The risk of dying by suicide in a male prison in England and Wales is 3.9 times higher than in the general population (Office for National Statistics (ONS), 2023). Incidences of non-fatal self-harm are common, as are attacks on other prisoners (Ministry of Justice (MoJ), 2023). Although the statistics are shocking, they do not provide any insight into what it is like to experience the prison environment.  This is why qualitative research in this field is so vital, if we are to understand the factors that lead to self-harm and violence.

Hemming et al.’s (2023) study is a secondary analysis of data first presented in Hemming et al. (2020). It is based on a novel participatory visual method, in which participants created drawings about their feelings.

Of particular interest to me was the fact that the participants in this study were chosen because they had difficulties identifying and describing their feelings – a trait known as alexithymia (Taylor, 2000). Hemming et al.’s previous work has suggested that alexithymia might be a factor in male prisoners’ self-harm and violence, because of the inability to talk about their feelings (Hemming et al., 2020). The authors aimed to explore the emotional experiences of male prisoners leading up to acts of suicide and/or violence.

Methods

The original study (Hemming et al., 2020) recruited adult male prisoners (median age 34), who had been resident in one of two prisons in the North West of England for a week or more. All had engaged in violence, or had had thoughts of violence, towards themselves or others within the past three months. Participants needed to score above 52 on the Toronto Alexithymia Scale (TAS; Bagby et al., 1994). The current analysis is based on interviews with the nine (of 15) participants who chose to take part in the drawing element of the study. Participants were asked to talk and draw about emotions they experienced in general, and specifically prior to an act or thoughts of violence or self-harm. The drawings and accompanying narratives were analysed using polytextual thematic analysis (Gleeson, 2011).

Results

The authors generated three themes from the analysis of the nine interviews and 19 images.

The Outside Picture described outward displays of emotion, such as behavioural or facial displays, often contextualised to particular situations in which these emotions might be experienced. Often participants drew faces, most commonly depicting negative emotions such as anger, sadness, or anxiety. In their explanations, several participants said that they had deliberately only included themselves in the drawing to indicate how these emotions made them feel lonely and separate from other people. Five participants drew pictures of positive emotions (e.g., love, hope). These drawings were associated with situations that might occur outside prison, such as being in sunlight, spending time with their children or going fishing.

The Inside Picture, in contrast, described how emotions were experienced by the participant. Particularly in the context of self-harm or violence, emotions could be experienced either as an overwhelming mix of different emotions or an absence of emotions. The feeling of being overwhelmed was illustrated in one example as a mix of colour, words, and textures. In contrast, the empty feeling was illustrated by one participant as an empty bottle and by another by covering the page in black ink.

The Complexity of the Picture captured the way in which over half of the pictures illustrated a combination of concurrent emotions. Similar emotions (e.g., anger and sadness) were associated with violence towards others and with self-harm. Participants described the way in which emotions might change within a situation, so that, for example, sadness might lead to anger at the need to hide the sadness, resulting in behaviour that then caused regret.

In the discussion, the authors drew three main inferences from their findings.

First, they highlighted the distinction between external displays of emotion, and internally experienced emotions, and suggest that this may reflect prisoners’ fear of revealing their ‘true’ feelings in an unsafe environment. This is a useful reminder of the need to give adequate weight to situational drivers of suicidal behaviour (here the prison environment), not merely individual factors such as alexithymia (Favril et al., 2019).

Second, the second theme appears to be consistent with the difficulties understanding emotions inherent to alexithymia, and how that can be experienced as an emotionally overwhelming situation and/or as an absence of emotion (Hemming et al., 2020; Norman et al., 2023a). The literature indicates that this may be particularly acute at times of stress, such as prior to an act of violence or self-harm (Horne & Csipke, 2009).

Third, the evidence that similar emotions are experienced before both self-harm and violence towards others is supportive of models of ‘dual harm’, which posits that both behaviours may have similar emotional and cognitive antecedents (Shafti et al., 2021).

Conclusions

The study shows how a similar and complex range of emotions are experienced by male prisoners before thoughts and acts of violence towards themselves or others. Importantly, the study used a novel methodology which allowed participants who might otherwise struggle to verbalise their emotional experience to illustrate it through drawings.

Strengths and limitations

This study has two notable strengths. The first is the use of a visual method and polytextual thematic analysis. As mentioned above, allowing participants to communicate their experience using something other than words is an excellent way of overcoming the inherent difficulty of conducting qualitative research with certain groups. In my own research I have encouraged participants with high alexithymia to use photographs as part of the interview (Norman et al., 2022, 2023a). The other strength of this study is the involvement of people with lived experience at all stages of design and analysis, including co-authorship.

