Treating self-harm behaviors in prisons: Effectiveness and implementation of the STEPPS program

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However, significant challenges arise when implementing evidence-based programs within this complex setting. Despite these hurdles, the Systems Training for Emotional Predictability and Problem Solving (STEPPS) program has garnered recognition, notably in the United States, for its efficacy in tackling such issues. This study aimed to examine inmate profiles in prisons located in Catalonia, Spain, and to investigate the STEPPS program's effectiveness and implementation process. Method Forty-one inmates participated in the study and completed measures covering self-harm behaviors, emotion regulation, impulsivity, mental health symptoms, and satisfaction with the intervention. Twenty-four professionals who implemented the STEPPS program completed satisfaction, normalization process, burnout, acceptability, appropriateness, and feasibility measures. Results The results suggest that the STEPPS program significantly reduced symptoms of emotional dysregulation, motor impulsivity, and compulsive symptomatology among inmates. The intervention was well-received by professionals, and perceived as appropriate and feasible. The perception of feasibility decreased after implementation, likely due to contextual factors such as inmate and organization characteristics. Additionally, professionals remained committed to the implementation, dedicating time and effort to the process and engaging in thorough evaluations, without increasing their levels of burnout. Conclusions These findings deepen the understanding of self-harm behaviors in prisons and demonstrate the effectiveness of the program. However, improvements in the STEPPS program are still necessary to enhance its implementation in this setting. Trial Registration NCT06297460 (ClinicalTrials.gov, retrospectively registered, 2022/01/01). Self-harm behaviors Correctional facilities Penitentiary intervention Implementation Research STEPPS Figures Figure 1 Figure 2 Background The prevalence of self-harm behaviors among incarcerated individuals is a significant concern within correctional facilities. Research has consistently demonstrated that the prevalence of self-harm is notably higher in prison populations compared to the general population. An annual prevalence of around 5–6% is observed among male inmates and 20–24% among female inmates, compared to the less than 1% of self-harm incidents observed among adults in the broader community ( 1 , 2 ). This significant contrast underscores the unique challenges associated with addressing self-harm in correctional settings. The complex interplay of factors such as mental health disorders, substance abuse, social isolation, and the stressful environment of prisons have been identified as significant contributors to the manifestation of self-harm behaviors among inmates ( 3 – 6 ). Major Depressive Disorder and Borderline Personality Disorder (BPD) show a more prominent association with self-injurious behaviors, along with psychotic disorders, anxiety disorders, and substance abuse( 3 , 6 ). Furthermore, emotional problems are highlighted as triggers for these self-injurious behaviors. In fact, in this context, the use of self-harm as a strategy for emotional regulation has been observed as the main motivation, both in men (60%) and women (67%) ( 7 , 8 ). Providing mental health care in correctional facilities has been reported to be insufficient and markedly lower than that offered to the general population ( 9 ). This inadequacy not only exacerbates the risk of self-harm and suicide but also leads to substantial personal and economic costs, encompassing physical and health challenges, an increase in disciplinary infractions, difficulties in interpersonal relationships, and elevated levels of stigma, among other consequences( 10 ). Furthermore, the implementation of Evidence-Based Treatments (EBTs) to address self-harm in correctional settings is often challenging. Limited resources, staff training, and organizational barriers can significantly impact the successful deployment of evidence-based strategies ( 11 – 13 ). Understanding the unique context of prisons and the perspectives of the stakeholders involved in the implementation process of these strategies is crucial for the successful adoption of interventions aimed at reducing self-harm incidents ( 14 ). To bridge the gap between mental health and correctional institutions, the implementation of a validated treatment adapted to the specific context is imperative ( 3 , 15 ). The psychological intervention program Systems Training for Emotional Predictability and Problem Solving (STEPPS) ( 16 ) has garnered widespread recognition for its effectiveness, in both clinical and correctional environments. Studies have demonstrated a significant improvement in symptomatology related to emotional and behavioral dysregulation, self-harming behaviors, and an overall enhancement in functioning. This improvement is accompanied by a decrease in depression levels and a high level of participant satisfaction, with these benefits persisting in the long term ( 16 – 22 ). In addition, the STEPPS program in the United States was considered highly suitable for implementation in prison settings ( 17 ). This is due to its features, such as its 20-week duration, ease of application aided by a well-documented manual, and minimal training required for professionals. The STEPPS program utilizes cognitive-behavioral elements to actively work on skills training in group therapy ( 17 ). Although the STEPPS program initially targeted BPD, its effectiveness has been shown to be determined not by the diagnosis, but by the presence of symptoms associated with emotional and behavioral dysregulation ( 21 ). Furthermore, the STEPPS program focuses specifically on addressing behavioral and emotional dysregulation problems. In populations engaging in self-harming behaviors, various diagnostic conditions are usually established. Nevertheless, emotional, and behavioral dysregulation represent the primary symptomatology, which is in line with the focus of the STEPPS program ( 23 ). Research has shown that the STEPPS program is suitable for addressing this issue in both prison settings and among individuals who engage in self-injurious behaviors ( 7 , 22 ). Despite the availability of EBTs, such as the STEPPS program, for addressing self-harm behaviors ( 11 – 13 ), the know-do-gap becomes evident given how inmates are not benefiting from it ( 24 , 25 ). To address this problem and according to Implementation Research (IR) designs, a hybrid type III implementation-effectiveness study has been conducted to implement the STEPPS program in the Penitentiary Centers (PCs) of Catalonia (Spain). The primary objective of the study addresses implementation outcomes and processes. For this purpose, the effectiveness of the intervention and implementation outcomes, such as acceptability, appropriateness, feasibility, and satisfaction, were quantitatively analyzed. In addition, the present study aims to improve the understanding of the profile of self-harm behaviors among inmates, providing information regarding the contributing factors, psychological processes, and circumstances surrounding self-harm behaviors. Furthermore, this study represents the first implementation of the STEPPS program in PCs in Spain. By examining the real-world application of STEPPS within prisons, it offers valuable insights to shape policy and practice, ultimately enhancing the well-being of incarcerated individuals. Method Study Design A hybrid type III implementation-effectiveness study to address self-harm behaviors was conducted in all but one of the PCs in Catalonia. Furthermore, the remaining center has been included in the new implementation studies. Hybrid models allow for the dual evaluation of the effectiveness of the clinical intervention and the implementation process to varying degrees. In this study, the hybrid type III was applied using a dual approach to assess the effectiveness of the STEPPS program in addressing self-harm behavior and implementation outcomes, barriers, and facilitators in correctional settings, placing greater emphasis on the implementation analysis. This design was chosen given that the main objective of this study is to address the applicability of the intervention in the PCs, whose effectiveness has already been widely supported by previous research ( 18 , 20 , 26 ). Barriers and facilitators are not presented in this work, which mainly focuses on quantitative data. The study was approved by General Directorate of Penitentiary Affairs of Catalonia (Code = Steppscp’s). Participants and Recruitment The study participants include both patient (inmates who engage in self-harm behaviors) and the implementers (psychologist or educators of PCs). According to the IR, the professionals participating in the implementation process of the intervention are an additional factor in the process evaluation. Consequently, their assessment as a key influence is essential. In this case, the professionals were selected from the centers themselves, with the suitability of the profiles being assessed by the center's management team. The research team only established the criteria of a minimum of two professionals per center and the condition that at least one of them must have a degree in psychology. The professionals in charge of the implementation were responsible for recruiting the inmates who would participate in the STEPPS program. Patients were defined as the inmates of the PCs in Catalonia. Inclusion criteria were: (a) Male or female inmates serving sentences in a penitentiary center in Catalonia, (b) presence of self-harm behaviors, (c) sufficient understanding and command of the Spanish language to participate in the STEPPS program, (d) sufficient cognitive competence to carry out the study, and (e) mental capacity to provide informed consent. Inmates were excluded when they met any of the following criteria: (a) Inmates serving under security measures or classified in the first level of treatment, (b) inmates with language difficulties, (c) presence of severe pathologies that hinder the study's completion, and (d) inmates with the possibility of imminent release, imminent transfers to other penitentiary centers, or pending trials. The participants did not receive any penitentiary compensation for participating in the program, their participation was entirely voluntary. Intervention STEPPS is a program based on a cognitive-behavioral approach and skills training. The original program consists of 20 weekly sessions, each lasting 2 hours. The different sessions address each of the skills worked on in the program. The program is divided into three main components. The first component (sessions: 1–2) teaches participants to replace misconceptions about the presented issues with greater awareness of the thoughts, feelings, and behaviors that characterize them, as well as to identify their own thought patterns (i.e., cognitive filters) that drive their behaviors. The second component (sessions 3–12) teaches skills to manage the cognitive and emotional effects of the issues more effectively, such as distancing, communication, challenge, distraction, and problem-solving. The third component (sessions 13–19) teaches behavioral skills, encouraging participants to master healthy eating habits, sleep hygiene, regular exercise, leisure activities, health monitoring (such as medication adherence), self-harm prevention, and interpersonal effectiveness. The therapeutic objectives of the three components address ( 1 ) illness awareness, ( 2 ) emotional regulation, and ( 3 ) behavioral regulation. Another characteristic of the STEPPS program is the inclusion of "system" members, including the support network identified by the participants. Before this study, a pilot study was conducted with a single group from one of the participating centers ( Quatre Camins ). It involved carrying out the 20 pre-established sessions. Additionally, meetings were held throughout the implementation process to document any necessary adjustments or changes. Throughout the implementation process, it is important to consider the stakeholders' perspective both to identify the gap and adapt the implementation perspective ( 27 , 28 ). When planning the implementation of the intervention for the PCs, the initial adjustment involved reducing the number of modules from 20 to 16 while maintaining all effectiveness components. Essential information about the 20-module-sessions STEPPS could be found in previous literature ( 20 ). This decrease in the number of modules was considered in the pilot study based on the infrastructure characteristics, the average time that inmates spend in a specific module, and the overlapping of basic psychoeducational content delivered in other programs. The reduction in the number of sessions does not lead to a reduction in contents, but rather a reorganization to fit the specific needs of the environment. The session reorganization was the result of joint meetings with implementers during the conducted pilot study. This collaborative approach enables maintaining the core components of the intervention while adapting it to the specific context and needs. Measures Effectiveness Outcomes The effectiveness variables in the present study have been determined considering the psychological characteristics of the population and the program approaches (see Table 1 ). Table 1 Assessment battery Instruments Assessment area Target Assessment time Patients Professionals Pre Post Effectiveness outcomes BEST Intensity, thoughts, and behavioral and emotional dysregulation X X X BIS Attentional impulsiveness, moto impulsiveness and non-planning impulsiveness. X X X SIS Suicide attempts: present and past X X ISAS Presence, frequency, and functionality of self-injurious behaviors. X X X BHS Hopelessness: expectations about life, feelings about the future and loss of motivation X X Implementation outcomes AIM Intervention’s acceptability. X X X IAM Intervention’s adequacy for the context. X X X FIM Intervention’s feasibility. X X X NoMAD Normalization process of the intervention in the system. X X CBI Personal burnout, work-related burnout, and users-related burnout X X X CSQ Implementers’ and patients’ satisfaction with the intervention. X X X AIM = Acceptability of Intervention Measure; BEST = Borderline Evaluation of Severity Over the Time; BHS = Beck Hopeless Scale; BIS = Barratt Impulsiveness Scale; BSI = Brief Symptom Inventory CBI = Copenhagen Burnout Inventory; CSQ = Client Satisfaction Questionnaire; FIM = Feasibility of Intervention Measure; IAM = Intervention Appropriateness Measure; ISAS = Inventory of Statements About Self-injury; NoMAD = Normalization Measure Development; SIS = Suicide Intent Scale. Longitudinal assessment of the severity of emotional and behavioral dysregulation (Borderline Evaluation of Severity Over Time, BEST) ( 16 ). The BEST is a 15-item questionnaire with a 5-point Likert scale (1 = none/very mild; 5 = extremely) that assesses three areas: the intensity of thoughts and emotions, and negative and positive behaviors. This questionnaire was developed together with the STEPPS program to assess the severity of symptoms over time, as well as treatment effectiveness. The test has proven to be highly valid, reliable, and internally consistent (Cronbach's alpha = 0.86–0.92) and sensitive to change in a period of just 4 weeks ( 20 ). The total score of BEST does not have a cutoff point; higher scores indicate greater emotional and behavioral dysregulation. Barratt Impulsiveness Scale (BIS) ( 29 ). The BIS is a self-report questionnaire designed to assess impulsiveness in different areas. It consists of 30 items that are scored on a 4-point scale (from rarely or never ( 1 ) to always or almost always ( 4 ). The scale measures three aspects of impulsiveness: Attentional Impulsiveness, Motor Impulsiveness, and Non-Planning Impulsiveness. The scale has been found to be internally