience of his relationship between his past and present and how this resulted in his dual harm. However, the interplay between his past and present was experienced slightly differently for self-harm and violence. P2’s self-harm was more explicitly and readily linked to what he called his ‘PTSD’, the experience of which and the associated past events were powerfully expressed as being ‘stuck in my brain’; a fundamental and physical part of him. The sensations associated with this were visceral and hopelessly out of his control:

I would say it was the emotional pain, it was just the way it affects me, like I said, one minute I could be happy, as soon as I see something whether it be on the wings or whether it be outside, it just sends me back to what happened at home … I can feel it, see it, smell it, things around me as if I was there back in my home, ummm I suffer with anxiety and I get hot and sweaty and its uncontrollable and I just can’t help it. (P2)

When P2 was faced with his PTSD, he would often self-harm but paradoxically, this would strengthen a connection with his past adverse experiences, meaning that there was no escape from this on-going painful cycle of moving between his past and present:

With the emotional part, it, I don’t think it does. Ummmm, it makes me happy because my mind is taken off it because if I’m concentrating on the pain on my own body … it does try makes it a little bit worse because I’m doing to my own body what somebody else has already done. (Sniffs). So even though I’m having flashbacks of my childhood abuse, it’s still having an effect on me physically because I can, by doing that, its bringing it all back again. (P2)

With respect to P2’s violence, his painful emotions were routed and continued to exist in this dynamic interplay between his past and present. Ultimately, his pain gave him power over the memories of his adverse childhood experiences:

And my violence just got worser and worser. But I think that’s because at that time, I felt, I felt a lot better, having more power and control over another person. Ummm, to me growing up, I was weak, ummmmm, for allowing it to happen to me. But as an adult, I could put that weakness to the side and become a lot stronger and put, put the violence to use on other people … to gain what I wanted. (P2)

Similar to the findings of Power et al. (2016), P2 recognised that violence in prison entailed having to ‘suffer’ the consequences. For P2, the anticipated consequences were retaliation from his peers, which he expected to mirror the physical injuries and feeling of powerlessness his past abusers inflicted on him during childhood. Due to these consequences for his violence in custody, P2 explained how his violence had started to decrease more recently. This may explain why P2 reported having engaged in more self-harm than violence.

P6’s accepted that his dual harm had always been in his life in equal amounts: ‘I think from an early age, that them two things were there’. More recently, his dual harm was a result of his ‘sadness and bad memories’. The past and present connection was also implicitly experienced as his current and future progress was often inhibited due to him experiencing happiness at his progress, something that his past self never felt. His subsequent guilt undermined his current and future progress and he experienced ‘self-destruction’, sending him back into dual harm and subsequent familiar past affective experiences.

Similarly, P3 also experienced links between his past and present. However, this resulted in dual harm to protect others from encountering similar situations from his past, such as being made to feel weak:

I used to get beat you know … if I go back to my cousins and my uncles and say someone beat me, everyone’s laughing about me you know, they aren’t coming to protect me, everyone’s laughing, you’re weak … And I have to stand up for myself … I have to learn how to fight … and sometimes I see someone get bullied, I remember that I used to be like him you know and I know that that person needs help and stop that happening. (P3)

P3’s narrative reflects earlier research which found a link between the prisoner’s upbringing and how they learnt to hurt themselves or others in response to their distressing emotions (Hemming, Bhatti, et al., 2020; Hemming, Pratt, et al., 2020).

For P4, his clear and suggested past/present connections were scattered across his narrative, where he would quickly jump between periods of his life. It became apparent that he was aware that he would become violent ‘based on history, based on present circumstances … ’, he experienced his violence and self-harm as one and the same. Through understanding P4’s narrative, his past and present connections were rooted in his early experiences of receiving care. P4 described intense guilt following his present perpetration of violence as this went against his mother’s ideals, a relationship that was maintained and lost during his early childhood and to which P4 attached complex feelings and thoughts. When experiencing guilt following his violence, this would trigger memories of a multitude of past actions, which he voiced regretting and amplifying his current state of guilt. Violence and guilt are connected to his self-harm as a way to ‘purge’ and ‘punish’ himself for what he had done.

