Self-harm among women is a serious health concern in Canada. In recent years the Elizabeth Fry Society of Manitoba, in its work with women in conflict with the law, recognized an alarming increase in the number of women who identified themselves as self-injurers and the need for expanded research and understanding. The link between childhood experiences of violence and abuse (physical, sexual, emotional, neglect) and self-harm is well-documented in the research literature. An unexamined focus is the relationship between adult experiences of abuse and violence and self-harm. This study addresses two areas of self-harm that have received little attention: (1) the needs, supports and services of women in conflict with the law in both the community and institutional settings, and (2) Aboriginal women in conflict with the law. Each of our data sources offered a unique perspective from which to address the research focus: interviews with women, both in the community and correctional institutions; a focus group with incarcerated women; community agency and correctional staff interviews; correctional staff surveys; and review of community and correctional institute policies. Our study concentrated on the Prairie Region of Canada.

Considerable insight and understanding has been gained in this research regarding the needs, supports and services of women who self-harm while incarcerated and in the community. This study has enabled us to examine helpful and unhelpful responses to self-harm in these settings. Special awareness has been attained in these areas regarding the importance of Aboriginal culture in responding to the needs, supports and services of women who self-harm.

The narratives of the women in the community and correctional institutions were combined for the data analysis. The main reason was that all women, with one exception, had a history of conflict with the law, with the majority having experienced a period of incarceration. Particular attention was paid to Aboriginal women's experiences of self-harm. As well, information gathered on community and correctional staff members was combined due to the limited number of staff respondents and the close similarity between the two groups. Where feasible, however, general references are made to denote whether a community or institutional context applies.

Informed by the women's narratives, and supported by staff perceptions and accounts and a review of the inter-disciplinary literature, our definition of self-harm evolved in this research as: Any behaviour, be it physical, emotional, social, or spiritual, that a woman commits with the intention to cause herself harm. It is a way of coping and surviving emotional pain and distress which is rooted in traumatic childhood and adult experiences of abuse and violence. It is a meaningful action which fulfills a variety of functions for women in their struggle for survival.

A diversity of women's experiences of self-harm were uncovered and classified into a Holistic Model of Self-Harm. This model represents the inter-connected and complex nature of women's self-harm. It was evident from our findings that there are no clear boundaries in defining self-harm, nor is there any one explanation. The Model demonstrates the wide range of conduct that involves the body in the expression of emotional pain and distress, from inflicting external physical forms of harm, such as slashing the skin to less visible, internal forms of harm, such as substance abuse. The Model is framed within a woman-centered approach and incorporates the connection between a woman's individual life experiences and her position in the broader social structure. This fills an important gap in the literature which frequently overlooks the relationship. Our study examines critical events in the women's childhood and adult lives that preceded their involvement in self-harm. These life experiences are typically characterized by a marginalized status, one portrayed by poverty, sexism, racism, and discrimination. Within this broader framework, we examined how some women coped and survived the violence and emotional pain in their lives by self-harming. Self-harm is viewed as a necessary though unhealthy way of responding to distressing and oppressive conditions in the women's lives.

Antecedents/Origins of Self-Harm
Information was gathered on women's childhood and adult experiences. It was found that women had the greatest likelihood of self-harm when in highly unstable and unsupportive families. Such families were characterized by: frequent moving and intermittent or permanent placements in foster and group homes; absent, weak or traumatic bonds with primary caregivers (especially the mother); unmet emotional and social needs; childhood abuse and violence (sexual, emotional, physical, and neglect); and adult abuse and violence, primarily by a partner (sexual, emotional, physical, and neglect). In our study the majority of women endured traumatic childhood and adult experiences. Similar to the women's narratives, staff identified the origins/antecedents of self-harm also to be within highly unstable and unsupportive families.

Coping and Survival Functions
The women expressed several functions of their self-harm which helped them cope and survive their emotional pain and distress. These included: a cry for attention and nurturing; self-punishment and self-blame; dealing with isolation and loneliness; distracting and deflecting emotional pain; response to an abusive partner; release and cleansing of emotional pain; opportunity to feel and bring back to reality; expression and message of painful life experiences; and a sense of power and control.

Most of the functions of self-harm identified by the staff correspond closely with those specified by the women. The main difference was the degree of importance assigned to some functions. Key departures from the women's perceptions were: minimalization of the women's need for attention and nurturing; expanded interpretation of control to include women influencing others to take control for them; less significance given to the role of isolation and loneliness in the women's lives; lack of recognition of self-harm as a means to express painful life experiences; and the inclusion of self-harm as a form of manipulation.