consistent and has potential clinical utility for measuring impulsiveness among selected patients but also within inmate populations ( 30 ). Furthermore, the Spanish validation has shown high psychometric properties (Cronbach's alpha = 0.87) ( 31 ). Beck Suicidal Intent Scale (SIS) ( 32 ). This questionnaire assesses the characteristics and likelihood of a suicide attempt in the present and the past. It addresses circumstances during the attempt, attitudes towards life and death, thoughts before, during, and after the attempt, and substance use. The questionnaire consists of 20 items rated on a 3-point scale (0 to 2). The test exhibits excellent psychometric properties, with high reliability (Cronbach's alpha = 0.89) and excellent validity and discriminative ability ( 33 ). For interpretation, if items 4 and 5 are scored as 0, it is established that there is no suicide risk. In the case of scoring on these items, the score will be interpreted without establishing a cutoff point, indicating that a higher score signifies a greater risk of suicide. Inventory of Statements About Self-injury (ISAS) ( 34 ). The ISAS is a questionnaire that explores self-injurious behaviors and is divided into two sections. The first section evaluates the presence and frequency of 13 different types of self-injuries, and the second section assesses the functionality of self-injurious behaviors on a 3-point Likert scale. This questionnaire assesses self-injurious behaviors throughout the treatment and enables drawing conclusions about the program's effectiveness in addressing these behaviors. The ISAS has been recently validated in Spanish, showing good psychometric properties with good internal consistency ( 35 ). Beck Hopeless Scale (BHS) ( 36 ). The BHS is a 20-item true/false scale that assesses individuals' feelings of hopelessness. In this case, it evaluates three aspects of hopelessness: 1. A person's expectations about life; 2. Their feelings about the future, and 3. The loss of motivation. The instrument has been validated in Spanish, showing excellent internal consistency (Kuder-Richardso-20 coefficient = 0.88) ( 37 ). The scale indicates greater severity with a higher score, establishing the following levels of hopelessness based on the following cutoff points: 0–3: none or minimal, 4–8 = mild, 9–14 = moderate, and 15–20 = severe. [INSERT Table 1 ABOUT HERE] Implementation Outcomes The implementation variables are essential for evaluating the implementation process of the intervention in the penitentiary centers of Catalonia. The following aspects have been assessed: A battery of three scales including Acceptability of Intervention Measure (AIM) , Intervention Appropriateness Measurement (IAM) Feasibility of Intervention Measure (FIM) ( 38 ). These measures constitute a set of three scales: AIM, IAM, and FIM. The AIM assesses acceptability based on stakeholders' perceptions of the intervention's utility or satisfaction across four items on a 5-point Likert scale. This scale has demonstrated robust psychometric properties, with good internal consistency (Cronbach's alpha = 0.85) and a test-retest reliability coefficient of 0.83. The IAM comprises four 5-point Likert scale items designed to explore the adequacy of the intervention, considering its perceived relevance or compatibility in the given context. IAM exhibits excellent internal consistency (Cronbach's alpha = 0.91) and good test-retest reliability coefficients (0.87). The FIM encompasses four items designed to measure the feasibility of the intervention, indicating the extent to which the intervention can be successfully executed within the system, using a 5-point Likert scale. In terms of psychometric properties, the FIM demonstrates high internal consistency (Cronbach's alpha = 0.89) and robust test-retest reliability (Coefficient = 0.88). These scales lack a predefined cutoff point for interpretation; a higher score signifies a heightened perception of acceptability, appropriateness, and feasibility. Normalization Measure Development (NoMAD) ( 39 , 40 ). The NoMAD questionnaire is a brief self-report instrument based on the Normalization Process Theory (NPT), designed to assess the progress toward normalization over time in an implementation project. It consists of 20 items on a 5-point Likert scale (from 1 = completely agree to 5 = completely disagree) that address four subscales: Coherence (CO), Cognitive Participation (CP), Cognitive Allocation (CA), and Reflexive Monitoring (RM). No cutoff point was established by authors, however they indicated that higher scores should be interpreted as indicating higher level of normalization of the implemented innovation. Copenhagen Burnout Inventory (CBI) ( 41 ). Although not a direct measure of implementation variables, the CBI has been considered due to its potential influence on the implementation process. The CBI is a 19-item questionnaire on a 5-point Likert scale that measures burnout syndrome, differentiating three sub-dimensions: personal burnout, work-related burnout, and user-related burnout. The questionnaire has shown good psychometric properties in all three subscales with high consistency in the personal (Cronbach's alpha = 0.9), work-related (Cronbach's alpha = 0.83), and user-related (Cronbach's alpha = 0.82) subscales ( 42 ). Client Satisfaction Questionnaire (CSQ) ( 43 , 44 ). The CSQ is an eight-item questionnaire that assesses participants' overall satisfaction with the intervention received on a 4-point scale. It has proven to be a reliable tool with good internal consistency (Cronbach's alpha = 0.89) in the Spanish validation ( 45 ). No cutoff point has been established; instead, higher scores are indicative of a higher degree of satisfaction. Procedure The project's implementation followed several key steps (See Fig. 1 ), as outlined below: Beginning of collaboration The coordination and collaboration between the Department of Justice of Catalonia and Jaume I University begins. The Department of Justice contacted the (blinded for peer review) laboratory upon detecting the need to address self-harm behaviors in PCs. Pilot Testing at Quatre Camins Penitentiary Center. Initiating the project involved collaborative efforts with the Quatre Camins Penitentiary Center. A single-case pilot study was undertaken to preliminarily assess the program's feasibility. Numerous meetings were convened to address complications related to program evaluation and its implementation. Initial Adaptation of the STEPPS Manual. Drawing from the insights of implementers at the Quatre Camins Penitentiary Center and collaborative meetings, the STEPPS manual was first adapted to meet the specific needs of the penitentiary context. This initial adjustment resulted in a content reduction to 16 sessions (from the original 20 sessions), with a heightened emphasis on addressing self-destructive behaviors. Training Professionals in Self-Harm and Implementing the STEPPS Manual. Following the initial adaptation, a four-day training session was held for professionals in charge of the implementation. The training centered on the initial adaptation of the manual. Manual Implementation in Penitentiary Centers. After selecting participants based on established inclusion and exclusion criteria, the implementation was carried out in nine penitentiary centers in Catalonia. Biweekly Supervision during Implementation. Regular biweekly supervision ensured the reliability of implementation, provided support to implementers, and identified necessary adaptations during the implementation process. Quantitative and Qualitative Evaluation of Professionals. A thorough evaluation of the professionals implementing the intervention was conducted, utilizing both quantitative and qualitative methods to measure performance and gather experiences and feedback. In this article only implementation outcomes are presented. Evaluation of Patients' Symptomatology. The symptomatology of patients receiving the intervention was assessed to measure changes and determine the effectiveness of the STEPPS program. [INSERT FIGURE 1 ABOUT HERE] Data analysis The IBM SPSS Statistics v.28 was used to conduct all the statistical analyses. Descriptive analyses were performed to describe the sample characteristics and explore the profile of self-harm behaviors among the inmates of PCs in Catalonia (Spain). As our sample was small (< 50 samples), the Shapiro-Wilk test was used to decide whether the sample fit with a normal distribution (Mishra et al., 2019). Given the lack of normality, the Wilcoxon signed-rank test was used instead of the t-test to compare the pre-and post-intervention values on all the effectiveness and implementation outcomes. Z and p values are reported for each analysis. Results Inmate profile The sample for this study consists of 11 women (26.8%) and 30 men (73.2%) from 8 penitentiary centers in Catalonia. The mean age was 32.62 (SD = 10.79) years, ranging from 21 to 63 years. The majority of the sample was Spanish (n = 23, 56.1%) or Moroccan (n = 9, 22%), followed by Romanian (n = 2, 4.9%), Brazilian (n = 2, 4.9%), Belgian (n = 1, 2.4%), Chilean (n = 1, 2.4%), and Nigerian (n = 1, 2.4%). Two participants (4,5%) did not respond to the question regarding their nationality. Regarding the number of sessions completed by each participant, information was only available for 32 inmates. Specifically, 18 inmates were able to complete 7 or more sessions, and 9 inmates completed the entire program. Fourteen inmates completed less than 7 sessions, and 2 of them did not start the program. The forms of self-injury carried out by most inmates were self-cutting, self-carving, and self-hitting (Table 2 ). Specifically, 87.8% of them reported having performed self-cutting, 56.1% self-carving, and 73% self-hitting as a form of self-injury at some time in their lives. Generally, the time that elapses from the moment they feel the need to self-injure until they act is less than 1 hour (75.6%). It is also worth noting that during the evaluation session, many of the inmates specified a shorter period (“not even minutes”, “seconds”). Also, most inmates reported that they do it when they are alone (63.4%) and 50% reported not feeling pain. Table 2 Self-injury characteristics of the inmate sample Total N % (n) Self-injury behaviors Banging/hitting self 39 76.9 (n = 30) Biting 40 27.5 (n = 11) Burning 40 32.5 (n = 13) Carving 33 69.7 (n = 23) Cutting 40 90 (n = 36) Wound picking 40 52.5 (n = 21) Needle-sticking 40 12.5 (n = 5) Pitching 40 22.5 (n = 9) Hair pulling 39 28.2 (n = 11) Rubbing skin against rough surfaces 39 25.6 (n = 10) Severe scratching 39 33.3 (n = 13) Swallowing chemicals 40 55 (n = 22) Age of onset 9–12 38 21.1 (n = 8) 13–17 38 26.3 (n = 10) 18–21 38 28.9 (n = 11) 22–30 38 15.8 (n = 6) 31–55 38 7.9 (n = 3) Experience of pain during self-injury Yes 40 29.3 (n = 12) Sometimes 40 19.5 (n = 8) No 40 48.8 (n = 20) Self-harm alone Yes 40 63.4 (n = 26) Sometimes 40 26.8 (n = 11) No 40 7.3 (n = 3) Time between the urge to self-injure Less than 1 hour 40 75.6 (n = 31) 1–3 h 40 9.8 (n = 4) 3-6h 40 4.9 (n = 2) 6-12h 40 2.4 (n = 1) Desire to stop self-injuring Yes 40 87.8 (n = 36) No 40 2.4 (n = 1) Not sure 40 7.3 (n = 3) Suicidal ideation (Yes) 39 47.5 (n = 17) Hopelessness None-minimal 40 30 (n = 12) Mild 40 20 (n = 8) Moderate 40 37.5 (n = 15) Severe 40 12.5 (n = 5) [INSERT Table 2 ABOUT HERE] Regarding the self-injury function, affect regulation, anti-dissociation, self-punishment, and communicating discomfort showed the highest values (Fig. 2 ). In addition, most inmates expressed a desire to stop self-injury behavior (87.8%) compared to a smaller proportion who were ambivalent (7.3%) or expressed a desire to continue engaging in these behaviors (2.4%). Importantly, 70% of inmates participating in this study reported mild to severe symptoms of hopelessness, and 47.5% showed suicidal ideation. [INSERT FIGURE 2 ABOUT HERE] Professional characteristics A total of 24 professionals from 9 different penitentiary centers across Catalonia participated in this study. The mean age of the participants was 46 years (SD = 6.9), with the majority being women (70.8%, n = 17). Most (87.5%) were psychologists (n = 21), 8.3% (n = 2) were social workers (n = 2) and 4.2% (n = 1) were head of specialized care programs. On average, the professionals had 15.26 (SD = 11.13) years of experience working in penitentiary centers, showing a diverse range of expertise. The least experienced professional had 2 years of experience, while the most experienced had 40 years. Effectiveness outcomes As shown in Table 3 , inmates exhibited a significant decrease in their BEST scores from the baseline to the post-treatment assessment, indicating an improvement in emotional and behavioral dysregulation. In addition, they showed a significant decrease in the motor impulsivity subscale and obsessive-compulsive symptoms (BSI). Table 3 Wilcoxon Signed Rank test for effectiveness outcomes before and after the intervention. N Baseline Md Post-intervention Md Z Asymp Sig (2-Tailed) BEST 9 36 24 -2.67 a .008 BIS Cognitive 11 22.00 23.00 − .89 a .370 Motor 11 28.00 26.00 -2.05 a .041 Non-planning 11 30.00 27.27 − .93 a .350 BSI Depression 10 2.5 3.62 -1.94 .053 Somatization 11 1.64 1 -1.52 .130 Paranoid ideation 11 2.5 1.78 -1.68 .092 Obsession-compulsion 11 1.9 1.7 -2.04 .041 Phobic anxiety 11 .45 .50 − .18 .868 Hostility/Aggressivity 11 2.5 1.81 -1.13 .260 a Based on positive ranks: BEST: Borderline Evaluation of Severity Over Time; BIS: Barratt Impulsiveness Scale; BSI: Brief Symptom Inventory [INSERT Table 3 ABOUT HERE] Implementation outcomes In terms of satisfaction with the intervention, inmates obtained a mean score of 25.4 (SD = 4.27) on the CSQ, indicating a high level of satisfaction with the intervention. Table 4 shows the satisfaction levels of the professionals regarding the support provided by the external researchers and the STEPPS program, along with the interest they have in continuing with the implementation of STEPPS in the future. Overall, professional’s satisfaction was good, being the higher level of satisfaction obtained for the support provided by the stakeholders. Table 4 Implementation outcomes reported by the professionals Baseline Mean (SD) Baseline Md Post-Intervention Mean (SD) Post- Intervention Md Z Asymp Sig (2-Tailed) Satisfaction (CSQ) With external researchers - - 4.47(0.8) 5.00 - - With the STEPPs program - - 3.82(.95) 4.00 - - Interest in implementing STEPPS in the future - - 3.94(1.14) 4.00 - - Normalization (NoMAD) Coherence - - 1.94(.51) 2.00 - - Cognitive Participation - - 1.56(.55) 1.50 - - Collective Action -- 2.68(1.03) 2.29 - - Reflexive Monitoring - 1.96(.66) 2.10 - - Burnout (CBI) Personal related 48.61(14.02) 45.83 54.17(13.53) 52.08 -1.75 a .081 Work related 36.01(15.63) 30.36 36.60(12.93) 32.14 − .27 a .788 Client related 32.99(9.31) 33.33 34.72(10.41) 31.25 − .72 a .470 Acceptability (AIM) 4.40 (.50) 4.00 4.27(.61) 4.25 − .72 a .474 Appropriateness (IAM) 4.28(.57) 4.12 4.16(.61) 4.25 − .66 a .509 Feasibility (FIM) 3.75(.72) 3.50 3.2(.92) 2.88 -2.05 a .041 a Based on positive ranks AIM = Acceptability of Intervention Measure; CBI = Copenhagen Burnout Inventory; CSQ = Client Satisfaction Questionnaire; FIM = Feasibility of Intervention Measure; IAM = Intervention Appropriateness Measure; NoMAD = Normalization Measure Development; Additionally, evaluations of appropriateness, acceptability and feasibility showed high ratings during both the baseline and in the post-intervention assessment (Table 4 ). While acceptability and appropriateness did not reveal significant differences between the baseline and post-intervention, there was a significant decrease in terms of feasibility from the baseline to the post-intervention, revealing a decrease in the professional’s perception of feasibility over the course of the study. In this line, this study found low values on the four constructs of the NoMAD (coherence, cognitive participation, collective action, and reflexive monitoring), indicating a good level of normalization in the context of the STEPPS implementation. [INSERT Table 