This subordinate theme could be contextualised by the literature regarding trauma and connections between the past and present becoming interlinked (e.g. Wigren, 1994) and a trauma narrative being developed as the individual attempts to find meaning in their experience (Tuval-Mashiach et al., 2004). This potentially signposts to the utility of practitioners considering a psychodynamically informed approach when working towards a collaborative understanding of a male prisoner’s dual harm behaviours. Furthermore, this complex and changeable dynamic between individuals’ past and present appears to lead to a skewed interpretation of their daily experiences in prison, guided primarily by their repeated past adverse experiences and complex child – care-giver relationships.

Pain, pleasure and escape

This theme captures how the participants’ harmful behaviours allowed the removal of their negative internal states, providing temporary relief from their psychological distress. This process facilitated the experience of escape, which for some, was experienced as pleasurable.

Distress was strongly apparent across all of the participants’ experiences in the lead-up to their harmful behaviours. For some, they were retrospectively aware of their distress increasing over time, stating they ‘bottled’ their emotions (P6); ‘It’s been building up and building’ (P2) and ‘I let my emotions get on top of me’ (P6). The narratives of P6 alluded to him experiencing a confusing and adverse emotional whirlwind contributing to his dual harm stating that he would lash out ‘not only at myself but others’ because ‘I didn’t know really how to tell the difference between one emotion and another emotion’. The participants’ experiences of this study suggest that the dual harm population may have particular difficulties in identifying the slow increase of their distress, and/or may have difficulties in processing and regulating distress in adaptive ways before it results in dual harm as a way to cope. This has been suggested by Hemming, Bhatti, et al. (2020), where experiences of alexithymia and the link to suicidal and violent thoughts, and, or behaviours were explored.

Through deeper analysis of the data, a pattern emerged whereby dual harm would remove or enable escape from psychological distress. For example, three participants experienced self-harm as a physical stimulus to focus their attention on and this acted as a distraction from their distress. This seemed to be a conceptual variation of mindfulness (Langer, 1989). Self-harm and the associated physical pain provided a powerful concrete stimulus to redirect their attention and focus away from their psychological and emotional distress. P3 explained why he would self-harm, stating ‘just because I’m because I’m upset and I have to concentrate that anger on something’. Furthermore, for P2, the physical pain and physical injury would provide a visible and located point of focus to attribute his pain to:

Ummmm, it makes me happy because my mind is taken off it because if I’m concentrating on the pain on my own body. (P2)

The above extract highlights that stopping or escaping from psychological distress was subsequently experienced as pleasurable for P2. Similarly, self-harm was often experienced as a gateway to release some of their emotional pressure and pain building inside them and to ‘ease the tension’ (P1). For example, many participants’ psychological and emotional pain was relentless and self-harm gave a temporary way out of their adverse states:

You know I feel like I’m the one who’s being tortured, you know, mental torture, you know … and the only way out of it is self-harm you know. (P1)

 … like when I did it [self-harm] I did feel relieved and then I didn’t really coz I knew that I would have to go back and it would be exactly the same if you know what I mean? Guess it was just a way to actualise the pain I guess … What I mean there was no way of getting rid of it really but obviously when I burnt myself, I had something physical and something would get better and obviously the stress seemed to go away for a while. (P5)

Over time, the physical injury became synonymous with the escape from negative states, so it became associated with feelings of pleasure and a sense of calm. P4 explicitly commented on this in relation to his self-harm, demonstrating the intensity and unparalleled sensation of the pleasure he felt when inflicting physical damage and pain on himself:

And so every time I saw that blood, every time I saw the, I felt the pain, it was like  … it was almost orgasmic. It wasn’t about sexual, sexual pleasure but it was like oh yea, that’s got rid of all my anger, that’s got rid of all my pain. (P4)

The two extracts below highlight a pattern of participants experiencing their harm as facilitating self-retribution.