Needs of Women Who Self-Harm
The women's perceptions of their needs and self-harm were complex. They included:
communication as an avenue to express emotional pain and distress; a sense of control and empowerment in their lives; attention to issues of both childhood and adult abuse and violence; an understanding about their self-harm and learning alternative safe and healthy ways to cope and survive; and implementing an integrated and comprehensive care plan to promote healing which is sensitive to the role of Aboriginal culture where appropriate.

Women's Agency & Creative Ways of Coping and Surviving
The women in this study demonstrated a capacity for and in numerous cases the enactment of creative responses to deal with their self-harm. Areas of individual ingenuity and established support included: personal supports, such as keeping busy, journaling, going for a walk, positive self talk, avoiding bad influences, smudging every day; informal supports, including turning to friends and partners; formal supports, such as individual counseling, group therapy, community programming, community agency support; and other supports, including volunteer work, babysitting, and other activities in which the women feel they are making a contribution (e.g., respite work).

Risk Factors for Women's Self-harm

Institutional
There was considerable similarity between the women's and correctional staff's identification of risk factors. However, there also were differences in their rankings of importance. In general, the women's main identified risk factors emphasized personal losses and trauma (e.g., loss of children) followed by institutional conditions (e.g., segregation). The staff's risk factors focused more on interpersonal factors and institutional conditions, such as stressed relationships with other incarcerated women and a lack of outlets for the women to communicate their distress.

Community
Once again, there was much similarity between the views of the women and staff with some differences in rankings. Similar to the institutional risks, the women highlighted personal factors whereas the staff identified situational and social factors. The women identified foremost partner abuse, then personal losses, and isolation and loneliness. The significant role of partner abuse in the women's self-identified risks is an important finding, one which is not highly recognized within the existing literature or by the staff. For staff, lack of support was the central factor followed by alcohol and drug abuse, unemployment, and poverty.

Helpful and Not Helpful Responses to Women's Self-Harm

Helpful
On the basis of the expertise and knowledge of the staff and community workers, we identified the most helpful responses to women's self-harm as well as some unhelpful responses. Insights were also gained into the responses the women did not consider helpful. Helpful responses included: following a harm reduction and protection planning model, based on the premise that it is inappropriate to completely remove a woman's sole means of coping with emotional pain and distress; support, empathy and listening from staff; empowering women; staff follow-through which entails both on-going and long-term support (especially if a woman discloses childhood abuse and adult violence); working with families of women who self-harm to broaden the basis of support and safety networks; and an Aboriginal approach to healing, programs, and supports.

Not Helpful
Some staff responses had a negative impact on the women, reinforcing their feelings of isolation, low self-worth, and loss of control. A punitive approach also had negative repercussions for staff. Unhelpful responses included: physical restraints and segregation; a disrespectful and judgmental approach to women who self-harm; and unclear policy and guidelines regarding self-harm and lack of staff awareness.

Recommendations for Working With Women Who Self-Harm
Based on the information generated from the women and staff in the community and correctional institutions, recommendations have been identified for working with women who self-harm, specifically those in conflict with the law. They are stated broadly to permit generalizability across various settings and contexts. They are: constructing and increasing awareness of policy and guidelines and adoption of an integrated holistic approach to self-harm incorporating elements of harm reduction, protection planning, empowerment and being woman-centred; implementing a non-punitive approach; providing education and training for staff; recognition and support for staff; ensuring consistent, confidential and non-judgmental counseling; access to peer support and healing activities; increasing availability of Aboriginal programming; developing awareness of self-harm as an important women's issue; planning harm reduction strategies for prevention; extensive pre-release preparation and follow-through in the community; drop-in centres and services for immediate crisis intervention; and addressing larger social issues, such as education and training and safe and affordable housing.

Suggestions for Policy Recommendations and Guidelines

This study has uncovered significant findings as well as directions for future research. During the process of interviewing the women in the community, it became clear that in future research it would be important for us to increase our community focus. This would entail an expansion of staff interviews across a broad spectrum of community agencies as well as with probation and parole officers. Increasing the number of interviews with women on probation and parole would further strengthen the research design to more adequately address the needs of women upon release from a correctional institution.

New knowledge, specifically that about the relationship between self-harm and adult experiences of violence and abuse, was gained in this research and has important implications for women's health. The findings have facilitated the development of policy recommendations on self-harm as a serious health concern for women within the community and correctional institute settings. There is a clear need for women-centred policies that account for women's unique histories and present circumstances which contribute to their "choice" of self-harm as a way of coping with emotional pain and distress.

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