4 ABOUT HERE] Discussion This study aimed to explore Non-Suicidal Self-Injury behaviors within a sample of inmates in Catalonia (Spain) and to test the efficacy of the STEPPS intervention, along with implementation outcomes such as satisfaction, appropriateness, acceptability, and feasibility, considering plausible changes from baseline to post-intervention. The acquired data has significantly enhanced the understanding of self-harming behaviors within the prison population, particularly in the Catalonian context. The outlined profile aligns with existing literature, where self-cutting emerges as the predominant form of these behaviors, primarily serving as a strategy for emotional regulation. The typology of self-harming behaviors may be influenced by the means that are more accessible, with self-cutting and self-hitting being more common due to their immediate availability. Additionally, the impulsivity of these behaviors also plays a significant role ( 46 , 47 ). Within the data, a noticeable pattern emerges, indicating a strong desire to cease self-harming behaviors. However, short-term reinforcement, powerful impulses, and, in certain cases, the absence of pain contribute to the persistence of these maladaptive emotional regulation strategies ( 3 , 48 ). By acknowledging that self-harm fulfills different functions, we can implement targeted interventions that address the underlying needs. Notably, the STEPPS program appears well-suited to tackle these needs, as evidenced by the results in this study. Specifically, a significant decrease in emotional and behavioral dysregulation was shown, in line with a decrease in impulsive motor actions and a decline in compulsive symptomatology exhibited among the inmates. These results add to the evidence of the efficacy of the STEPPS program in addressing key components of dysregulation and impulsivity. Implementation outcomes indicate that professionals accepted the intervention and perceived it as appropriate. Furthermore, results from the NoMAD assessment showed that the STEPPS program was well embedded and integrated in the professional routine, considering it in line with the CPs routine (CO). Professionals were committed with the implementation (CP), investing time and actions in the process (CA), and also overall thinking and evaluating it (RM). However, feasibility perception decreased over the phases of the study. This decrease may be attributed to professionals becoming aware of the difficulties that the implementation may have during the implementation process. Factors such as impulsivity or instability traits, high rates of dual diagnosis in the population, or contextual factors such as mobility within modules and centers, conflicts with other activities, and instances of punitive isolation could have become apparent. This may have led professionals to perceive the process as more challenging than they initially thought. These complications indicate the need to conduct specific adaptations for this setting. Some of these adaptations were already conducted during the study based on the follow-up meetings during the implementation, such as transmitting the content in a more dynamic way or filling out the BEST at the beginning of the session orally instead of written. As changes were introduced to the program, professionals demonstrated a strong willingness and ability to adapt to the modifications. Additionally, it is worth noting that significant satisfaction levels were recorded regarding collaboration with the (blinded for peer review) team and with the STEPPS program. These findings underscore the importance of effective collaboration between professionals and the research team, along with the positive perception of the intervention by those involved, which could have valuable implications for future developments and improvements in the program. Indeed, despite facing various challenges and recognizing the need for adaptations, professionals expressed a high interest in implementing the program in the future. All in all, our findings suggest an improvement in emotional and behavioral regulation strategies, as well as a decrease in impulsivity levels. Additionally, the program was well-valued by professionals and inmates. However, it is emphasized that there is a need to explore the context in detail to overcome observed difficulties and generate specific adaptations. This is essential and a key aspect of this study, to address the applicability of a needed intervention in an attentional setting with the personal, contextual, and economical resources to promote its scalability (Zomahoun et al., 2019). In fact, the lack of controllability was often a challenge during the development of the study, which led to several limitations. These challenges ranged from incomplete questionnaires to difficulties in collecting pre- and post-intervention data. To illustrate these difficulties, some questionnaires arrived incomplete and disordered by mail, and in some cases, content which was unrelated to the questionnaires but belonged to parts of the study manual was received. Additionally, during the design phase of the study the plan was for professionals to inform about the number of self-harm behaviors conducted during the pre- and post-intervention phases. However, these numbers were not reported by professionals adequately. Also, some post-assessments were not conducted due to the mobility of the inmates. Despite some inmates meeting this condition, questionnaires for some of these individuals were not available. The literature shows us that this is a common contextual barrier in research assessment ( 13 ). The absence of a measurement of implementation fidelity was also a limitation of this study. It would be valuable to incorporate mechanisms to assess and ensure consistency in the program's application. Lastly, the significant loss of the sample and questionnaire completion pose a potential limitation in the generalizability of the results. The study sample was diverse, encompassing various races, ages, and genders. However, no specific analyses were conducted in this regard due to the limited sample size. While previous literature did not reveal differences (Black et al., 2018), it is crucial to acknowledge this aspect for future studies and conduct dedicated analyses to validate these findings. Even with these limitations, the findings offer valuable insights into self-harming behaviors in prisons. However, it is imperative that future research addresses these limitations for a more comprehensive and accurate understanding of the results. Future research should focus on designing and testing implementation facilitators, fidelity levels, and developing the definitive adaptation of the STEPPS program for use in Catalonia's prisons. In conclusion, this study represents a significant step towards understanding the challenges and finding solutions to implementing an intervention program in Catalonia's correctional facilities. The combination of understanding the phenomenon while assessing the intervention and taking into consideration professionals’ perspective provides a comprehensive picture of the program's effectiveness and implementation process in Catalonia's PCs. Ultimately, these results have significant practical implications for addressing mental health in specific attentional contexts, specifically in correctional settings. Declarations Ethics approval and consent to participate : The study was approved by General Directorate of Penitentiary Affairs of Catalonia (Code=Steppscp’s) (1 June 2022). The consent of participation was given by all participants. Ethics declaration: The study has been conducted following the guidelines of the Helsinki and Tokyo Declaration. Consent for publication: Informed consent was obtained from all participants included in the study. Availability of data and materials: Materials used for STEPPS implementation cannot be shared because of copyright restrictions. All data and scripts are publicly available (https://osf.io/quhzv/). Competing interest: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Funding: (1) R.L.-C. is holder of PhD grant from “Consellería de Innovación, Universidades, Ciencia y Sociedad Digital, Generalitat Valencia (Spain). Subvenciones para la contratación de personal investigador de carácter predoctoral (ACIF/2020)”. Reference: ACIF/2020/332. (2) Agreement University of Jaume I ( Castelló , Spain) - "GENERALITAT DE CATALUNYA - CENTRE FOR LEGAL STUDIES AND SPECIALIZED TRAINING. Adaptation of the Systems Training for Emotional Predictability & Problem Solving (STEPPS) program for group treatment of emotional dysregulation and self-injurious behaviors in the Penitentiary Centers of Catalonia." (3) Ministerio de Ciencia, Innovación y Universidades (Spain). Instituto de Salud Carlos III. Convocatoria de Ayudas a la acción estratégica de salud. Reference: P19/00723. Acknowledgments: We would like to express our gratitude to all professionals who have contributed to the implementation of the STEPPS program across all centers, as well as to the General Directorate of Penitentiary Affairs for making this advancement possible. Additionally, we are grateful for the contribution of all inmates who chose to participate and engage in self-improvement efforts to enhance their quality of life. Authors’ contributions: X.B-H and B.F oversaw the recruitment, training, and management of both the centers and professionals involved. R.L-C and AG-P conducted the professionals’ training and provided supervision during the program implementation. R.L-C and IJ jointly manage the data. I.J conducted data analysis and interpretation. R.L-C formatted the manuscript to journal specifications, and I.J handled the submission. All authors reviewed and approved the final manuscript. References Borges G, Nock MK, Abad JMH, Hwang I, Sampson NA, Alonso J, et al. Twelve-month prevalence of and risk factors for suicide attempts in the world health organization world mental health surveys. J Clin Psychiatry. 2010;71(12):1617–28. Hawton K, Linsell L, Adeniji T, Sariaslan A, Fazel S. Self-harm in prisons in England and Wales: an epidemiological study of prevalence, risk factors, clustering, and subsequent suicide. Lancet (London England) març. 2014;383(9923):1147–54. Favril L, O’Connor RC, Hawton K, Vander Laenen F. Factors associated with the transition from suicidal ideation to suicide attempt in prison. Eur Psychiatry. 2020;63(1). Kent H, Magner-Parsons B, Leckie G, Dulgar T, Lusiandari A, Hogarth L et al. Profiles of vulnerability for suicide and self-harm in UK prisoners: Neurodisability, mood disturbance, substance use, and bullying. Sun CF, editorPLoS ONE. 3 gener. 2024;19(1):e0296078. Power J, Cuff R, Jewell H, Mcilwaine F, O’Neill I, U’Ren G. Working in a family therapy setting with families where a parent has a mental illness: Practice dilemmas and strategies. J Family Therapy. 2015;37(4):546–62. Verdolini N, Murru A, Attademo L, Garinella R, Pacchiarotti I, Bonnin C del. The aggressor at the mirror: Psychiatric correlates of deliberate self-harm in male prison inmates. Eur PSYCHIATRY juliol. 2017;44:153–60. Power J, Usher AM, Beaudette JN. Non-Suicidal Self-Injury in Male Offenders: Initiation, Motivations, Emotions, and Precipitating Events. Int J Forensic Mental Health. 2015;14(3):147–60. Power J, Brown SL, Usher AM. Non-Suicidal Self-Injury in Women Offenders: Motivations, Emotions, and Precipitating Events. Int J Forensic Mental Health. 2013;12(3):192–204. Fazel S, Hayes AJ, Bartellas K, Clerici M, Trestman R. The mental health of prisoners: a review of prevalence, adverse outcomes and interventions Europe PMC Funders Group. Lancet Psychiatry. 2016;3(9):871–81. Smith HP, Sitren AH, King S. «A call to action» - Mental illness and self-injurious behavior occuring in jails & prisons. J Health Human Serv Adm. 2019;41(4):16–44. Brennan CA, Crosby H, Sass C, Farley KL, Bryant LD, Rodriquez-Lopez R, et al. What helps people to reduce or stop self-harm? A systematic review and meta-synthesis of first-hand accounts. J Public Health 14 març. 2023;45(1):154–61. Hawton K, Witt KG, Salisbury TLT, Arensman E, Gunnell D, Hazell P, et al. Psychosocial interventions following self-harm in adults: a systematic review and meta-analysis. Lancet Psychiatry agost. 2016;3(8):740–50. Stijelja S, Mishara BL. Preventing suicidal and self-Injurious behavior in correctional facilities: A systematic literature review and meta-analysis. eClinicalMedicine setembre. 2022;51:101560. Martin K, Mullan Z, Horton R. Overcoming the research to policy gap. Lancet Global Health març. 2019;7:S1–2. Bauer MS, Kirchner JA. Implementation science: What is it and why should I care? Psychiatry Res. 2020;283(March 2019). Blum N, Pfohl B, St. John D, Monahan P, Black DW. STEPPS: A cognitive-behavioral systems-based group treatment for outpatients with borderline personality disorder - A preliminary report. Compr Psychiatr. 2002;43(4):301–10. Black DW, Blum Nancee J, DSt. Borderline personality disorder: STEPPS is practical, evidence-based, easier to use. Curr Psychiatry. 2009;8(10):18–37. Black DW, Blum N, McCormick B, Allen J. Systems training for emotional predictability and problem solving (STEPPS) group treatment for offenders with borderline personality disorder. J Nerv Mental Disease. 2013;201(2):124–9. Black DW, Simsek-duran F, Blum N. Antisocial Personality Disorder Benefit STEPPS. 2017;10(3):205–15. Blum N, St. John D, Pfohl B, Stuart S, McCormick B, Allen J, et al. Systems Training for Emotional Predictability and Problem Solving (STEPPS) for outpatients with borderline personality disorder: A randomized controlled trial and 1-year follow-up. Am J Psychiatry. 2008;165(4):468–78. Bos EH, Van Wel EB, Appelo MT, Verbraak MJPM. Effectiveness of systems training for emotional predictability and problem solving (STEPPS) for borderline personality problems in a «Real-World» sample: Moderation by diagnosis or severity? Psychother Psychosom. 2011;80(3):173–81. Harvey R, Black DW, Blum N. Systems training for emotional predictability and problem solving (STEPPS) in the United Kingdom: A preliminary report. J Contemp Psychother. 2010;40(4):225–32. Ekiz E, Van Alphen SPJ, Ouwens MA, Van De Paar J, Videler AC. Systems Training for Emotional Predictability and Problem Solving for borderline personality disorder: A systematic review. Personality Mental Health febrer. 2023;17(1):20–39. Morris ZS, wooding S, Grant J. The answer is 17 years, what is the question: Understanding time lags in translational research. J R Soc Med. 2011;104(12):510–20. Van Den Driessen Mareeuw F, Vaandrager L, Klerkx L, Naaldenberg J, Koelen M. Beyond bridging the know-do gap: A qualitative study of systemic interaction to foster knowledge exchange in the public health sector in the Netherlands. BMC Public Health. 2015;15(1):1–15. Black DW, Simsek-Duran F, Blum N, McCormick B, Allen J. Do people with borderline personality disorder complicated by antisocial personality disorder benefit from the STEPPS treatment program? Personality mental health agost. 2016;10(3):205–15. Kitson A, Straus SE. The knowledge-to-action cycle: identifying the gaps. Can Med Association J 9 febrer. 2010;182(2):E73–7. Woerkom PMV, van Zeijl-Rozema A. Improving local implementation of an MNC’s global CSR strategy: the importance of stakeholders. Int J Bus Environ. 2017;9:247–65. Barratt ES. Anxiety and impulsiveness related to psychomotor efficiency. Percept Mot Skills. 1959;9(3):191–8. Patton JH, Stanford MS, Barratt ES. Factor structure of the Barratt impulsiveness scale. J Clin Psychol novembre. 1995;51(6):768–74. Martínez-Loredo V, Fernández-Hermida JR, Fernández-Artamendi S, Carballo JL, García-Rodríguez O. Spanish adaptation and validation of the Barratt Impulsiveness Scale for early adolescents (BIS-11-A). Int J Clin Health Psychol desembre. 2015;15(3):274–82. Beck AT, Kovacs M, Weissman A. Assessment of suicidal intention: the Scale for Suicide Ideation. J Consult Clin Psychol abril. 