At first it was only minor self-harm but as I grew older, it progressed and got worse and worse and when I think about it now as an adult, it was more like, like self-punishment or like when emotions get too much, like a release. (P6)

 … and once I’d self-harmed, it was like all the anger, all the guilt, all the violent, not so much guilt, all the violent, the upsetting remarks, the, they would all coming flow out within in all that blood, they would come out. It’d be like (pause) it’d be like crucifying myself. (P4)

P4’s self-harm and violence were closely interlinked and occurred one after the other. His high punitive self-awareness and his experience of adverse emotional and psychological states when acknowledging the recent harm he had caused to others became too intolerable for him to hold. These states motivated him to move them out of his body through self-harm literally. P4’s use of the words ‘crucifying myself’ suggests that his self-harm would also be a form of self-sacrifice, remorse and symmetry, showing to people that he had harmed himself in response to his harm perpetrated to others, possibly in an attempt to gain forgiveness for his violence.

The extracts highlight how harmful behaviour and the associated experience of pain facilitated temporary relief from psychological distress and pain, thereby allowing escape from adverse states. This reflects a similar process proposed by Baumeister (1990) in relation to suicide; to escape from negative affect and punitive self-awareness, an individual would enter a state of cognitive deconstruction and shift to a less integrated form of thought. The deconstructed state lowers inhibitions and increases a willingness to attempt suicide, thus permanently terminating their adverse thoughts and feelings. All participants of the current study spoke about their experience of self-harm thoughts and/or behaviour as a way to escape:

Overwhelming emotions and then when I tied it, I go very very, like, very tight, and they struggled cutting it off. (P6)

I know obviously I don’t wanna escalate know what I mean … when you can’t think of a way out its bad for you I guess ermmmmm so obviously it’s a way to get rid of ermmmmm, well push that away really, the options. (P5)

For P3, his feeling of anger was integral to his dual harm and rejecting meaningful thought as ‘in the moment you’ve got so much emotion, so much energy, just don’t think … ’. He would become focused on the immediate goal of escaping from his anger and this could be achieved by different behaviours:

 … you just first thing that comes in your head you know, you just want to do it you know … so you end up smashing other things or self-harm … After, feel calm … after I do something, some some someone come and talk to you … I’m going to take this person away and I come and talk to you. (P3)

Baumeister (1990) proposed that escape from adverse states can also be achieved by the help received from significant others. As demonstrated here by P3, his harmful or ‘other’ behaviours (e.g. smashing up his cell) seems to bring about the unintended outcome of escape from his distress via affiliation and connectedness with others.

The analysis clearly shows that escaping psychological distress and pain was a key motivator behind most participant’s perpetration of harmful behaviour. However, the method in which they used to achieve escape seemed irrelevant and, therefore, they engaged in a wide range of behaviours and, or, fantasy in order to inflict harm/pain on themselves:

I was hanging out, looking for a fight and obviously I couldn’t find one so I, I cut myself and I remember standing there on a bridge I think and it wouldn’t be that hard to jump … I must have sat there for about, and I was just looking straight down with my arm bleeding urmmm and just like that, I seemed to calm myself down. (P5)

Similar to the above whereby P5 was unable to access his preferred method of harm in a particular situation, P2 explained that opportunity also dictated what type of harmful behaviour he engaged in. He described that being locked behind his door in prison restricted his ability to be violent, but he still needed to feel physical pain to escape his psychological pain.

When I’ve been really angry and that and I’ve felt like hurting somebody, I punch the wall, and I can feel that pain going up my hand and my arm and I wanna scream but I choose not to …  (P2)

A similar pattern was reported by Hemming, Bhatti, et al. (2020) where harm to self or others was determined by the present situation. Interestingly, P2 noted that the same experience did not apply in reverse as ‘I’ve never used violence on another person as a way of self-harming’.

