Self-harm in prison: moving towards contextual understanding.

Background: Rates of self-harm in prisons in England and Wales are historically high. Despite extensive evidence linking self-harm in custody to adversity exposure, psychiatric morbidity, neurodevelopmental conditions, acquired brain injury (ABI), substance misuse, and treatment in prison (including use of solitary confinement and experiences of victimisation), frontline officers frequently characterise self-harm as "manipulative". Framing self-harm as uncontextualized manipulation is associated with more hostile, and less therapeutic responses and may contribute to punitive institutional practices. Rationale: In this perspective, we argue that self-harm in prison is best understood as a multidetermined response to cumulative vulnerability within environments defined by profound power asymmetry. Behaviour perceived as instrumental may represent an attempt to regain safety, communicate urgency, or exert limited control in disempowering and, at times, traumatising conditions. Recognising the multiple drivers of self-harm, including trauma, mental illness, neurodivergence, ABI, and structural deprivation, is essential for compassionate and effective intervention. Conclusion: We contend that replacing simplistic interpretations, and the language of manipulation with contextual, clinically informed interpretations, alongside structural reform and staff support, is necessary to improve safety in custody and reduce harm to both prisoners and staff.