1979;47(2):343–52. de Rivera RFG. Evaluación y medición del riesgo de autolesión y suicidio. Medición Clínica en psiquiatría y psicología Barcelona-España Editorial Masson SA págs. 2000;225 – 44. Klonsky ED, Glenn CR. Assessing the functions of non-suicidal self-injury: Psychometric properties of the Inventory of Statements About Self-injury (ISAS). J Psychopathol Behav Assess setembre. 2009;31(3):215–9. Pérez S, García-Alandete J, Cañabate M, Marco JH. Confirmatory factor analysis of the Inventory of Statements About Self-injury in a Spanish clinical sample. J Clin Psychol. 2020;76(1):102–17. Beck AT, Weissman A, Lester D, Trexler L. The measurement of pessimism: The Hopelessness Scale. J Consult Clin Psychol. 1974;42(6):861–5. Rueda-Jaimes GE, Castro-Rueda VA, Rangel-Martínez-Villalba AM, Moreno-Quijano C, Martinez-Salazar GA, Camacho PA. Validation of the Beck Hopelessness Scale in patients with suicide risk. Revista de Psiquiatría y Salud Mental (English Edition). 2018;11(2):86–93. Weiner BJ, Lewis CC, Stanick C, Powell BJ, Dorsey CN, Clary AS, et al. Psychometric assessment of three newly developed implementation outcome measures. Implement Sci. 2017;12(1):1–13. Finch TL, Girling M, May CR, Mair FS, Murray E, Treweek S, et al. Improving the normalization of complex interventions: part 2 - validation of the NoMAD instrument for assessing implementation work based on normalization process theory (NPT). BMC Med Res Methodol. 2018;18(1):135. Rapley T, Girling M, Mair FS, Murray E, Treweek S, McColl E, et al. Improving the normalization of complex interventions: part 1 - development of the NoMAD instrument for assessing implementation work based on normalization process theory (NPT). BMC Med Res Methodol. 2018;18(1):133. Kristensen T, Borritz M, Villadsen E, Christensen K. The Copenhagen Burnout Inventory: A new tool for the assessment of burnout. Work and Stress - WORK STRESS. 1 juliol. 2005;19:192–207. Molinero Ruiz E, Basart Gómez-Quintero H, Moncada Lluis S. Fiabilidad y validez del Copenhagen Burnout Inventory para su uso en España. Rev Esp Salud Publica abril. 2013;87(2):165–79. Attkisson CC, Zwick R. The client satisfaction questionnaire. Psychometric properties and correlations with service utilization and psychotherapy outcome. Eval Program Plan. 1982;5(3):233–7. Larsen DL, Attkisson CC, Hargreaves WA, Nguyen TD. Assessment of client/patient satisfaction: Development of a general scale. Eval Program Plan. 1979;2(3):197–207. Vázquez FL, Torres Á, Otero P, Blanco V, Attkisson CC. Psychometric properties of the Castilian Spanish version of the Client Satisfaction Questionnaire (CSQ-8). Curr Psychol. 2019;38(3):829–35. Chamberlain P, Feldman SW, Wulczyn F, Saldana L, Forgatch M. Implementation and evaluation of linked parenting models in a large urban child welfare system. Child Abuse Negl. 2016;53:27–39. de Vogel V, Verstegen N. [Self-harming behavior by patients admitted to forensic psychiatry]. Tijdschrift voor psychiatrie. 2021;63(6):419–24. Brezean I, Moldovan H, Ferechide D, Vîlcu M, Petrea S. Self-harm in the prison system. Romanian J Legal Med. 2016;24(3):194–8. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5158022","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":384258988,"identity":"33104a3f-c279-4d82-ae72-330e89040f61","order_by":0,"name":"Rosa Lorente-Català","email":"","orcid":"","institution":"Universitat Jaume I","correspondingAuthor":false,"prefix":"","firstName":"Rosa","middleName":"","lastName":"Lorente-Català","suffix":""},{"id":384258989,"identity":"b9f87dbe-0c2f-4efa-8845-3dc0e872834f","order_by":1,"name":"Irene Jaén","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAoElEQVRIiWNgGAWjYBACNoYDQLKCgZmNRC1nSNECBoxtpKjmYzz88HHhvMPsfAzMhz8Q6bBjxsYztx0GOowtTYJILQfMpHnBWnjMiHMYG8Px779554C08H8m1mFnzJh5G8C2MBDrsDPF0jzH0pnZmNnMiNMiP+P4xs88NdbJ8u3Nj4lzGIPEATCVzMBMnHog4G8AU3ZEaxgFo2AUjIKRBwDG9CVMDNTdvAAAAABJRU5ErkJggg==","orcid":"","institution":"Universidad de Zaragoza","correspondingAuthor":true,"prefix":"","firstName":"Irene","middleName":"","lastName":"Jaén","suffix":""},{"id":384258990,"identity":"c135d4a2-82f9-4a6b-bd37-43c82c428924","order_by":2,"name":"Xavier Busca-Huertas","email":"","orcid":"","institution":"Generalitat de Catalunya","correspondingAuthor":false,"prefix":"","firstName":"Xavier","middleName":"","lastName":"Busca-Huertas","suffix":""},{"id":384258991,"identity":"908e98b5-4215-4de3-8282-f51428dfa1e2","order_by":3,"name":"Berta Framis","email":"","orcid":"","institution":"Rights and Memory. Generalitat de Catalunya","correspondingAuthor":false,"prefix":"","firstName":"Berta","middleName":"","lastName":"Framis","suffix":""},{"id":384258992,"identity":"b32148c2-6a73-47ad-962e-daa9dd9edf02","order_by":4,"name":"Azucena García-Palacios","email":"","orcid":"","institution":"Universitat Jaume I","correspondingAuthor":false,"prefix":"","firstName":"Azucena","middleName":"","lastName":"García-Palacios","suffix":""}],"badges":[],"createdAt":"2024-09-26 10:38:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5158022/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5158022/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s40359-024-02342-z","type":"published","date":"2025-01-16T15:57:29+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":71789839,"identity":"54c7ac02-cd95-4bbf-9554-53330b1dce1d","added_by":"auto","created_at":"2024-12-18 15:18:14","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":153154,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eImplementation process\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5158022/v1/675984cce126b1a283576944.jpg"},{"id":71789840,"identity":"1375eb4d-065a-42f2-86de-5fb0bf30910b","added_by":"auto","created_at":"2024-12-18 15:18:14","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":7261,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eScores on the ISAS for the Self-harm functions subscale\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Onlinedrawingimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-5158022/v1/ac4f398206b938a075b3f6cd.png"},{"id":74285625,"identity":"9284955d-4621-411e-9737-b268fe2b45e4","added_by":"auto","created_at":"2025-01-20 16:14:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1561229,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5158022/v1/2bd3426b-2f28-4f01-9fdf-2bf2043b595c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Treating self-harm behaviors in prisons: Effectiveness and implementation of the STEPPS program","fulltext":[{"header":"Background","content":"\u003cp\u003eThe prevalence of self-harm behaviors among incarcerated individuals is a significant concern within correctional facilities. Research has consistently demonstrated that the prevalence of self-harm is notably higher in prison populations compared to the general population. An annual prevalence of around 5\u0026ndash;6% is observed among male inmates and 20\u0026ndash;24% among female inmates, compared to the less than 1% of self-harm incidents observed among adults in the broader community (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). This significant contrast underscores the unique challenges associated with addressing self-harm in correctional settings.\u003c/p\u003e \u003cp\u003eThe complex interplay of factors such as mental health disorders, substance abuse, social isolation, and the stressful environment of prisons have been identified as significant contributors to the manifestation of self-harm behaviors among inmates (\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Major Depressive Disorder and Borderline Personality Disorder (BPD) show a more prominent association with self-injurious behaviors, along with psychotic disorders, anxiety disorders, and substance abuse(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Furthermore, emotional problems are highlighted as triggers for these self-injurious behaviors. In fact, in this context, the use of self-harm as a strategy for emotional regulation has been observed as the main motivation, both in men (60%) and women (67%) (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eProviding mental health care in correctional facilities has been reported to be insufficient and markedly lower than that offered to the general population (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). This inadequacy not only exacerbates the risk of self-harm and suicide but also leads to substantial personal and economic costs, encompassing physical and health challenges, an increase in disciplinary infractions, difficulties in interpersonal relationships, and elevated levels of stigma, among other consequences(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFurthermore, the implementation of Evidence-Based Treatments (EBTs) to address self-harm in correctional settings is often challenging. Limited resources, staff training, and organizational barriers can significantly impact the successful deployment of evidence-based strategies (\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Understanding the unique context of prisons and the perspectives of the stakeholders involved in the implementation process of these strategies is crucial for the successful adoption of interventions aimed at reducing self-harm incidents (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). To bridge the gap between mental health and correctional institutions, the implementation of a validated treatment adapted to the specific context is imperative (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe psychological intervention program Systems Training for Emotional Predictability and Problem Solving (STEPPS) (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) has garnered widespread recognition for its effectiveness, in both clinical and correctional environments. Studies have demonstrated a significant improvement in symptomatology related to emotional and behavioral dysregulation, self-harming behaviors, and an overall enhancement in functioning. This improvement is accompanied by a decrease in depression levels and a high level of participant satisfaction, with these benefits persisting in the long term (\u003cspan additionalcitationids=\"CR17 CR18 CR19 CR20 CR21\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). In addition, the STEPPS program in the United States was considered highly suitable for implementation in prison settings (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). This is due to its features, such as its 20-week duration, ease of application aided by a well-documented manual, and minimal training required for professionals.\u003c/p\u003e \u003cp\u003eThe STEPPS program utilizes cognitive-behavioral elements to actively work on skills training in group therapy (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Although the STEPPS program initially targeted BPD, its effectiveness has been shown to be determined not by the diagnosis, but by the presence of symptoms associated with emotional and behavioral dysregulation (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Furthermore, the STEPPS program focuses specifically on addressing behavioral and emotional dysregulation problems. In populations engaging in self-harming behaviors, various diagnostic conditions are usually established. Nevertheless, emotional, and behavioral dysregulation represent the primary symptomatology, which is in line with the focus of the STEPPS program (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Research has shown that the STEPPS program is suitable for addressing this issue in both prison settings and among individuals who engage in self-injurious behaviors (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite the availability of EBTs, such as the STEPPS program, for addressing self-harm behaviors (\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), the know-do-gap becomes evident given how inmates are not benefiting from it (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). To address this problem and according to Implementation Research (IR) designs, a hybrid type III implementation-effectiveness study has been conducted to implement the STEPPS program in the Penitentiary Centers (PCs) of Catalonia (Spain). The primary objective of the study addresses implementation outcomes and processes. For this purpose, the effectiveness of the intervention and implementation outcomes, such as acceptability, appropriateness, feasibility, and satisfaction, were quantitatively analyzed. In addition, the present study aims to improve the understanding of the profile of self-harm behaviors among inmates, providing information regarding the contributing factors, psychological processes, and circumstances surrounding self-harm behaviors. Furthermore, this study represents the first implementation of the STEPPS program in PCs in Spain. By examining the real-world application of STEPPS within prisons, it offers valuable insights to shape policy and practice, ultimately enhancing the well-being of incarcerated individuals.\u003c/p\u003e"},{"header":"Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eA hybrid type III implementation-effectiveness study to address self-harm behaviors was conducted in all but one of the PCs in Catalonia. Furthermore, the remaining center has been included in the new implementation studies.\u003c/p\u003e \u003cp\u003eHybrid models allow for the dual evaluation of the effectiveness of the clinical intervention and the implementation process to varying degrees. In this study, the hybrid type III was applied using a dual approach to assess the effectiveness of the STEPPS program in addressing self-harm behavior and implementation outcomes, barriers, and facilitators in correctional settings, placing greater emphasis on the implementation analysis. This design was chosen given that the main objective of this study is to address the applicability of the intervention in the PCs, whose effectiveness has already been widely supported by previous research (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Barriers and facilitators are not presented in this work, which mainly focuses on quantitative data.\u003c/p\u003e \u003cp\u003e The study was approved by General Directorate of Penitentiary Affairs of Catalonia (Code\u0026thinsp;=\u0026thinsp;Steppscp\u0026rsquo;s).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants and Recruitment\u003c/h3\u003e\n\u003cp\u003eThe study participants include both patient (inmates who engage in self-harm behaviors) and the implementers (psychologist or educators of PCs).\u003c/p\u003e \u003cp\u003eAccording to the IR, the professionals participating in the implementation process of the intervention are an additional factor in the process evaluation. Consequently, their assessment as a key influence is essential. In this case, the professionals were selected from the centers themselves, with the suitability of the profiles being assessed by the center's management team. The research team only established the criteria of a minimum of two professionals per center and the condition that at least one of them must have a degree in psychology. The professionals in charge of the implementation were responsible for recruiting the inmates who would participate in the STEPPS program.\u003c/p\u003e \u003cp\u003ePatients were defined as the inmates of the PCs in Catalonia. Inclusion criteria were: (a) Male or female inmates serving sentences in a penitentiary center in Catalonia, (b) presence of self-harm behaviors, (c) sufficient understanding and command of the Spanish language to participate in the STEPPS program, (d) sufficient cognitive competence to carry out the study, and (e) mental capacity to provide informed consent.\u003c/p\u003e \u003cp\u003eInmates were excluded when they met any of the following criteria: (a) Inmates serving under security measures or classified in the first level of treatment, (b) inmates with language difficulties, (c) presence of severe pathologies that hinder the study's completion, and (d) inmates with the possibility of imminent release, imminent transfers to other penitentiary centers, or pending trials.\u003c/p\u003e \u003cp\u003eThe participants did not receive any penitentiary compensation for participating in the program, their participation was entirely voluntary.