Working Towards a Harm Minimisation Policy for Self Injury

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Working Towards a Harm Minimisation Policy for
Self Injury

• Helen Duperouzel
• Rebecca Fish

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Staff experiences of working with people who
self injure
This paper outlined the experiences described by
staff of personal and organisational responses to
incidents of self-harm explanations that staff
use to understand the behaviour and
recommendations for change to treatment models
and the staff support system. The information
was gained using in-depth interviews. Staff
reported experiencing powerful emotional
responses to incidents of self-harm, ranging from
feelings of anger to feelings of inadequacy and
guilt.
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Staff experiences of working with people who
self injure

• Well I think that you might come to doubt your
  own abilities in your work to control things like
  that, not control them, but to deal with
  situations like that. Well you would feel if
  someone had really harmed themselves, and you had
  being trying to make it not happen, then you
  failed somehow. It might make you doubt your
  abilities.
• Theres a multitude of emotions ...theres
  things like failure that you didnt spot it and
  it is something that you should have observed,
  could have, you know, done differently. Em, you
  then worry about what response youll get from
  the managers about someone self harming, its not
  always supportive, although it is more than it
  used to be.

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Staff experiences of working with people who self
injure

• There is this, er, stigma and this blame
  culture within an institution that if she does
  cut herself, when youre filling critical
  incident forms in, youve got to explain what
  shes done its Well, hows she got it?Whys
  she got it? Hows she been allowed to get it?
  Shes on a one to one, hows she managed to get
  it? or Shes on a two to one or Why werent
  you watching her?
• Its still, its a case of blaming people there
  instead of, like, just realizing that the client
  is the person to blame. I mean theres no member
  of staff gonna say Here you are, cut yourself
  with that. Or Here you are, swallow that. So
  its not the staffs fault.

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Staff experiences of working with people who self
injure

• Some staff advocated a system of allowing self
  injury. They were of the view that if clients
  were treated with less control, and supported to
  use self-harm safely, they may find other coping
  strategies.
• A more permissive approach, of giving back the
  responsibility to the client, was seen as a way
  of relieving some of the stress experienced by
  staff.

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Cutting doesnt make you die (2000)
This study explored the views and understanding
of one woman's experiences of her self-injury
using a phenomenographic method. Cutting
doesnt make you die unless you do it deep
enough, serious enough. I dont do it serious
enough though.
No one accepts it, they dont like it. They feel
they have to stop me. They have to be seen to be
doing something. Nobodys bad for cutting up, you
shouldnt be punished either for cutting up, I
dont think. You do it to yourself dont you? Not
others. They should understand more. Well other
people regularly attack all the time dont they
and they get things in their room, its all
wrong. They dont want to understand.
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Cutting doesnt make you die

• People dont realize that I want to do it, why
  cant I? One day itll all stop but not now, it
  keeps me going. They dont want to understand,
  they dont want to do it my way. Just leave me to
  it, cos Id get bored in the end if no one was
  doing anything about it, wouldnt I? They should
  have a positive attitude, about self-injury.
• I like them not to make such a fuss, just to
  treat me and then forget about it. They shouldnt
  panic and that.
• How does that make you feel, when people
  panic?
• Catherine I feel worse inside, feel daft.
  Every time I look at the scars then I feel bad,
  messing peoples lives, its horrible.

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Cutting doesnt make you die

• The harm prevention strategies employed by the
  service were viewed as punitive by this service
  user
• These prevention strategies only served to make
  this service user feel controlled and powerless
  which resulted in a power struggle or battle of
  wills with staff.
• She felt she was being punished for something
  she wanted to do to her own body. Her feelings of
  failure and the fact that she was not being
  trusted increased her negative thoughts. It seems
  these negative feelings and the unfavourable
  attitudes she had sensed from others intensified
  her need to self-injure.
• Replication of this approach with others who
  harm themselves will deepen our understanding of
  this complex and characteristically individual
  phenomenon.

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Hurting no-one else's body but your own H
Duperouzel and R Fish

• Details the experiences of nine people with
  mild/moderate learning disabilities who self
  injure capturing the perceptions of their care in
  a medium secure unit.
• Little literature in this area so a
  phenomenological approach was used to determine
  the participants experiences.
• Four main themes emerged
• Coping strategies
• Staff and the organisational response
• Therapeutic communication
• Close/special observation

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Hurting no-one else's body but your own H
Duperouzel and R Fish

• Coping strategies
• It gets all my feelings out and you come back
  and you are happy
• Ive been on my section for eleven years, so I
  cut up after my TCPs and my section renewals. I
  go off my head thats why they wont let me go to
  this one...I Know what will happen Ill end up
  cutting up, and them are the bad ones.

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Hurting no-one else's body but your own H
Duperouzel and R Fish

• I think as a self harmer you should be entitled
  to what you do to your body as long as its
  hurting no-one else's but your own. I feel that I
  should be entitled to cut up as much as I want
  and when I want. I do feel that there's too many
  people laying the law down as far as Im
  concerned as my self harming.
• ...people shouldnt judge us as theyve never
  had to go through what weve had to go through.