As the authors acknowledge, the context and size of the sample mean that caution needs to be applied to the transferability of the findings. In addition, I would argue that two aspects of the method limit the conclusions that can be drawn. First, participants were asked about emotions in general as well about emotions prior to violence and self-harm. The analysis does not distinguish between these scenarios, although the authors comment that the confusion captured in the theme The Inside Picture tended to be associated with violent or suicidal thoughts or behaviours. The authors reference the Card Sort Task (Townsend et al., 2016) as a method that might more systematically track the chronology of emotions preceding and following different situations. Introducing drawings to the conventionally word-based Card Sort Task might be a way of combining the best from both methods.

Second, the participants were relatively heterogeneous in their experiences. Two of the nine participants had made suicide attempts and two had attempted violence against another prisoner. The others had had thoughts of suicide or violence. We know that the risk factors for suicidal ideation may be different to those for suicidal behaviour (O’Connor & Kirtley, 2018). It is important to consider whether the emotions, and the cognitions, that precede suicidal or violent thoughts in prison are different to those that precede actions.

Implications for practice

The authors suggest that psychoeducation could help prisoners recognise and identify emotions, as a precursor to communicating them to others. Drawing on the findings from this study in particular, experiencing either a turmoil of mixed emotions or an emotional void may be an indicator of a risk of subsequent violence to themselves or others. Lastly, the drawing task supports other research indicating that art therapy could be helpful for prisoners (Gussak, 2009).

I welcome this research as an important contribution to understanding the lived experience of alexithymia in different contexts. When I volunteered as a Samaritan listener I became very aware of the difficulties some callers had in answering the question, ‘how are you feeling?’. This motivated me to explore alexithymia in the context of suicide and self-harm. The qualitative research that I undertook as part of my PhD brought to life for me the way in which not being able to identify and describe emotions made people feel misunderstood and disconnected from others, often exacerbating their distress (Norman et al., 2023a). Helping people to find other ways of expressing themselves, as Hemming et al. have done in this study, feels to me to be an important contribution to research and practice.

Importantly, however, the programme of work by Hemming et al. suggests that environmental risk factors, such as the prison culture, may be as important as individual factors, such as alexithymia. Despite scoring highly on the TAS20 some of the participants were able to give quite detailed accounts of their emotions, distinguishing between, for example, fear, anger, sadness, and anxiety. These accounts appear to differ from published case studies of alexithymia, which highlight individuals’ tendency to focus on physical symptoms and external rather than inner experiences (Lumley et al., 2007; Smith et al., 2019). This study therefore is another reminder of the need to focus on the context, as well as the individual, when designing interventions to improve mental health.

Statement of interests

I have had no involvement in the preparation or publication of this study. I have no financial interests to declare. My own research interests include alexithymia and self-harm and I have published reviews (Norman et al., 2020; Norman & Borrill, 2015) and empirical work (Norman et al., 2022, 2023a, 2023b) on this subject.

Links

Hemming, Bhatti, P., Haddock, G., Shaw, J., & Pratt, D. (2023). What emotions do male prisoners experience in the lead-up to suicide and violence? A participatory visual method study. The Journal of Forensic Psychiatry & Psychology, 34(2), 193–215. https://doi.org/10.1080/14789949.2023.2199717

Other references

Bagby, R. M., Parker, J. D. A., & Taylor, G. J. (1994). The twenty-item Toronto Alexithymia scale—I. Item selection and cross-validation of the factor structure. Journal of Psychosomatic Research, 38(1), 23–32. https://doi.org/10.1016/0022-3999(94)90005-1

Favril, L., Wittouck, C., Audenaert, K., & Vander Laenen, F. (2019). A 17-Year National Study of Prison Suicides in Belgium. Crisis : The Journal of Crisis Intervention and Suicide Prevention, 40(1), 42–53. https://doi.org/10.1027/0227-5910/a000531

Gleeson, K. (2011). Polytextual thematic analysis for visual data—Pinning down the analytic. In Visual methods in psychology: Using and interpreting images in qualitative research (pp. 314–329). Routledge/Taylor & Francis Group.