\u003c/p\u003e\n\u003ch3\u003eIntervention\u003c/h3\u003e\n\u003cp\u003eSTEPPS is a program based on a cognitive-behavioral approach and skills training. The original program consists of 20 weekly sessions, each lasting 2 hours. The different sessions address each of the skills worked on in the program. The program is divided into three main components. The first component (sessions: 1\u0026ndash;2) teaches participants to replace misconceptions about the presented issues with greater awareness of the thoughts, feelings, and behaviors that characterize them, as well as to identify their own thought patterns (i.e., cognitive filters) that drive their behaviors. The second component (sessions 3\u0026ndash;12) teaches skills to manage the cognitive and emotional effects of the issues more effectively, such as distancing, communication, challenge, distraction, and problem-solving. The third component (sessions 13\u0026ndash;19) teaches behavioral skills, encouraging participants to master healthy eating habits, sleep hygiene, regular exercise, leisure activities, health monitoring (such as medication adherence), self-harm prevention, and interpersonal effectiveness.\u003c/p\u003e \u003cp\u003eThe therapeutic objectives of the three components address (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) illness awareness, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) emotional regulation, and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) behavioral regulation. Another characteristic of the STEPPS program is the inclusion of \"system\" members, including the support network identified by the participants.\u003c/p\u003e \u003cp\u003eBefore this study, a pilot study was conducted with a single group from one of the participating centers (\u003cem\u003eQuatre Camins\u003c/em\u003e). It involved carrying out the 20 pre-established sessions. Additionally, meetings were held throughout the implementation process to document any necessary adjustments or changes.\u003c/p\u003e \u003cp\u003eThroughout the implementation process, it is important to consider the stakeholders' perspective both to identify the gap and adapt the implementation perspective (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). When planning the implementation of the intervention for the PCs, the initial adjustment involved reducing the number of modules from 20 to 16 while maintaining all effectiveness components. Essential information about the 20-module-sessions STEPPS could be found in previous literature (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). This decrease in the number of modules was considered in the pilot study based on the infrastructure characteristics, the average time that inmates spend in a specific module, and the overlapping of basic psychoeducational content delivered in other programs. The reduction in the number of sessions does not lead to a reduction in contents, but rather a reorganization to fit the specific needs of the environment. The session reorganization was the result of joint meetings with implementers during the conducted pilot study. This collaborative approach enables maintaining the core components of the intervention while adapting it to the specific context and needs.\u003c/p\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eEffectiveness Outcomes\u003c/h2\u003e \u003cp\u003eThe effectiveness variables in the present study have been determined considering the psychological characteristics of the population and the program approaches (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eAssessment battery\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eInstruments\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAssessment area\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eTarget\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eAssessment time\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eProfessionals\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePre\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePost\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eEffectiveness outcomes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBEST\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntensity, thoughts, and behavioral and emotional dysregulation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBIS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAttentional impulsiveness, moto impulsiveness and non-planning impulsiveness.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSIS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSuicide attempts: present and past\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eISAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePresence, frequency, and functionality of self-injurious behaviors.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBHS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHopelessness: expectations about life, feelings about the future and loss of motivation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eImplementation outcomes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAIM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u0026rsquo;s acceptability.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIAM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u0026rsquo;s adequacy for the context.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFIM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u0026rsquo;s feasibility.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNoMAD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormalization process of the intervention in the system.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCBI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePersonal burnout, work-related burnout, and users-related burnout\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCSQ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImplementers\u0026rsquo; and patients\u0026rsquo; satisfaction with the intervention.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eAIM\u0026thinsp;=\u0026thinsp;Acceptability of Intervention Measure; BEST\u0026thinsp;=\u0026thinsp;Borderline Evaluation of Severity Over the Time; BHS\u0026thinsp;=\u0026thinsp;Beck Hopeless Scale; BIS\u0026thinsp;=\u0026thinsp;Barratt Impulsiveness Scale; BSI\u0026thinsp;=\u0026thinsp;Brief Symptom Inventory CBI\u0026thinsp;=\u0026thinsp;Copenhagen Burnout Inventory; CSQ\u0026thinsp;=\u0026thinsp;Client Satisfaction Questionnaire; FIM\u0026thinsp;=\u0026thinsp;Feasibility of Intervention Measure; IAM\u0026thinsp;=\u0026thinsp;Intervention Appropriateness Measure; ISAS\u0026thinsp;=\u0026thinsp;Inventory of Statements About Self-injury; NoMAD\u0026thinsp;=\u0026thinsp;Normalization Measure Development; SIS\u0026thinsp;=\u0026thinsp;Suicide Intent Scale.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eLongitudinal assessment of the severity of emotional and behavioral dysregulation\u003c/b\u003e (Borderline Evaluation of Severity Over Time, BEST) (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). The BEST is a 15-item questionnaire with a 5-point Likert scale (1\u0026thinsp;=\u0026thinsp;none/very mild; 5\u0026thinsp;=\u0026thinsp;extremely) that assesses three areas: the intensity of thoughts and emotions, and negative and positive behaviors. This questionnaire was developed together with the STEPPS program to assess the severity of symptoms over time, as well as treatment effectiveness. The test has proven to be highly valid, reliable, and internally consistent (Cronbach's alpha\u0026thinsp;=\u0026thinsp;0.86\u0026ndash;0.92) and sensitive to change in a period of just 4 weeks (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The total score of BEST does not have a cutoff point; higher scores indicate greater emotional and behavioral dysregulation.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cb\u003eBarratt Impulsiveness Scale (BIS)\u003c/b\u003e (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). The BIS is a self-report questionnaire designed to assess impulsiveness in different areas. It consists of 30 items that are scored on a 4-point scale (from rarely or never (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) to always or almost always (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The scale measures three aspects of impulsiveness: Attentional Impulsiveness, Motor Impulsiveness, and Non-Planning Impulsiveness. The scale has been found to be internally consistent and has potential clinical utility for measuring impulsiveness among selected patients but also within inmate populations (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Furthermore, the Spanish validation has shown high psychometric properties (Cronbach's alpha\u0026thinsp;=\u0026thinsp;0.87) (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eBeck Suicidal Intent Scale (SIS)\u003c/b\u003e (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). This questionnaire assesses the characteristics and likelihood of a suicide attempt in the present and the past. It addresses circumstances during the attempt, attitudes towards life and death, thoughts before, during, and after the attempt, and substance use. The questionnaire consists of 20 items rated on a 3-point scale (0 to 2). The test exhibits excellent psychometric properties, with high reliability (Cronbach's alpha\u0026thinsp;=\u0026thinsp;0.89) and excellent validity and discriminative ability (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). For interpretation, if items 4 and 5 are scored as 0, it is established that there is no suicide risk. In the case of scoring on these items, the score will be interpreted without establishing a cutoff point, indicating that a higher score signifies a greater risk of suicide.\u003c/p\u003e \u003cp\u003e \u003cb\u003eInventory of Statements About Self-injury (ISAS)\u003c/b\u003e (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). The ISAS is a questionnaire that explores self-injurious behaviors and is divided into two sections. The first section evaluates the presence and frequency of 13 different types of self-injuries, and the second section assesses the functionality of self-injurious behaviors on a 3-point Likert scale. This questionnaire assesses self-injurious behaviors throughout the treatment and enables drawing conclusions about the program's effectiveness in addressing these behaviors. The ISAS has been recently validated in Spanish, showing good psychometric properties with good internal consistency (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eBeck Hopeless Scale (BHS)\u003c/b\u003e (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). The BHS is a 20-item true/false scale that assesses individuals' feelings of hopelessness. In this case, it evaluates three aspects of hopelessness: 1. A person's expectations about life; 2. Their feelings about the future, and 3. The loss of motivation. The instrument has been validated in Spanish, showing excellent internal consistency (Kuder-Richardso-20 coefficient\u0026thinsp;=\u0026thinsp;0.88) (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). The scale indicates greater severity with a higher score, establishing the following levels of hopelessness based on the following cutoff points: 0\u0026ndash;3: none or minimal, 4\u0026ndash;8\u0026thinsp;=\u0026thinsp;mild, 9\u0026ndash;14\u0026thinsp;=\u0026thinsp;moderate, and 15\u0026ndash;20\u0026thinsp;=\u0026thinsp;severe.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e[INSERT Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e ABOUT HERE]\u003c/h2\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eImplementation Outcomes\u003c/h2\u003e \u003cp\u003eThe implementation variables are essential for evaluating the implementation process of the intervention in the penitentiary centers of Catalonia. The following aspects have been assessed:\u003c/p\u003e \u003cp\u003eA battery of three scales including \u003cb\u003eAcceptability of Intervention Measure (AIM)\u003c/b\u003e, \u003cb\u003eIntervention Appropriateness Measurement (IAM) Feasibility of Intervention Measure (FIM)\u003c/b\u003e (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). These measures constitute a set of three scales: AIM, IAM, and FIM. The AIM assesses acceptability based on stakeholders' perceptions of the intervention's utility or satisfaction across four items on a 5-point Likert scale. This scale has demonstrated robust psychometric properties, with good internal consistency (Cronbach's alpha\u0026thinsp;=\u0026thinsp;0.85) and a test-retest reliability coefficient of 0.83. The IAM comprises four 5-point Likert scale items designed to explore the adequacy of the intervention, considering its perceived relevance or compatibility in the given context. IAM exhibits excellent internal consistency (Cronbach's alpha\u0026thinsp;=\u0026thinsp;0.91) and good test-retest reliability coefficients (0.87). The FIM encompasses four items designed to measure the feasibility of the intervention, indicating the extent to which the intervention can be successfully executed within the system, using a 5-point Likert scale. In terms of psychometric properties, the FIM demonstrates high internal consistency (Cronbach's alpha\u0026thinsp;=\u0026thinsp;0.89) and robust test-retest reliability (Coefficient\u0026thinsp;=\u0026thinsp;0.88). These scales lack a predefined cutoff point for interpretation; a higher score signifies a heightened perception of acceptability, appropriateness, and feasibility.\u003c/p\u003e \u003cp\u003e \u003cb\u003eNormalization Measure Development (NoMAD)\u003c/b\u003e (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). The NoMAD questionnaire is a brief self-report instrument based on the Normalization Process Theory (NPT), designed to assess the progress toward normalization over time in an implementation project. It consists of 20 items on a 5-point Likert scale (from 1\u0026thinsp;=\u0026thinsp;completely agree to 5\u0026thinsp;=\u0026thinsp;completely disagree) that address four subscales: Coherence (CO), Cognitive Participation (CP), Cognitive Allocation (CA), and Reflexive Monitoring (RM). No cutoff point was established by authors, however they indicated that higher scores should be interpreted as indicating higher level of normalization of the implemented innovation.\u003c/p\u003e \u003cp\u003e \u003cb\u003eCopenhagen Burnout Inventory (CBI)\u003c/b\u003e (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Although not a direct measure of implementation variables, the CBI has been considered due to its potential influence on the implementation process. The CBI is a 19-item questionnaire on a 5-point Likert scale that measures burnout syndrome, differentiating three sub-dimensions: personal burnout, work-related burnout, and user-related burnout. The questionnaire has shown good psychometric properties in all three subscales with high consistency in the personal (Cronbach's alpha\u0026thinsp;=\u0026thinsp;0.9), work-related (Cronbach's alpha\u0026thinsp;=\u0026thinsp;0.83), and user-related (Cronbach's alpha\u0026thinsp;=\u0026thinsp;0.82) subscales (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eClient Satisfaction Questionnaire (CSQ)\u003c/b\u003e (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). The CSQ is an eight-item questionnaire that assesses participants' overall satisfaction with the intervention received on a 4-point scale. It has proven to be a reliable tool with good internal consistency (Cronbach's alpha\u0026thinsp;=\u0026thinsp;0.89) in the Spanish validation (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). No cutoff point has been established; instead, higher scores are indicative of a higher degree of satisfaction.