The participants’ stories alluded to a sense of satisfaction when they had harmed and caused pain to others. The data highlighted that when a participant was driven to experience physical pain to escape their psychological pain, it sometimes did not appear to matter whether the pain was their own or others; the focus was that pain was being caused. For example, P5 talked earlier about how his self-harm was experienced as a way to ‘actualise’ his emotional pain. When exploring his understanding of any links between his self-harm and violence, the concept of pain was central to this:

But obviously with self-harm it just involves you. With the violence, it can involve somebody else in it. Obviously trying well I guess in some weird way share your pain … Because its, really I can’t see any other way really obviously or trying to get rid of your pain by hitting somebody. (P5)

For others, their own psychological pain was transferred to others when they caused someone else physical harm. This narrative relating to this experience of ‘pain transfer’ was pleasurable for some participants. In one case, this pain transfer had brought about an intensely powerful, almost euphoric experience for him, thus providing an escape from his own psychological distress:

 … although I knew it was wrong what I was doing, it was that thrill and that enjoyment I got out of it and putting pain on to other people. It was like well you can have a bit of my pain, see how it feels … yea I just wanted to put all my emotions and what I was feeling on to them and took whatever it took to do that. (P2)

The participants’ stories and the above findings could be understood from a biological perspective of pain. When the body detects pain, physiological, neural and hormonal processes are activated to achieve homeostasis (Loeser & Melzack, 1999). Logically, the more severe the pain, the more profound the attempts made by the body to achieve homeostasis. Dual harm populations have been found to engage in more severe, more diverse and more frequent harmful behaviours (e.g. Slade, 2018). This could be due to their ‘pain pathway’ (Caterina et al., 2000) being desensitised over time. Therefore, over time, they need to inflict more severe damage in order to experience the body’s pain responses. Indeed, three of the six participants in this study reported (via the interview schedule) engaging in dual harm from childhood/adolescence, hence their pain pathways may have been desensitised over time.

The participants’ stories highlighted a pattern where their dual harm behaviours escalated in lethality over time. This could reflect the concept of escape theory (Baumeister, 1990), whereby participants who chronically experience negative states find that their usual methods of escape become less effective over time, requiring them to engage in more severe methods to achieve the same level of escape. Therefore, when experiencing sudden or extreme psychological distress, the apparent intense need to escape this, combined with the available opportunities and methods to enable escape, may explain why Slade (2018) and Slade et al. (2020) found that dual harmers engage in a more lethal, diverse and frequent range of behaviours/incidents.

Analytical summary

The present qualitative study was largely explorative and sought to hear and understand the experiences of men in prison who carry out dual harm behaviours and the meaning-making of their dual harm behaviours. It presents patterns of experiences and sheds light on why prisoners engage in dual harm behaviour and what influences their decision to engage in one type of harm over the other at any given time. The findings indicate that co-occurrence is not coincidental and highlights temporal and complex experiential relationships underpinning the two behaviours. The analysis demonstrates that participants experienced a combination of interlinking factors; connections to early adverse experiences, experiencing difficult and unpredictable environments, incoherent identity and painful psychological and emotional states. The method of subsequent harmful behaviour was mediated by immediate circumstance, opportunity and the importance of pain in facilitating escape from their adverse psychological and emotional states. For all the participants, their sense-making of dual harm experiences was complex and often difficult to articulate. Participants’ narratives uncovered a sense of being trapped by their past, which connected to their former pain and adverse experiences. This reflects the existing trauma literature and connections between past and present becoming interlinked (e.g. Wigren, 1994) and a trauma narrative being developed as the individual attempts to find meaning in their experience (Tuval-Mashiach et al., 2004). Given that four of the six participants discussed their past painful (often childhood) experiences and three reported having engaged in dual harm from childhood/adolescence, these findings could be further contextualised and understood by the wider attachment and developmental trauma literature and self-protective strategies developed in childhood transgressing into adulthood (e.g. Crittenden, 2006; Glaser, 2000; Nemeroff, 2004; Öhman, 2005; Van der Kolk, 2014). However, simply attributing dual harm as a response to trauma does not adequately distinguish dual harm populations from sole harm and no harm populations which may also have had adverse experiences.

