Morocco: investigating suicide and self-harm

Maha Aon. It is indeed a complex subject, but our research work was made much easier by the fact that the request came from the Moroccan prison authorities themselves. They had noted a significant increase in the number of suicides in the country’s prisons and wanted to find a way of tackling this issue. When we started our research on suicide in prison, we quickly realised that the vast majority of studies came from high-income Western countries. As suicide is both an intimate and cultural phenomenon, it seemed difficult to transpose to Morocco the practises recommended in Australia or the United States. The research came out of necessity: we needed to know what the situation was in Morocco, in order to provide an appropriate response.

The prison administration already kept registers recording all suicides that occurred over the past few years. The authorities gave us access to these registers, so we did not start from scratch. However, the information recorded was mainly for security purposes and not collected as part of a comprehensive health research. For example, the registers did not contain the data needed to implement preventive measures. Indeed, about the means used by people in prison to self-harm, the registers almost systematically mentioned “self-made or handmade sharp tool”. This is a very broad category that can refer to all sorts of things: a broken piece of food tray, a phone, etc. Yet, depending on the tool, the implications for self-harm prevention would be different. The lack of precision in the data recorded was therefore a major challenge.

We were also confronted with the reluctance of prison staff to report cases of self-harm. Many felt that prisoners were using self-harm to manipulate the authorities. As a result, they only took it seriously when there were serious physical injuries, such as causing a lot of blood, or if the person had fainted. More subtle cases of self-harm were therefore not always recorded.

This situation is also attributable to the fact that the authorities had no definition of suicide or self-harm. Suicide might seem like an obvious concept, but when you start breaking it down, you realise just how difficult it is to define. What happens if a person goes on hunger strike and dies because of it? Is it suicide? The beginning of our work was therefore dedicated to developing these definitions.

It was important for us to start from definitions elaborated locally, rather than relying on dictionary definitions, or those used in other countries. The issue of self-harm has a very important cultural dimension. We first used the French term auto-mutilation but the prison administration did not like it. It implied direct physical harm, so some cases could risk being excluded from the definition: what if a person swallows a battery, they’re not mutilating themselves, but is it still self-harm? There was a whole spiritual discussion about the ‘self’ and the meaning of that ‘self’? Is it physical? Is it soul? The Moroccan authorities came up with their own expression, namely atteinte à l’intégrité physique which means that a person harms the physical integrity of their body.

MA. First, the research highlighted the fact that the suicide rate is much lower in Moroccan prisons than in other countries, particularly high-income ones. We also found that both suicide and attempted suicide are particularly gendered phenomena. Although more men than women die as a result of suicide, more women attempt suicide. The methods used for self-harm and suicide in Morocco are very similar to those also observed in high-income Western countries: mainly cutting for self-harm and hanging for suicide. Finally, we noted that people who repeatedly self-harm are generally sentenced to life imprisonment: their self-harm rates are twice as high as the rest of the prison population. People who have been repeatedly incarcerated are also about 33% more likely to self-harm. For some prisoners, self-harm can become a kind of language in prison, a way of expressing themselves and making their voices heard.

Some of these findings surprised the prison administration, others did not. The methods used to self-harm, for example, were already quite known to the authorities. However, the fact that self-harm was a subject they had to be concerned about surprised them. When I mentioned self-harm during a prison visit, prison staff laughed and said: “You can’t stop self-harm, this is so normal”. It was completely new for them to learn that they had to be concerned about self-harm and the means of preventing it. The gender difference regarding suicide also came as a surprise.

It is interesting to note that the prison administration is ahead of the Ministry of Health when it comes to tackling suicide and self-harm. When we started this programme, the Ministry of Health came to meet us. Morocco did not yet have a national policy on suicide, and the Ministry wanted to involve those responsible for developing a policy for prisons, so as to transfer it to the national level.

MA. This research was carried out as a basis for a programme and thus enabled the development of a well-informed national policy on suicide and self-harm in prisons. Morocco is the first country in the Middle East and North Africa region, if not the only one, to have developed a framework of principles on suicide and self-harm in prisons. This was possible because the recommendations we made to the prison authority were based on evidence coming directly from their country.

A comprehensive training programme and procedures manual were drawn up based on our research. The training module is aimed not only at health staff, but also at security and social services personnel. We made sure it was not us from Copenhagen who provided the training, but that a group of local prison staff became trainers. The team has since trained more than 2,000 personnel, including all the medical staff and key staff in every prison in the country. Training is provided annually so that all new key staff in each facility are trained in the policy and the manual.

A monitoring system has also been put in place. For every self-harm and suicide case, data is now collected from all departments, not just the health department. At the end of the year, trends can now be identified and compared from one year to the next, for example in terms of the tools being used for self-harm.

An internal multidisciplinary committee, made of different departments within the prison service, has been established as a result of our study. This committee should meet once a year to examine annual trends and review policies accordingly. It is coordinated by the health department and brings together the security department, the social services, the human resources, etc. Its primary objective is to enable the prison authorities to be aware of what is happening in their prisons. It provides them with an overview of the tendencies and an understanding of them, rather than just considering individual cases. For example, the committee discussed the issue of razors at its last meeting. The prison administration has very rigorous and comprehensive policies on when prisoners are supposed to get a razor and return it. We discussed this at the last meeting to make the administration aware that perhaps this issue needed to be re-examined. Solitary confinement and its alternatives were also discussed, but it is clear that change takes effort and time. This committee therefore allows a wide range of discussions to take place, some of them quite practical, others more policy-oriented.

It should nevertheless be emphasised that while policies and measures aimed at reducing the number of suicides and cases of self-harm are being put in place, mental health problems in Moroccan prisons are still a challenge due to chronic overcrowding and understaffing.

We are continuing to support the prison administration and, in particular, over the next few years we will be carrying out a study into the risk factors for self-harm in Moroccan prisons, rather than just looking at cases as we did in this research. This time, it will be a case-control study: we will compare people who have self-harmed with those who have not, in order to determine what the risk factors are. This will enable us to identify the people at risk, so that we can better target measures to prevent self-harm.