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eProcedure\u003c/h3\u003e\n\u003cp\u003eThe project's implementation followed several key steps (See Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), as outlined below:\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eBeginning of collaboration\u003c/h2\u003e \u003cp\u003eThe coordination and collaboration between the Department of Justice of Catalonia and Jaume I University begins. The Department of Justice contacted the (blinded for peer review) laboratory upon detecting the need to address self-harm behaviors in PCs.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePilot Testing at\u003c/b\u003e \u003cb\u003eQuatre Camins\u003c/b\u003e \u003cb\u003ePenitentiary Center.\u003c/b\u003e Initiating the project involved collaborative efforts with the \u003cem\u003eQuatre Camins\u003c/em\u003e Penitentiary Center. A single-case pilot study was undertaken to preliminarily assess the program's feasibility. Numerous meetings were convened to address complications related to program evaluation and its implementation.\u003c/p\u003e \u003cp\u003e \u003cb\u003eInitial Adaptation of the STEPPS Manual.\u003c/b\u003e Drawing from the insights of implementers at the \u003cem\u003eQuatre Camins\u003c/em\u003e Penitentiary Center and collaborative meetings, the STEPPS manual was first adapted to meet the specific needs of the penitentiary context. This initial adjustment resulted in a content reduction to 16 sessions (from the original 20 sessions), with a heightened emphasis on addressing self-destructive behaviors.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTraining Professionals in Self-Harm and Implementing the STEPPS Manual.\u003c/b\u003e Following the initial adaptation, a four-day training session was held for professionals in charge of the implementation. The training centered on the initial adaptation of the manual.\u003c/p\u003e \u003cp\u003e\u003cb\u003eManual Implementation in Penitentiary Centers.\u003c/b\u003e After selecting participants based on established inclusion and exclusion criteria, the implementation was carried out in nine penitentiary centers in Catalonia.\u003c/p\u003e \u003cp\u003e \u003cb\u003eBiweekly Supervision during Implementation.\u003c/b\u003e Regular biweekly supervision ensured the reliability of implementation, provided support to implementers, and identified necessary adaptations during the implementation process.\u003c/p\u003e \u003cp\u003e \u003cb\u003eQuantitative and Qualitative Evaluation of Professionals.\u003c/b\u003e A thorough evaluation of the professionals implementing the intervention was conducted, utilizing both quantitative and qualitative methods to measure performance and gather experiences and feedback. In this article only implementation outcomes are presented.\u003c/p\u003e \u003cp\u003e \u003cb\u003eEvaluation of Patients' Symptomatology.\u003c/b\u003e The symptomatology of patients receiving the intervention was assessed to measure changes and determine the effectiveness of the STEPPS program.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e[INSERT FIGURE \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e ABOUT HERE]\u003c/h2\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThe IBM SPSS Statistics v.28 was used to conduct all the statistical analyses. Descriptive analyses were performed to describe the sample characteristics and explore the profile of self-harm behaviors among the inmates of PCs in Catalonia (Spain). As our sample was small (\u0026lt;\u0026thinsp;50 samples), the Shapiro-Wilk test was used to decide whether the sample fit with a normal distribution (Mishra et al., 2019). Given the lack of normality, the Wilcoxon signed-rank test was used instead of the t-test to compare the pre-and post-intervention values on all the effectiveness and implementation outcomes. Z and p values are reported for each analysis.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eInmate profile\u003c/h2\u003e \u003cp\u003eThe sample for this study consists of 11 women (26.8%) and 30 men (73.2%) from 8 penitentiary centers in Catalonia. The mean age was 32.62 (SD\u0026thinsp;=\u0026thinsp;10.79) years, ranging from 21 to 63 years. The majority of the sample was Spanish (n\u0026thinsp;=\u0026thinsp;23, 56.1%) or Moroccan (n\u0026thinsp;=\u0026thinsp;9, 22%), followed by Romanian (n\u0026thinsp;=\u0026thinsp;2, 4.9%), Brazilian (n\u0026thinsp;=\u0026thinsp;2, 4.9%), Belgian (n\u0026thinsp;=\u0026thinsp;1, 2.4%), Chilean (n\u0026thinsp;=\u0026thinsp;1, 2.4%), and Nigerian (n\u0026thinsp;=\u0026thinsp;1, 2.4%). Two participants (4,5%) did not respond to the question regarding their nationality. Regarding the number of sessions completed by each participant, information was only available for 32 inmates. Specifically, 18 inmates were able to complete 7 or more sessions, and 9 inmates completed the entire program. Fourteen inmates completed less than 7 sessions, and 2 of them did not start the program.\u003c/p\u003e \u003cp\u003eThe forms of self-injury carried out by most inmates were self-cutting, self-carving, and self-hitting (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Specifically, 87.8% of them reported having performed self-cutting, 56.1% self-carving, and 73% self-hitting as a form of self-injury at some time in their lives. Generally, the time that elapses from the moment they feel the need to self-injure until they act is less than 1 hour (75.6%). It is also worth noting that during the evaluation session, many of the inmates specified a shorter period (\u0026ldquo;not even minutes\u0026rdquo;, \u0026ldquo;seconds\u0026rdquo;). Also, most inmates reported that they do it when they are alone (63.4%) and 50% reported not feeling pain.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eSelf-injury characteristics of the inmate sample\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eTotal N\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e% (n)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSelf-injury behaviors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eBanging/hitting self\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e76.9 (n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eBiting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e27.5 (n\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eBurning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e32.5 (n\u0026thinsp;=\u0026thinsp;13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCarving\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e69.7 (n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCutting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e90 (n\u0026thinsp;=\u0026thinsp;36)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eWound picking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e52.5 (n\u0026thinsp;=\u0026thinsp;21)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eNeedle-sticking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e12.5 (n\u0026thinsp;=\u0026thinsp;5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePitching\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e22.5 (n\u0026thinsp;=\u0026thinsp;9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eHair pulling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e28.2 (n\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eRubbing skin against rough surfaces\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e25.6 (n\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSevere scratching\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e33.3 (n\u0026thinsp;=\u0026thinsp;13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSwallowing chemicals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e55 (n\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAge of onset\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e9\u0026ndash;12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e21.1 (n\u0026thinsp;=\u0026thinsp;8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e13\u0026ndash;17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e26.3 (n\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e18\u0026ndash;21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e28.9 (n\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e22\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e15.8 (n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e31\u0026ndash;55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e7.9 (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eExperience of pain during self-injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e29.3 (n\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSometimes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e19.5 (n\u0026thinsp;=\u0026thinsp;8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e48.8 (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSelf-harm alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e63.4 (n\u0026thinsp;=\u0026thinsp;26)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSometimes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e26.8 (n\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e7.3 (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eTime between the urge to self-injure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eLess than 1 hour\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e75.6 (n\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e1\u0026ndash;3 h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e9.8 (n\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e3-6h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e4.9 (n\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e6-12h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e2.4 (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eDesire to stop self-injuring\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e87.8 (n\u0026thinsp;=\u0026thinsp;36)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e2.4 (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eNot sure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e7.3 (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSuicidal ideation (Yes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e47.5 (n\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eHopelessness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eNone-minimal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e30 (n\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e20 (n\u0026thinsp;=\u0026thinsp;8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e37.5 (n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSevere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e12.5 (n\u0026thinsp;=\u0026thinsp;5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e[INSERT Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e ABOUT HERE]\u003c/h2\u003e \u003cp\u003eRegarding the self-injury function, affect regulation, anti-dissociation, self-punishment, and communicating discomfort showed the highest values (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In addition, most inmates expressed a desire to stop self-injury behavior (87.8%) compared to a smaller proportion who were ambivalent (7.3%) or expressed a desire to continue engaging in these behaviors (2.4%). Importantly, 70% of inmates participating in this study reported mild to severe symptoms of hopelessness, and 47.5% showed suicidal ideation.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e[INSERT FIGURE \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e ABOUT HERE]\u003c/h2\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003eProfessional characteristics\u003c/h2\u003e \u003cp\u003eA total of 24 professionals from 9 different penitentiary centers across Catalonia participated in this study. The mean age of the participants was 46 years (SD\u0026thinsp;=\u0026thinsp;6.9), with the majority being women (70.8%, n\u0026thinsp;=\u0026thinsp;17). Most (87.5%) were psychologists (n\u0026thinsp;=\u0026thinsp;21), 8.3% (n\u0026thinsp;=\u0026thinsp;2) were social workers (n\u0026thinsp;=\u0026thinsp;2) and 4.2% (n\u0026thinsp;=\u0026thinsp;1) were head of specialized care programs. On average, the professionals had 15.26 (SD\u0026thinsp;=\u0026thinsp;11.13) years of experience working in penitentiary centers, showing a diverse range of expertise. The least experienced professional had 2 years of experience, while the most experienced had 40 years.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eEffectiveness outcomes\u003c/h2\u003e \u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, inmates exhibited a significant decrease in their BEST scores from the baseline to the post-treatment assessment, indicating an improvement in emotional and behavioral dysregulation. In addition, they showed a significant decrease in the motor impulsivity subscale and obsessive-compulsive symptoms (BSI).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eWilcoxon Signed Rank test for effectiveness outcomes before and after the intervention.\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003cp\u003eMd\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePost-intervention\u003c/p\u003e \u003cp\u003eMd\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eZ\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAsymp Sig (2-Tailed)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBEST\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-2.67\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBIS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCognitive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.89 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.370\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMotor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-2.05 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.041\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-planning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.93 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.350\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBSI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-1.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.053\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSomatization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-1.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.130\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParanoid ideation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-1.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.092\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObsession-compulsion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-2.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.041\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhobic anxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.868\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHostility/Aggressivity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-1.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.260\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003ea\u003c/sup\u003eBased on positive ranks: BEST: Borderline Evaluation of Severity Over Time; BIS: Barratt Impulsiveness Scale; BSI: Brief Symptom Inventory\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e[INSERT Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e ABOUT HERE]\u003c/h2\u003e \u003cdiv id=\"Sec21\" class=\"Section3\"\u003e \u003ch2\u003eImplementation outcomes\u003c/h2\u003e \u003cp\u003e In terms of satisfaction with the intervention, inmates obtained a mean score of 25.4 (SD\u0026thinsp;=\u0026thinsp;4.27) on the CSQ, indicating a high level of satisfaction with the intervention. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows the satisfaction levels of the professionals regarding the support provided by the external researchers and the STEPPS program, along with the interest they have in continuing with the implementation of STEPPS in the future. Overall, professional\u0026rsquo;s satisfaction was good, being the higher level of satisfaction obtained for the support provided by the stakeholders.