By examining the participants’ stories and their experiences within the context of their wider constructed world, a holistic view of multiple identities was uncovered; the identity that the participants independently held and the ‘bad’ identity that they felt the world reflected to them. To resolve the dissonance between these identities, participants resisted/fought against the undesirable identity, sometimes literally, or succumbed to their externally reflected identity. This parallels the concept of labelling theory (Becker, 1963; Lemert, 1967) and the golem effect (Babad et al., 1982), whereby low expectations bring about low outcomes. Both pathways to identity resolution would be wrapped up in the participants’ perpetration of harmful behaviours, either to themselves or others thereby strengthening the externally reflected ‘bad’ parts of themselves. Such an experience could be contextualised by the concept of a double bind (Bateson, 1972; Bateson et al., 1956). Furthermore, participants’ ‘bad’ identities may be habitually reflected to them, possibly as a result of the environment they resided in, i.e. being a prisoner in an establishment for those convicted of sexual offences. Therefore, dual harm is maintained as the conflict and discrepancy between the two identities is on-going. In particular, P4’s journey of dual harm and eventual moving towards a non-harming identity corroborates the existing literature regarding therapeutic relationships with staff and positive treatment outcomes (e.g. Lambert & Barley, 2001) and the Galatea effect (high expectations enhance achievement and outcomes) (Babad et al., 1982). Furthermore, Cantor (1976) proposed that suicidal individuals have a strong need for nurturance and affiliation. Whist not explicitly suicidal, this could be a similar experience for those who dual harm, the paradox being that the nature of their current (prison) environment and their dual harm behaviour reduces the likelihood of others meeting these needs. Therefore, their adverse psychological states, and the subsequent need to escape them via dual harm, are likely to continue.

Dual harm behaviours were found to be expressed publicly and privately. Whilst there was no consistent pattern to indicate which type of harm would be expressed either publicly or privately, there were variables that appeared to influence expression. Some of these variables included avoiding consequences of violence (as found by Power et al., 2016), seeking help, wanting to be noticed by Officers, or avoiding the processes and protocols activated in response to self-harm (i.e. ACCTs). Dual harm provided participants with a choice of whether to let people into their experiences, a sense of ownership, and a sense of control over themselves, the prison establishment and those within it. These are likely to be salient experiences for prisoners who dual harm, particularly given that prisons are often environments that restrict prisoner autonomy and self-determination and those who dual harm are likely to spend frequent and longer periods in further restricted areas of the prison, i.e. segregation (Slade, 2018; Slade et al., 2020).

Lastly, temporarily escaping adverse psychological states through the experience of physical pain mirrored the process of suicide as proposed by Baumeister (1990). Over time, experiencing physical pain was experienced as pleasurable because of the psychological and emotional relief it provided the participants. The analysis highlighted that the method of experiencing pain was somewhat irrelevant, leading to a diverse range of methods used to experience pain and achieve escape, including an experience of ‘pain transfer’ by causing someone else pain. This could explain why Slade (2018) found that those who dual harm engage in more diverse and frequent harmful and disruptive behaviours. Furthermore, three of the six participants reported (via the interview schedule) engaging in dual harm since they were a child/adolescent. It is possible that their pain pathways (Caterina et al., 2000) had been desensitised over time; therefore, participants needed to inflict more severe damage in order to experience the body’s pain response and subsequent escape. This could explain previous findings of those who dual harm engaging in more lethal behaviours (Slade, 2018). These experiences may be what distinguishes those who dual harm from those who sole harm.