Gussak, D. (2009). The effects of art therapy on male and female inmates: Advancing the research base. The Arts in Psychotherapy, 36(1), 5–12. https://doi.org/10.1016/j.aip.2008.10.002

Hemming, L., Bhatti, P., Haddock, G., Shaw, J., & Pratt, D. (2023). What emotions do male prisoners experience in the lead-up to suicide and violence? A participatory visual method study. The Journal of Forensic Psychiatry & Psychology, 34(2), 193–215. https://doi.org/10.1080/14789949.2023.2199717

Hemming, L., Bhatti, P., Shaw, J., Haddock, G., & Pratt, D. (2020). Words Don’t Come Easy: How Male Prisoners’ Difficulties Identifying and Discussing Feelings Relate to Suicide and Violence. Frontiers in Psychiatry, 11, 581390–581390. https://doi.org/10.3389/fpsyt.2020.581390

Horne, O., & Csipke, E. (2009). From Feeling Too Little and Too Much, to Feeling More and Less? A Nonparadoxical Theory of the Functions of Self-Harm. Qualitative Health Research, 19(5), 655–667. https://doi.org/10.1177/1049732309334249

Lumley, M. A., Neely, L. C., & Burger, A. J. (2007). The Assessment of Alexithymia in Medical Settings: Implications for Understanding and Treating Health Problems. Journal of Personality Assessment, 89(3), 230–246. https://doi.org/10.1080/00223890701629698

Ministry of Justice (MoJ). (2023). Safety in Custody Statistics, England and Wales: Deaths in Prison Custody to December 2021, Assaults and Self-harm to September 2021. https://www.gov.uk/government/statistics/safety-in-custody-quarterly-update-to-september-2021/safety-in-custody-statistics-england-and-wales-deaths-in-prison-custody-to-december-2021-assaults-and-self-harm-to-september-2021

Norman, H., & Borrill, J. (2015). The relationship between self-harm and alexithymia. Scandinavian Journal of Psychology, 56(4), 405–419. https://doi.org/10.1111/sjop.12217

Norman, H., Marzano, L., Oskis, A., & Coulson, M. (2022). “My Heart and My Brain Is What’s Bleeding, These Are Just Cuts.” An Interpretative Phenomenological Analysis of Young Women’s Experiences of Self-Harm. Published Version. https://doi.org/10.3389/fpsyt.2022.914109

Norman, H., Marzano, L., Oskis, A., & Coulson, M. (2023a). “I can’t describe it and they can’t see the rain.” an interpretative phenomenological analysis of the experience of self-harm in young adults who report difficulties identifying and describing their feelings. Current Psychology (New Brunswick, N.J.), 42(12), 10151–10162. https://doi.org/10.1007/s12144-021-02273-7

Norman, H., Marzano, L., Oskis, A., & Coulson, M. (2023b). The relationship between alexithymia and self-harm: The mediating role of mindfulness. Accepted Version. https://doi.org/10.1007/s12144-021-01553-6

Norman, H., Oskis, A., Marzano, L., & Coulson, M. (2020). The relationship between self‐harm and alexithymia: A systematic review and meta‐analysis. Published Version. https://doi.org/10.1111/sjop.12668

O’Connor, R. C., & Kirtley, O. J. (2018). The integrated motivational–volitional model of suicidal behaviour. Philosophical Transactions of the Royal Society B: Biological Sciences, 373(1754), 20170268. https://doi.org/10.1098/rstb.2017.0268

Office for National Statistics (ONS). (2023). Drug-related deaths and suicide in prison  custody in England and Wales: 2008 to 2019. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/drugrelateddeathsandsuicideinprisoncustodyinenglandandwales/2023-01-26

Shafti, M., Taylor, P. J., Forrester, A., & Pratt, D. (2021). The Co-occurrence of Self-Harm and Aggression: A Cognitive-Emotional Model of Dual-Harm. Frontiers in Psychology, 12, 586135–586135. https://doi.org/10.3389/fpsyg.2021.586135

Smith, R., Kaszniak, A. W., Katsanis, J., Lane, R. D., & Nielsen, L. (2019). The importance of identifying underlying process abnormalities in alexithymia: Implications of the three-process model and a single case study illustration. Consciousness and Cognition, 68, 33–46. https://doi.org/10.1016/j.concog.2018.12.004

Taylor, G. J. (2000). Recent developments in alexithymia theory and research. Canadian Journal of Psychiatry. Revue Canadienne De Psychiatrie, 45(2), 134–142. https://doi.org/10.1177/070674370004500203

Townsend, E., Wadman, R., Sayal, K., Armstrong, M., Harroe, C., Majumder, P., Vostanis, P., & Clarke, D. (2016). Uncovering key patterns in self-harm in adolescents: Sequence analysis using the Card Sort Task for Self-harm (CaTS). Journal of Affective Disorders, 206, 161–168. https://doi.org/10.1016/j.jad.2016.07.004

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