The number of inmates in federal prisons who intentionally harm themselves has more than tripled over the past decade, spiking again last year, prompting Canada's correctional investigator to call for changes to ensure such prisoners are treated as patients who require medical care.
The statistics underscore the challenges of incarcerating people with mental illness, whose behaviour is sometimes dealt with through solitary confinement or force instead of treatment.
There were 1,082 incidents of self harm in the 2016-17 fiscal year, according to data from Correctional Service Canada, compared with 255 a decade earlier. Of the incidents last year, just one inmate accounted for 284.
Ivan Zinger, the federal correctional investigator, said that trend has outpaced the increase in the prison population over the same time.
"For serious and chronic self-injury ... those individuals should be transferred outside to a hospital setting," Mr. Zinger said in an interview.
"Corrections is not a hospital setting. By design, corrections' first concern is security. It's very difficult in prison to offer an appropriate therapeutic environment for complex cases."
Self injury refers to bodily disfigurement or harm without suicidal intent. The most common forms include cutting, head-banging and using ligatures.
The term does not include getting a tattoo or going on a hunger strike.
Alison Granger-Brown, a recently retired human development specialist who helped inmates with mental health and self harm in B.C. institutions, said the practice can be viewed as a coping mechanism to respond to stress.
"Most self-harm is a way of bringing calm back into unmanageable anxiety," she said. "It releases endorphins in the brain. Bioneurologically, it's calming."
Self-injury, like mental illness, is vastly overrepresented in Canadian prisons.
Up to half of incarcerated Canadians have a history of self-injury, compared with about 4 per cent of adults in the general population.
"I try to make the analogy with physical health care, because people understand physical health care," Mr. Zinger said.
"If you require surgery, corrections doesn't try to devise expertise to do in-house surgery. But for some reason, when we talk about individuals that require specialized mental health care, corrections believes they can do it themselves."
Inside the prison system, inmates caught harming themselves have been physically restrained or sent to therapeutic seclusion – which looks identical to solitary confinement.
The correctional service has acknowledged the problem with such reactions, but the correctional investigator found that in 2014-15, force was used against inmates in 14 per cent of self-injury incidents.
Dr. Granger-Brown said isolation is used to prevent inmates from killing themselves, but she said most people who self-harm are actually not suicidal.
And while correctional staff may exaggerate the risk that someone who is self-harming may be suicidal, isolating could actually aggravate that risk.
"The issues of self-harm are often exacerbated by the environment," Dr. Granger-Brown said. "In a federal correctional setting, it's longer term, it's much more regimented. And usually, people are serving much longer sentences. Therefore there's a hopelessness."
Correctional Service Canada declined to provide anyone to comment on this story, instead issuing a statement that said correctional staff receive training on how to respond to self-injury or attempted suicide.
The correctional investigator examined the issue following a 2013 coroner's inquest into Ashley Smith's death, looking specifically at female inmates who chronically injure themselves. Ms. Smith died in a segregation cell.
Following that, the service created intermediate mental-health care units in some of its institutions. The units are intended for inmates who require more care than the prison clinic can provide but whose cases are not serious enough to warrant psychiatric hospitalization.
But Mr. Zinger said that in order to fund those intermediate mental-health care units, the federal agency closed two-thirds of its existing psychiatric beds.
"We certainly don't think that was a sound approach," he said.
Dr. Granger-Brown wants to see small, specialized units with highly trained personnel that could operate as treatment centres. She admits that idea would be very expensive.
"[What] the correctional investigator has said is we should partner with mental health facilities in the province. We would love to, but they won't partner with us," she said. "They're already overworked and our people are the most complicated cases."
Treatments such as cognitive behavioural therapy and dialectical behavioural therapy have been shown to help patients who self-injure.
While sometimes responses can go wrong, Dr. Granger-Brown says it needs to be acknowledged that staff are doing their best in a very stressful situation.
"It's very easy to criticize corrections," she said. "But there are a lot of people trying to do their best under very difficult circumstances where we don't have the tools or the setting we need."