Limitations and future research

The participants of this study were all male prisoners convicted of sexual offences residing in a Category B establishment. The findings of this study may not represent those across other populations. This study relied on participant self-selection and, therefore, may have resulted in the interviews containing a particular narrative. Additionally, participants were identified from the local incident log based on having dual harmed within a recent three-year period. This may have skewed the participant selection towards those who engage in dual harm more frequently. However, it may also have resulted in participants being able to narrate their experiences more vividly and accurately. Lastly, Shafti et al. (2021) discuss possible issues in relation to the definition of dual harm, which currently reflects the behaviour occurring any time during lifetime, whereby there remain questions as to the relevance of the extent and frequency of a person’s dual harm.

The authors acknowledge that their personal and professional identities, experiences and biases may have affected their individual analytical position and interpretation of the data and took reasonable actions to lessen biases. Whilst IPA does not require large sample sizes (Smith & Osborn, 2003), further larger-scale studies are required to increase understanding of dual harm and those who engage in this behaviour. Future qualitative studies should be undertaken with those from more diverse groups, e.g. males and females residing in different prison security categories; potential participant samples incarcerated internationally; those who have left prison or are serving community sentences; those who do not have a forensic history, but engage or have engaged in dual harm; forensic populations who are no longer engaging in dual harming behaviours. The latter would require consideration to define the concept of dual harm desistance; for example, the length of time required since the last incident of dual harm; would desist from one harmful behaviour or both be required. Such research would explain the cessation process and inform future theoretical developments. Furthermore, given that three of the six participants in the current study reported having first engaged in dual harm during childhood or adolescence, there is a clear rationale for research focusing on younger populations who engage in dual harm behaviour, as well as those who begin only in adulthood. Such research would provide insight into the aetiology of dual harm and could further inform theoretical developments and early intervention.

Conclusion

The present study is novel in focus as it sought to qualitatively explore and understand the behaviour development, salient experience or the meaning ascribed by men in prison who dual harm. The interviewing and analysis of the data has shed light on why prisoners dual harm and the complex processes involved in one type of harm occurring over the other at any given time. This study indicates that co-occurrence is not coincidental and prisoners who dual harm are a distinct group with complex intra- and interpersonal experiences and needs. This likely reinforces the understandable confusion and/or conflict that staff may experience when working with prisoners who dual harm. Therefore, implications for practice must be considered in light of the current study and wider research focusing on dual harm in prisons. The findings add weight to the need for an integrated approach for the effective management of dual harm within prisons, the timing of which is consistent with prisons in England and Wales becoming trauma-informed and a focus on seeking to understand ‘what has happened’ to prisoners. Integration could be achieved by the policies, systems and processes designed to manage self-harm and violence being reviewed (e.g. relevant Prison Service Instructions) with the development of specific consideration of informed management strategies for dual harm; reviewing the CSIP and ACCT processes and how such processes can be developed and used to address both types of harmful behaviours simultaneously; careful consideration being given before the placement of dual harm prisoners in traditional segregation units; signposting to psychologically informed formulations and intervention strategies to be completed with prisoners who dual harm; and robust multi-disciplinary team working and decision-making between clinical, operational and managerial groups. On-going and further awareness, understanding and research of dual harm is an important and exciting prospect and is so needed for institutions, practitioners and importantly, for those who dual harm.

Acknowledgements

Thank you to the participants of this study for sharing their life and dual harm experiences to aid the better understanding of this important topic. Thank you to the Director of the prison for supporting the research. Thank you to the anonymous peer reviewers for their helpful feedback. No financial interest or benefit has arisen from the authors completion or application of the research. The lead author was employed at the prison establishment when the data was collected.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The dataset for this study has not been made open as this was not included within the research application or the participant consent process.

Notes

1 In the UK, adult male prisons are categorised by security level, with category ‘A’ being maximum security and category ‘D’ being the lowest level of security as an open prison.

2 A training prison offers facilities to prisoners, such as employment, education and offending behaviour programmes (National Offender Management Service, Freedom of Information Request, April 2013, FoI /81993).

3 Software that facilitates custodial management, providing prisoner information to staff; prisoner appointments, bookings and activity timetables; and electronic communication between staff and prisoners.