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eImplementation outcomes reported by the professionals\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBaseline Md\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePost-Intervention\u003c/p\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePost- Intervention\u003c/p\u003e \u003cp\u003eMd\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eZ\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAsymp Sig (2-Tailed)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSatisfaction (CSQ)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWith external researchers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.47(0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWith the STEPPs program\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.82(.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterest in implementing STEPPS in the future\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.94(1.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormalization (NoMAD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoherence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.94(.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCognitive Participation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.56(.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollective Action\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.68(1.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReflexive Monitoring\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.96(.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBurnout (CBI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePersonal related\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48.61(14.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54.17(13.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e52.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-1.75 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.081\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWork related\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36.01(15.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.60(12.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.27 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.788\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClient related\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32.99(9.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34.72(10.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.72 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.470\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcceptability (AIM)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.40 (.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.27(.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.72\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.474\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAppropriateness (IAM)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.28(.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.16(.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.66\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.509\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFeasibility (FIM)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.75(.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.2(.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-2.05\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.041\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003csup\u003ea\u003c/sup\u003eBased on positive ranks\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eAIM\u0026thinsp;=\u0026thinsp;Acceptability of Intervention Measure; CBI\u0026thinsp;=\u0026thinsp;Copenhagen Burnout Inventory; CSQ\u0026thinsp;=\u0026thinsp;Client Satisfaction Questionnaire; FIM\u0026thinsp;=\u0026thinsp;Feasibility of Intervention Measure; IAM\u0026thinsp;=\u0026thinsp;Intervention Appropriateness Measure; NoMAD\u0026thinsp;=\u0026thinsp;Normalization Measure Development;\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAdditionally, evaluations of appropriateness, acceptability and feasibility showed high ratings during both the baseline and in the post-intervention assessment (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). While acceptability and appropriateness did not reveal significant differences between the baseline and post-intervention, there was a significant decrease in terms of feasibility from the baseline to the post-intervention, revealing a decrease in the professional\u0026rsquo;s perception of feasibility over the course of the study. In this line, this study found low values on the four constructs of the NoMAD (coherence, cognitive participation, collective action, and reflexive monitoring), indicating a good level of normalization in the context of the STEPPS implementation.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003e[INSERT Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e ABOUT HERE]\u003c/h2\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to explore Non-Suicidal Self-Injury behaviors within a sample of inmates in Catalonia (Spain) and to test the efficacy of the STEPPS intervention, along with implementation outcomes such as satisfaction, appropriateness, acceptability, and feasibility, considering plausible changes from baseline to post-intervention.\u003c/p\u003e \u003cp\u003eThe acquired data has significantly enhanced the understanding of self-harming behaviors within the prison population, particularly in the Catalonian context. The outlined profile aligns with existing literature, where self-cutting emerges as the predominant form of these behaviors, primarily serving as a strategy for emotional regulation. The typology of self-harming behaviors may be influenced by the means that are more accessible, with self-cutting and self-hitting being more common due to their immediate availability. Additionally, the impulsivity of these behaviors also plays a significant role (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWithin the data, a noticeable pattern emerges, indicating a strong desire to cease self-harming behaviors. However, short-term reinforcement, powerful impulses, and, in certain cases, the absence of pain contribute to the persistence of these maladaptive emotional regulation strategies (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). By acknowledging that self-harm fulfills different functions, we can implement targeted interventions that address the underlying needs.\u003c/p\u003e \u003cp\u003eNotably, the STEPPS program appears well-suited to tackle these needs, as evidenced by the results in this study. Specifically, a significant decrease in emotional and behavioral dysregulation was shown, in line with a decrease in impulsive motor actions and a decline in compulsive symptomatology exhibited among the inmates. These results add to the evidence of the efficacy of the STEPPS program in addressing key components of dysregulation and impulsivity.\u003c/p\u003e \u003cp\u003eImplementation outcomes indicate that professionals accepted the intervention and perceived it as appropriate. Furthermore, results from the NoMAD assessment showed that the STEPPS program was well embedded and integrated in the professional routine, considering it in line with the CPs routine (CO). Professionals were committed with the implementation (CP), investing time and actions in the process (CA), and also overall thinking and evaluating it (RM). However, feasibility perception decreased over the phases of the study. This decrease may be attributed to professionals becoming aware of the difficulties that the implementation may have during the implementation process. Factors such as impulsivity or instability traits, high rates of dual diagnosis in the population, or contextual factors such as mobility within modules and centers, conflicts with other activities, and instances of punitive isolation could have become apparent. This may have led professionals to perceive the process as more challenging than they initially thought.\u003c/p\u003e \u003cp\u003eThese complications indicate the need to conduct specific adaptations for this setting. Some of these adaptations were already conducted during the study based on the follow-up meetings during the implementation, such as transmitting the content in a more dynamic way or filling out the BEST at the beginning of the session orally instead of written. As changes were introduced to the program, professionals demonstrated a strong willingness and ability to adapt to the modifications. Additionally, it is worth noting that significant satisfaction levels were recorded regarding collaboration with the (blinded for peer review) team and with the STEPPS program. These findings underscore the importance of effective collaboration between professionals and the research team, along with the positive perception of the intervention by those involved, which could have valuable implications for future developments and improvements in the program. Indeed, despite facing various challenges and recognizing the need for adaptations, professionals expressed a high interest in implementing the program in the future.\u003c/p\u003e \u003cp\u003eAll in all, our findings suggest an improvement in emotional and behavioral regulation strategies, as well as a decrease in impulsivity levels. Additionally, the program was well-valued by professionals and inmates. However, it is emphasized that there is a need to explore the context in detail to overcome observed difficulties and generate specific adaptations. This is essential and a key aspect of this study, to address the applicability of a needed intervention in an attentional setting with the personal, contextual, and economical resources to promote its scalability (Zomahoun et al., 2019).\u003c/p\u003e \u003cp\u003eIn fact, the lack of controllability was often a challenge during the development of the study, which led to several limitations. These challenges ranged from incomplete questionnaires to difficulties in collecting pre- and post-intervention data. To illustrate these difficulties, some questionnaires arrived incomplete and disordered by mail, and in some cases, content which was unrelated to the questionnaires but belonged to parts of the study manual was received. Additionally, during the design phase of the study the plan was for professionals to inform about the number of self-harm behaviors conducted during the pre- and post-intervention phases. However, these numbers were not reported by professionals adequately. Also, some post-assessments were not conducted due to the mobility of the inmates. Despite some inmates meeting this condition, questionnaires for some of these individuals were not available. The literature shows us that this is a common contextual barrier in research assessment (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe absence of a measurement of implementation fidelity was also a limitation of this study. It would be valuable to incorporate mechanisms to assess and ensure consistency in the program's application. Lastly, the significant loss of the sample and questionnaire completion pose a potential limitation in the generalizability of the results. The study sample was diverse, encompassing various races, ages, and genders. However, no specific analyses were conducted in this regard due to the limited sample size. While previous literature did not reveal differences (Black et al., 2018), it is crucial to acknowledge this aspect for future studies and conduct dedicated analyses to validate these findings. Even with these limitations, the findings offer valuable insights into self-harming behaviors in prisons. However, it is imperative that future research addresses these limitations for a more comprehensive and accurate understanding of the results. Future research should focus on designing and testing implementation facilitators, fidelity levels, and developing the definitive adaptation of the STEPPS program for use in Catalonia's prisons.\u003c/p\u003e \u003cp\u003eIn conclusion, this study represents a significant step towards understanding the challenges and finding solutions to implementing an intervention program in Catalonia's correctional facilities. The combination of understanding the phenomenon while assessing the intervention and taking into consideration professionals\u0026rsquo; perspective provides a comprehensive picture of the program's effectiveness and implementation process in Catalonia's PCs. Ultimately, these results have significant practical implications for addressing mental health in specific attentional contexts, specifically in correctional settings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e: The study was approved by General Directorate of Penitentiary Affairs of Catalonia (Code=Steppscp\u0026rsquo;s) (1 June 2022).\u0026nbsp;The consent of participation was given by all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declaration:\u003c/strong\u003e The study has been conducted following the guidelines of the Helsinki and Tokyo Declaration.\u003cbr\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Informed consent was obtained from all participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eMaterials used for STEPPS implementation cannot be shared because of copyright restrictions. All data and scripts are publicly available (https://osf.io/quhzv/).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003e(1) R.L.-C. is holder of PhD grant from \u0026ldquo;Conseller\u0026iacute;a de Innovaci\u0026oacute;n, Universidades, Ciencia y Sociedad Digital, Generalitat Valencia (Spain). Subvenciones para la contrataci\u0026oacute;n de personal investigador de car\u0026aacute;cter predoctoral (ACIF/2020)\u0026rdquo;. Reference: ACIF/2020/332. (2) Agreement University of Jaume I (\u003cem\u003eCastell\u0026oacute;\u003c/em\u003e, Spain) - \u0026quot;GENERALITAT DE CATALUNYA - CENTRE FOR LEGAL STUDIES AND SPECIALIZED TRAINING. Adaptation of the Systems Training for Emotional Predictability \u0026amp; Problem Solving (STEPPS) program for group treatment of emotional dysregulation and self-injurious behaviors in the Penitentiary Centers of Catalonia.\u0026quot; (3) Ministerio de Ciencia, Innovaci\u0026oacute;n y Universidades (Spain). Instituto de Salud Carlos III. Convocatoria de Ayudas a la acci\u0026oacute;n estrat\u0026eacute;gica de salud. Reference: P19/00723.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e We would like to express our gratitude to all professionals who have contributed to the implementation of the STEPPS program across all centers, as well as to the General Directorate of Penitentiary Affairs for making this advancement possible. Additionally, we are grateful for the contribution of all inmates who chose to participate and engage in self-improvement efforts to enhance their quality of life.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u003c/strong\u003e X.B-H and B.F oversaw the recruitment, training, and management of both the centers and professionals involved. R.L-C and AG-P conducted the professionals\u0026rsquo; training and provided supervision during the program implementation. R.L-C and IJ jointly manage the data. I.J conducted data analysis and interpretation. R.L-C formatted the manuscript to journal specifications, and I.J handled the submission. All authors reviewed and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBorges G, Nock MK, Abad JMH, Hwang I, Sampson NA, Alonso J, et al. Twelve-month prevalence of and risk factors for suicide attempts in the world health organization world mental health surveys. J Clin Psychiatry. 2010;71(12):1617\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHawton K, Linsell L, Adeniji T, Sariaslan A, Fazel S. Self-harm in prisons in England and Wales: an epidemiological study of prevalence, risk factors, clustering, and subsequent suicide. Lancet (London England) mar\u0026ccedil;. 2014;383(9923):1147\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFavril L, O\u0026rsquo;Connor RC, Hawton K, Vander Laenen F. Factors associated with the transition from suicidal ideation to suicide attempt in prison. Eur Psychiatry. 