Year: 2018
Type: article
Abstract: Self-harm is common on mental health wards, an unsurprising fact given that the patient group comprises some of the most unwell people from the local community. One systematic review of 25 studies (Swannell, Martin, Page, Hasking, & St John, 2014) suggested a pooled prevalence for self-harm by inpatient mental health service users of 17.4% (range 0.7%–68.8%) including up to 21% specifically by self-cutting. It has long been recognized that custodial, coercive approaches to inpatient self-harm management are problematic, invalidate the individual's distress and disrespect their agency and autonomy. Over the years, the issue of harm-reduction approaches to self-harm has been periodically raised, most commonly as discussions of ethical and legal obligations and boundaries (Sullivan, 2017). While periodic re-examination of the fundamental principles underlying different courses of nursing management is meritorious, it is only by the generation or acquisition of new data that we can truly move the debate forward. Put bluntly, while values are important, new evidence can create the conditions for change. Recently, two studies have made important contributions. James, Samuels, Moran, and Stewart (2017) published work detailing qualitative results from interviews with UK mental health practitioners regarding their use of harm-minimization techniques. They reported patchy implementation and considerable ambivalence about their use. Our own research, recently published in this journal, took a different approach. We developed a means of quantifying support for the various approaches to management of self-cutting in the inpatient setting. The result is the Attitudes to Self-cutting Management Scale (ASc-Me), and we think the results offer some important pointers for policy and practice in mental health nursing. But first, what is harm reduction in relation to self-cutting? Fundamentally, harm reduction in all its guises starts from the premise that the end goal is neither necessarily nor inevitably abstinence. Rather—as the name suggests—it is to recognize that the extinction of some particular form of behaviour may not be realistic for, or even desired by, the individual. It seems that harm-reduction approaches are becoming increasingly accepted. For example, a 2016 review of 20 years of harm- reduction approaches noted considerable progress in relation to HIV and viral hepatitis prevention among intravenous drug users and overdose prevention (Harm Reduction International, 2016). Harm reduction for intravenous drug use is exemplified by needle exchanges and supervised injection sites. Taxpayer-funded exhortations to consume alcohol within recommended limits and to gamble safely are also rooted in a harm-reduction paradigm. In applying a harm-reduction approach to self-harm, it may be that a parallel is best drawn with cigarette smoking, where all available evidence shows negative outcomes even in small doses. Yet, even for smoking, advice to smoke fewer cigarettes, to inhale less deeply or to smoke lower tar brands has brought a harm-reduction perspective alongside the punitive tactics of graphic images on cigarette packets and taxation. Yet, despite the need for pragmatism, it genuinely is very difficult to imagine how self-harm methods such as self-poisoning, firearms or asphyxiation could have a nonabstinence message attached since there simply is “no safe limit” (NICE, 2004). Self-cutting, in contrast, does seem to be compatible with a harm-reduction approach. Some might argue that, like smoking, there are no benefits. However, we know that, for some, self-cutting provides relief from tension and is not suicidally motivated. Self-cutting can have a primarily functional purpose, and there are practical issues which, if heeded, could seriously disrupt the likelihood of severe damage: use of sterile blades, cutting relatively “safe” areas and wound cleansing. What does not a harm-reduction approach encompass? Clearly, it must not be used as an excuse to provide an uncaring approach where compassion is substituted for a brusque “you're going to do it anyway so here's some bandages, get on with it.”. And while potentially helpful, suggestions to swap out self-cutting for cold baths, drawing on the skin with red pen or twanging an elastic band on the skin are better viewed as substitution or distraction methods rather than as harm reduction. In developing the ASc-Me, we identified four main harm-reduction management techniques used by health professionals for self-cutting specifically: providing advice on wound hygiene, providing first-aid supplies, providing sterile cutting equipment and remaining with the individual to offer support during a self-cutting episode. We developed the scale to measure the acceptability of these approaches and that of non-harm-reduction approaches for comparison. Broadly, we identified three additional self-cutting management approaches—encompassing 13 specific and unique techniques—in relevant guidelines and literature. These are supportive psychosocial therapeutic interventions (including care planning, advising on distraction/substitution techniques, informing other staff of an individual's intention to self-cut), containing interventions (offering PRN medication, placing on intermittent or close observations, seclusion, restraint) and inappropriate interventions (refuse to treat, provide inappropriate treatment such as suturing without pain relief). Perhaps unsurprisingly, the therapeutic-type interventions are the most favoured method of both service user and nurse respondents. However, here were some notable differences between the groups. Service users ranked PRN medication as the third most suitable method while staff ranked it eighth. Nurses overvalued the utility of their therapeutic-type interventions relative to the service user respondents. And, with regard to harm reduction, advising on wound care (ranked fourth by nurses and second by service users) and provision of first-aid supplies (seventh and sixth, respectively) were ranked top half approaches. While the more controversial interventions such as maintaining a supportive presence (11th and 12th of 17 for both groups) were ranked lower, they still were preferred to seclusion, restraint, forced IM and, of course, the inappropriate treatment options. From our perspective, this begs the question: Why on earth would any nurse be considering the use of seclusion, restraint and so on to manage self-cutting if they have not broached harm-reduction approaches with individual service users and their team colleagues? On reflection, these findings were not a great surprise to us. There are many accounts in the literature where service users describe nonsuicidal reasons, and indeed positive, adaptive ones, for self-cutting including as a means of self-validation or in order to achieve a sense of self-mastery (Edmondson, Brennan, & House, 2016). In our clinical experience, certainly in inpatient scenarios, the resources that are mobilized to extinguish what may be functional and distress-relieving behaviour can detract from something much more valuable: the opportunity to talk with the individual in distress and work with her, instead of against her. To allow, or even facilitate, self-harm may seem counter-intuitive, even alien to our values, and may require cognitive and emotional dissonances to be aligned. However, it occurs to us that if the mechanism of harming oneself physically is alleviating a much greater emotional pain, then perhaps the focus needs to be on the latter rather than the former. Preventing a person from utilizing their coping mechanisms could well be counterproductive. At the heart of this potential moral dilemma are the competing ethical principles of autonomy vs. beneficence/nonmaleficence. Recognizing that the right-hand side of the equation is not all inevitably and implacably against harm reduction is an important first step. Our view is that we should direct resources into working with people by—and if desired—helping them to work out what works for them and subsequently helping them do it. Current advice and guidelines regarding harm minimization is, however, vague. In the UK, NICE (2012:68) states that in the community “a tentative approach to harm minimisation” is merited but offers little in terms of actual management techniques. In Australia, the equivalent guidelines (Royal Australian New Zealand College of Psychiatrists 2016) simply talk about “preventing and reducing” self-harm, not about helping people do what works for them. While there is plentiful unwarranted kneejerk bashing of the medical profession among mental health nurses, this is a striking example of how to demonstrate that you are not listening and really do not care too much what people want. ASc-Me productively adds to the overall body of evidence on self-cutting management and delivers a means of generating quantifiable, meaningful data that facilitates collection of valid and reliable information about service user and staff preference vis-a-vis harm-reduction and other approaches. At the point when a patient or service user moves from being acutely unwell and into their recovery phase, nurses must consider how they move from being reactive and defensive in their approach to a proactive choice-promoting position. We are both of the opinion that in some circumstances, and with some service users, a conversation should be had about the necessity for allowing self-harm to continue.
DOI: 10.1111/jpm.12508
Authors: Geoffrey L. Dickens, Leah Hosie
Language: English
Subfield: Clinical Psychology
Field: Psychology
Domain: Social Sciences
Open Access status: bronze
OpenAlex ID: W2902256553