Article Text

Download PDFPDF
110 Therapeutic diversion units, alternatives to restrictive housing, as tools for self-injury prevention and mental health improvement
  1. Molly Remch1,
  2. Rebecca Naumann1,2,
  3. Charles Mautz3,
  4. Gary Junker3
  1. 1University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Epidemiology, Chapel Hill, USA
  2. 2UNC Injury Prevention Research Center, Chapel Hill, USA
  3. 3NC Department of Public Safety, Raleigh, USA


Statement of Purpose In North Carolina prisons, Therapeutic Diversion Units (TDUs) were developed to reduce the cycling of individuals with mental health conditions through restrictive housing (i.e., solitary confinement). We evaluated if TDUs have an impact on outcomes including violent (A-level) infractions and self-harm.

Methods/Approach Using 2016 to 2019 prison records, we compared rates of infractions, inpatient mental health admissions, and self-harm in restrictive housing to rates in TDU. To do so, we used Poisson regression with generalized estimating equations to estimate rate ratios (RRs) with confidence intervals (CIs). Additionally, after individuals were released from their respective placement, we compared hazards of infractions, inpatient mental health admissions, self-harm, and subsequent restrictive housing placement to assess sustained impact of the TDU program using a Fine-Gray subdistribution model to estimate hazard ratios (HRs). In both sets of analyses, we used inverse probability of treatment weights to adjust for confounding.

Results As compared to in TDU, the rate of violent infractions in restrictive housing was five times as high (RR=5.00; 95% CI: 3.40, 7.50), the inpatient mental health admissions rate was three times as high (RR=2.85; 95% CI: 1.46, 5.56), and the self-injury rate was nearly four times as high (RR=3.86; 95% CI: 2.54, 5.85). Following release into the general prison population, the benefits of TDU placement were sustained for infractions and subsequent restrictive housing placement; however, placement in TDU increased the hazard of self-injury and did not have an effect on violent infractions.

Conclusion TDU use had strong impacts on infractions, mental health, and self-injury, but not all benefits remained after return to the general prison population.

Significance Programming such as TDUs can be effective tools to reduce violent infractions and self-injury. These findings suggest a need for additional investments in restrictive housing diversion programming, including support for sustained mental health services.

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.