2020;63(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKent H, Magner-Parsons B, Leckie G, Dulgar T, Lusiandari A, Hogarth L et al. Profiles of vulnerability for suicide and self-harm in UK prisoners: Neurodisability, mood disturbance, substance use, and bullying. Sun CF, editorPLoS ONE. 3 gener. 2024;19(1):e0296078.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePower J, Cuff R, Jewell H, Mcilwaine F, O\u0026rsquo;Neill I, U\u0026rsquo;Ren G. Working in a family therapy setting with families where a parent has a mental illness: Practice dilemmas and strategies. J Family Therapy. 2015;37(4):546\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVerdolini N, Murru A, Attademo L, Garinella R, Pacchiarotti I, Bonnin C del. The aggressor at the mirror: Psychiatric correlates of deliberate self-harm in male prison inmates. Eur PSYCHIATRY juliol. 2017;44:153\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePower J, Usher AM, Beaudette JN. Non-Suicidal Self-Injury in Male Offenders: Initiation, Motivations, Emotions, and Precipitating Events. Int J Forensic Mental Health. 2015;14(3):147\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePower J, Brown SL, Usher AM. Non-Suicidal Self-Injury in Women Offenders: Motivations, Emotions, and Precipitating Events. Int J Forensic Mental Health. 2013;12(3):192\u0026ndash;204.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFazel S, Hayes AJ, Bartellas K, Clerici M, Trestman R. The mental health of prisoners: a review of prevalence, adverse outcomes and interventions Europe PMC Funders Group. Lancet Psychiatry. 2016;3(9):871\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith HP, Sitren AH, King S. \u0026laquo;A call to action\u0026raquo; - Mental illness and self-injurious behavior occuring in jails \u0026amp; prisons. J Health Human Serv Adm. 2019;41(4):16\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrennan CA, Crosby H, Sass C, Farley KL, Bryant LD, Rodriquez-Lopez R, et al. What helps people to reduce or stop self-harm? A systematic review and meta-synthesis of first-hand accounts. J Public Health 14 mar\u0026ccedil;. 2023;45(1):154\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHawton K, Witt KG, Salisbury TLT, Arensman E, Gunnell D, Hazell P, et al. Psychosocial interventions following self-harm in adults: a systematic review and meta-analysis. Lancet Psychiatry agost. 2016;3(8):740\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStijelja S, Mishara BL. Preventing suicidal and self-Injurious behavior in correctional facilities: A systematic literature review and meta-analysis. eClinicalMedicine setembre. 2022;51:101560.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartin K, Mullan Z, Horton R. Overcoming the research to policy gap. Lancet Global Health mar\u0026ccedil;. 2019;7:S1\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBauer MS, Kirchner JA. Implementation science: What is it and why should I care? Psychiatry Res. 2020;283(March 2019).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlum N, Pfohl B, St. John D, Monahan P, Black DW. STEPPS: A cognitive-behavioral systems-based group treatment for outpatients with borderline personality disorder - A preliminary report. Compr Psychiatr. 2002;43(4):301\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlack DW, Blum Nancee J, DSt. Borderline personality disorder: STEPPS is practical, evidence-based, easier to use. Curr Psychiatry. 2009;8(10):18\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlack DW, Blum N, McCormick B, Allen J. Systems training for emotional predictability and problem solving (STEPPS) group treatment for offenders with borderline personality disorder. J Nerv Mental Disease. 2013;201(2):124\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlack DW, Simsek-duran F, Blum N. Antisocial Personality Disorder Benefit STEPPS. 2017;10(3):205\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlum N, St. John D, Pfohl B, Stuart S, McCormick B, Allen J, et al. Systems Training for Emotional Predictability and Problem Solving (STEPPS) for outpatients with borderline personality disorder: A randomized controlled trial and 1-year follow-up. Am J Psychiatry. 2008;165(4):468\u0026ndash;78.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBos EH, Van Wel EB, Appelo MT, Verbraak MJPM. Effectiveness of systems training for emotional predictability and problem solving (STEPPS) for borderline personality problems in a \u0026laquo;Real-World\u0026raquo; sample: Moderation by diagnosis or severity? Psychother Psychosom. 2011;80(3):173\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarvey R, Black DW, Blum N. Systems training for emotional predictability and problem solving (STEPPS) in the United Kingdom: A preliminary report. J Contemp Psychother. 2010;40(4):225\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEkiz E, Van Alphen SPJ, Ouwens MA, Van De Paar J, Videler AC. Systems Training for Emotional Predictability and Problem Solving for borderline personality disorder: A systematic review. Personality Mental Health febrer. 2023;17(1):20\u0026ndash;39.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorris ZS, wooding S, Grant J. The answer is 17 years, what is the question: Understanding time lags in translational research. J R Soc Med. 2011;104(12):510\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVan Den Driessen Mareeuw F, Vaandrager L, Klerkx L, Naaldenberg J, Koelen M. Beyond bridging the know-do gap: A qualitative study of systemic interaction to foster knowledge exchange in the public health sector in the Netherlands. BMC Public Health. 2015;15(1):1\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlack DW, Simsek-Duran F, Blum N, McCormick B, Allen J. Do people with borderline personality disorder complicated by antisocial personality disorder benefit from the STEPPS treatment program? Personality mental health agost. 2016;10(3):205\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKitson A, Straus SE. The knowledge-to-action cycle: identifying the gaps. Can Med Association J 9 febrer. 2010;182(2):E73\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWoerkom PMV, van Zeijl-Rozema A. Improving local implementation of an MNC\u0026rsquo;s global CSR strategy: the importance of stakeholders. Int J Bus Environ. 2017;9:247\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarratt ES. Anxiety and impulsiveness related to psychomotor efficiency. Percept Mot Skills. 1959;9(3):191\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatton JH, Stanford MS, Barratt ES. Factor structure of the Barratt impulsiveness scale. J Clin Psychol novembre. 1995;51(6):768\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMart\u0026iacute;nez-Loredo V, Fern\u0026aacute;ndez-Hermida JR, Fern\u0026aacute;ndez-Artamendi S, Carballo JL, Garc\u0026iacute;a-Rodr\u0026iacute;guez O. Spanish adaptation and validation of the Barratt Impulsiveness Scale for early adolescents (BIS-11-A). Int J Clin Health Psychol desembre. 2015;15(3):274\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeck AT, Kovacs M, Weissman A. Assessment of suicidal intention: the Scale for Suicide Ideation. J Consult Clin Psychol abril. 1979;47(2):343\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ede Rivera RFG. Evaluaci\u0026oacute;n y medici\u0026oacute;n del riesgo de autolesi\u0026oacute;n y suicidio. Medici\u0026oacute;n Cl\u0026iacute;nica en psiquiatr\u0026iacute;a y psicolog\u0026iacute;a Barcelona-Espa\u0026ntilde;a Editorial Masson SA p\u0026aacute;gs. 2000;225\u0026thinsp;\u0026ndash;\u0026thinsp;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKlonsky ED, Glenn CR. Assessing the functions of non-suicidal self-injury: Psychometric properties of the Inventory of Statements About Self-injury (ISAS). J Psychopathol Behav Assess setembre. 2009;31(3):215\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eP\u0026eacute;rez S, Garc\u0026iacute;a-Alandete J, Ca\u0026ntilde;abate M, Marco JH. Confirmatory factor analysis of the Inventory of Statements About Self-injury in a Spanish clinical sample. J Clin Psychol. 2020;76(1):102\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeck AT, Weissman A, Lester D, Trexler L. The measurement of pessimism: The Hopelessness Scale. J Consult Clin Psychol. 1974;42(6):861\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRueda-Jaimes GE, Castro-Rueda VA, Rangel-Mart\u0026iacute;nez-Villalba AM, Moreno-Quijano C, Martinez-Salazar GA, Camacho PA. Validation of the Beck Hopelessness Scale in patients with suicide risk. Revista de Psiquiatr\u0026iacute;a y Salud Mental (English Edition). 2018;11(2):86\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeiner BJ, Lewis CC, Stanick C, Powell BJ, Dorsey CN, Clary AS, et al. Psychometric assessment of three newly developed implementation outcome measures. Implement Sci. 2017;12(1):1\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFinch TL, Girling M, May CR, Mair FS, Murray E, Treweek S, et al. Improving the normalization of complex interventions: part 2 - validation of the NoMAD instrument for assessing implementation work based on normalization process theory (NPT). BMC Med Res Methodol. 2018;18(1):135.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRapley T, Girling M, Mair FS, Murray E, Treweek S, McColl E, et al. Improving the normalization of complex interventions: part 1 - development of the NoMAD instrument for assessing implementation work based on normalization process theory (NPT). BMC Med Res Methodol. 2018;18(1):133.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKristensen T, Borritz M, Villadsen E, Christensen K. The Copenhagen Burnout Inventory: A new tool for the assessment of burnout. Work and Stress - WORK STRESS. 1 juliol. 2005;19:192\u0026ndash;207.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMolinero Ruiz E, Basart G\u0026oacute;mez-Quintero H, Moncada Lluis S. Fiabilidad y validez del Copenhagen Burnout Inventory para su uso en Espa\u0026ntilde;a. Rev Esp Salud Publica abril. 2013;87(2):165\u0026ndash;79.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAttkisson CC, Zwick R. The client satisfaction questionnaire. Psychometric properties and correlations with service utilization and psychotherapy outcome. Eval Program Plan. 1982;5(3):233\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLarsen DL, Attkisson CC, Hargreaves WA, Nguyen TD. Assessment of client/patient satisfaction: Development of a general scale. Eval Program Plan. 1979;2(3):197\u0026ndash;207.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eV\u0026aacute;zquez FL, Torres \u0026Aacute;, Otero P, Blanco V, Attkisson CC. Psychometric properties of the Castilian Spanish version of the Client Satisfaction Questionnaire (CSQ-8). Curr Psychol. 2019;38(3):829\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChamberlain P, Feldman SW, Wulczyn F, Saldana L, Forgatch M. Implementation and evaluation of linked parenting models in a large urban child welfare system. Child Abuse Negl. 2016;53:27\u0026ndash;39.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ede Vogel V, Verstegen N. [Self-harming behavior by patients admitted to forensic psychiatry]. Tijdschrift voor psychiatrie. 2021;63(6):419\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrezean I, Moldovan H, Ferechide D, V\u0026icirc;lcu M, Petrea S. Self-harm in the prison system. Romanian J Legal Med. 2016;24(3):194\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Self-harm behaviors, Correctional facilities, Penitentiary intervention, Implementation Research, STEPPS","lastPublishedDoi":"10.21203/rs.3.rs-5158022/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5158022/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eImproving mental health within correctional facilities, specifically to address self-harm behaviors, is a crucial endeavor. However, significant challenges arise when implementing evidence-based programs within this complex setting. Despite these hurdles, the Systems Training for Emotional Predictability and Problem Solving (STEPPS) program has garnered recognition, notably in the United States, for its efficacy in tackling such issues. This study aimed to examine inmate profiles in prisons located in Catalonia, Spain, and to investigate the STEPPS program's effectiveness and implementation process.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eForty-one inmates participated in the study and completed measures covering self-harm behaviors, emotion regulation, impulsivity, mental health symptoms, and satisfaction with the intervention. Twenty-four professionals who implemented the STEPPS program completed satisfaction, normalization process, burnout, acceptability, appropriateness, and feasibility measures.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe results suggest that the STEPPS program significantly reduced symptoms of emotional dysregulation, motor impulsivity, and compulsive symptomatology among inmates. The intervention was well-received by professionals, and perceived as appropriate and feasible. The perception of feasibility decreased after implementation, likely due to contextual factors such as inmate and organization characteristics. Additionally, professionals remained committed to the implementation, dedicating time and effort to the process and engaging in thorough evaluations, without increasing their levels of burnout.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThese findings deepen the understanding of self-harm behaviors in prisons and demonstrate the effectiveness of the program. However, improvements in the STEPPS program are still necessary to enhance its implementation in this setting.\u003c/p\u003e\u003ch2\u003eTrial Registration\u003c/h2\u003e \u003cp\u003eNCT06297460 (ClinicalTrials.gov, retrospectively registered, 2022/01/01).\u003c/p\u003e","manuscriptTitle":"Treating self-harm behaviors in prisons: Effectiveness and implementation of the STEPPS program","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-18 15:18:09","doi":"10.21203/rs.3.rs-5158022/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-29T11:27:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-17T15:33:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-05T12:48:18+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-25T12:48:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"236298842386821095450280785941159181445","date":"2024-10-23T13:07:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"323857401130997654380838600455387960648","date":"2024-10-18T11:01:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"281504236361891689440630965657050783879","date":"2024-10-17T09:38:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"101558296482225554716804985909451139079","date":"2024-10-17T06:27:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"116015502878821417454510992616203336784","date":"2024-10-15T08:22:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"235873904300935450420530031512412701642","date":"2024-10-15T05:53:22+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-10-14T21:57:24+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-10-01T08:48:53+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-09-29T23:59:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-09-29T23:59:25+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychology","date":"2024-09-26T10:30:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"59cb673f-4617-49e6-9120-7631f0f06fc3","owner":[],"postedDate":"December 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-01-20T16:09:30+00:00","versionOfRecord":{"articleIdentity":"rs-5158022","link":"https://doi.org/10.1186/s40359-024-02342-z","journal":{"identity":"bmc-psychology","isVorOnly":false,"title":"BMC Psychology"},"publishedOn":"2025-01-16 15:57:29","publishedOnDateReadable":"January 16th, 2025"},"versionCreatedAt":"2024-12-18 15:18:09","video":"","vorDoi":"10.1186/s40359-024-02342-z","vorDoiUrl":"https://doi.org/10.1186/s40359-024-02342-z","workflowStages":[]},"version":"v1","identity":"rs-5158022","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5158022","identity":"rs-5158022","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}