What is the nurses role in supporting people who self harm

[andy]

I was talking to a nursing colleague who states that many nurses appear to have major difficulties with issues such as controlled cutting etc. There is a conflcit with the NHS system and nurses perceived 'duty of care'. The nursing colleague doe not see a conflict but, others do. From my own point of view issues such as 'controlled cutting' especially for teenagers requires clinical freedoms which are not always apparent in the NHS. There is an initiative to be proposed at the next Royal College of Nursing congress by some members which aims to clarify why such methods are difficult to address in the Health Service.

What do people think?

[anon_e-mouse]

I don't understand
Are you saying that patients are allowed to cut themselves and nurses will support them to do so.

This seems crazy.

[andy]

Anon e mouse asked the question so i feel I should respond. The straight answer is 'yes'. In extreme cases the compulsion to cut is overwhelming and there is some evidence that allowing a person to cut in a limited and controlled way may reduce anxiety. It is an extremely controversial subject and obviously as a method is open to abuse.

[anon_e-mouse]

Thanks Andy, it seems like that was difficult for you to give that answer.

I am still surprised. When people are a risk either to themselves or others they require care. I would hope that when receiving that care they would have the likelihood of harm reduced or managed.

Is it not an easy option to avoid providing care and allowing people to harm themselves? this is one obvious area of potential abuse.

my reason for thinking this way is probably too black and white but if i substituted another behavior which causes harm into the same rationale it makes even less sense.

eg, In extreme cases the compulsion to head bang is overwhelming and allowing someone to head bang in a limited and controlled way may reduce anxiety.

In extreme cases the compulsion to hit other people is overwhelming and allowing someone to hit other people in a limited and controlled way may reduce anxiety.

You can substitute other harmful behaviors if you want into the statement.

So my question now becomes "is there something unique about allowing cutting behavior in a limited and controlled way, that does not apply to allowing other behaviors in a limited and controlled way?"

(The nurses role is surely to provide best possible care.)

[fuddsi]

would not the answer be,to agree a strategy as a team. it should not be left to one individual to agree what is right or wrong, as presumably there is more than one professional involved. what does the "self harmer" think. are they able to agree to agreed limits? this seems to cause more anxiety for the nurse than the person in their care?

[ged]

One positive aspect of supporting people to self-harm is that we can reduce the risks involved, and thus the impact of the C/B. We can provide clean equipment, clean environment, first aid on tap, counselling. If the person cuts in secret, none of these may be available.

A primary goal is to reduce the impact of the C/B, so by managing something which will happen anyway, we make the risks predicable.

I'd equate this to making sure that the punches thrown by the person who has a compulsion to hit people don't damage the staff, but that he hits a punch mitt which a staff member is holding instead. Same action, but managable consquence.

I can't say that I've ever supported people to self-harm, and I'd find it quite a challenge. It runs against all instinct to let the people in your charge harm themselves. I see some problems in the practicalities of it as well. Sharps are generally well controlled in psych units.

Ged

[Louise]

I have worked with women who self harm and I have to admit that I was horrified as a deputy manager when my new manager devised a new approach to supporting women who self harm. I have supported women to self harm in a controlled and safer way and it has shown that further risks have been reduced. There are many ways to support self harmers and with risk assessments and agreed support specifications it pays for this to be the way forward. I would rather see a person self harm in a way thats safe and agreed rather than see a person become completely frustrated and ram their head through a glass window.

[nikkij]

I recently read something, which I think would be beneficial to look further into. Having not worked with individuals who self-harm I am unsure if this could be something that could help:

An alternative to cutting could be to use ice-cubes; when an ice-cube is placed on an area of skin for some time (such as the forearm) it produces a similar stinging sensation as the cutting does....

I've not looked into how much research has been done on this, but think it could make a very interesting study....I'm sure as with everything this technique may only help a few individuals....I was just interested in people's thoughts on this....

Nikki

[steveg]

A topical subject as last week in the media a local hospital (Staffordshire) has adopted the approach of allowing self harmers to do so in supervised conditions.

Their thinking is that the individual will seek and do so anyway, so supporting them in the unit to do so, will hopefully reduce further risks, as someone stated above.

[anon_e-mouse]

A topical subject as last week in the media a local hospital (Staffordshire) has adopted the approach of allowing self harmers to do so in supervised conditions.

FYI
http://news.scotsman.com/uk.cfm?id=468552006

[Hans]

I think that the issue is more why the person selfharm. Is it because of anxiety of a way of getting care? Is it because it makes them take control over them self when they feel pain? (had a young man with aspergers who told me that he experiented it in that way) How far will the person go in the self harming activity?

It is important that we know all kinds of facts before making our decision on how we should act.

I´ve worked with young women who selfharmed, and it some of the cases simply ignoring their small cutting was the best for them. If we started to ask about the selfharm, normally the behaviour got worse. Others we helped by offering them time with a psychologist, who normally used cognitive therapy. Others again we helped to get a safe enviroment for the behaviour.

I don´t think that you can decide one or another way. You have to se why, and plan the way of responding according to the best for the person.

[janelord]

I have worked in mental health services for many years now(too many to be specific!) The mental health unit that i worked in adopted a strategy for managing self injurous behaviour depending on the risks involved. Most people should remember that self injury and cutting are not necessarily an indicator of suicidal intent and that when the compulsion to self harm is so great it would serve no purpose and actually increase a persons distress and the risk of harm to others to try and prevent these behaviours. What we did was not so much to encourage or allow these behaviours but try to talk them through rationally and get to the bottom of the "why" rather than the "what" but provide the person with clean dressings and materials to clean and dress their wounds in a quiet calm manner not designed to either make someone feel even worse about themselves but also to try and not "glamourise" or encourage further self harm and to reduce the distress of the person harming and those who have to witness it or the aftermath.This is not a new approach-this was 10 years ago-and had a firm evidence base following studies in the US. It was also shown to actually reduce self injurous behaviours in some (and I stress some) of this client group. It is only news now because the media have got hold of the story!

[janeth]

I am working in two settings with very differing views on the subject of self harm. One minimises its importance, offers clean dressings and would not prevent a Yp from doing it, but does offer distractions when a yp gets into htat space.They will also supervise cuutiing at times of great emotional stress if it is felt to be inthe best interests. theother attempts to control it not allowing sharps, frequent room searches, and punishments if a yp has been found to do it. I have seen young peoepl in the first environment decrease their self harm significantly or increase their levels of psuedo self harm e.g. wearing bandages with no cuts underneath to express their emotions and give staff the opportunity to engage in dialogue.
No such thing in the second. Actula self harm may reduce through lack of availability of things to use but the urge to do it and the creative ways of self harming thay they have come up with even a piece of paper are still high. Personally i am infavour of the giving of sharps to self injure under certain circumstances. i would rather limit the chance of infection, and often the worse injuries are caused by lumps of broken pot which leave huge goudges etc.. however this needs to be doen in an atmosphere of trust and where dialogue is possible between all concerned.