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Hurting no-one else's body but your own H
Duperouzel and R Fish

• Staff and the organisational response-
  therapeutic communication
• Being understood and listened to
• I feel that I just want to sit down, if I could
  talk to somebody you know. They didnt cope with
  it at all they didnt have a clues what to do
  with me, theyd take me to hospital get me
  stitched up and you know, no one would talk to me
  about it no

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Hurting no-one else's body but your own H
Duperouzel and R Fish

• Nurse patient interactions and relationship
• Ill admit I dont like cutting up, but some
  say I do it for the attention but I dont, that
  gets right up my nose. Usually I dont tell them
  till the day after.
• I self harm and thats all Ive said. I dont
  really go into detail about why Im self harming
  and what triggers it off. I dont really go into
  that much detail. I feel scared. I dont think
  they would understand. I just think they would
  increase my supervision level.
• Its like because you pissed them off so much,
  because theyve got to do all the
  paperwork, hows this person managed to cut
  himself, though they were on a one to one type of
  thing and they are going to get into trouble with
  the managers.

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Hurting no-one else's body but your own H
Duperouzel and R Fish

• Special observation
• Well when Ive cut up in the past theres your
  punishment of putting you on a level three for a
  few months until things get better. Thats what
  they have always done with me. They punish me by
  putting me on a higher supervision level,
  increase my supervision level to a level
  three..., Id feel bad, they didnt trust me,
  once Ive cut Im all-right I wouldnt do it
  again cos I feel better.
• I used to use everything and anything I could
  get hold of . I picked up a tack or pin in my
  shoe, I would take it out and use it. I was put
  on a stricter level, even then I smuggled a pen
  in my mouth.
• ...the procedures whats in here to supposedly
  protect you as well as the member of staff which
  is looking after you, which is a load of
  cobblers. Like i said I self injured whilst being
  on a one to one!

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Hurting no-one else's body but your own H
Duperouzel and R Fish

• Discussion
• What are the goals stopping someone from
  cutting? This has historically failed and will
  continue to do so, we only delay acts of self
  injury.
• Any motivation to stop or reduce the harm to
  their bodies was hindered by the protective
  measures employed by staff. Prevention often
  results in more intense and opportunist acts of
  self injury which potentially can cause more
  damage.

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Coping with their lives women, learning
disabilities, self harm and the secure unit
Melissa James and Sam Warner . British Journal of
learning Disabilities 2005

• Identify how women are understood using a
  Q-methodological study with clients and staff.
• Themed results
• Coping as a unique experience
• Coping with the here and now
• Coping with powerlessness and abuse (self harm as
  self-preservation and a way of regaining some
  power and control)
• Controlling emotional distress, blame and coping
  as an unknowable experience
• Aspects of interventions may actually increase
  the likelihood of self harm

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Why couldnt I stop her? (2007)

• Synthesis of two pre-existing studies, comparing
  the experiences of 9 people with learning
  disabilities who self injure and those who work
  with them.
• At the time of the study the participants were
  living and working in a medium secure unit at
  Calderstones NHS Trust.
• A phenomenological approach was used and rich
  descriptions emerged detailing four main themes
• Understanding
• Communication
• Control
• Blame

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Theyve said their job would be on the line if
they continually let me self-harm like I wanted
to do. Trying to control clients self-injury
affects the therapeutic relationship.
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(No Transcript)
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Changing practice?

• Policy development
• Presentations at conferences/local events, to
  small groups of staff and dissemination of
  research
• Presentations from others
• Individual advice and support for care planning
• Staff training

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Policy development (Underlying principles and
values, 2007)

• Existing policy at that time included self injury
  and suicide prevention and was based on
  prevention, the emphasis being on the individual
  not a blanket response, and to involve that
  individual in their assessment and care.
• New policy understands self injury as symptomatic
  of some greater distress. The Trust attempted to
  developed an approach which whilst not condoning
  self harm, tolerated it as a means of coping
  whilst seeking alternatives. The policy
  recognised an inclusive approach to supporting
  clients/patients, working in genuine partnership,
  to find alternative coping strategies to self
  harm, rather than an exclusive prevention model.
• This policy urges staff to adopt a
  non-judgmental, non punitive and emphatic
  response to self injury, where the client retains
  the responsibility between further acts of self
  harm and in developing alternatives (unless there
  is a perceived threat to life or threat of
  considerable injury).

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Policy development (2007)

• The routine use of placing clients under
  observations tends to make the person more likely
  to self injure. The client may be supported in
  avoiding self injury by helping them with problem
  solving and other techniques such as distraction.
• Providing the right support at such times can
  help a person avoid, delay or reduce the extent
  of the self injury. Even if this is not the
  result, talking is very valuable in helping that
  person understand their feelings and actions and
  feel supported and heard.
• It was noted that cultural change and training
  may be needed to enable staff to appreciate the
  importance of empowerment and education in
  equipping the client/patient to make informed
  choices in line with accepting limitations and
  responsibilities.

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Staff training

• Induction of new nursing staff with open invite
• Client involvement in the training (personal
  perspectives)
• Training leans heavily on gaining understanding
  of self injury and to refocusing nursing activity
  away from restrictive practices
• Evidence suggests that in practice the
  preventative model still rules!

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Harm minimisationSurvey undertaken with staff
2009
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Definition of harm minimisation

• For people who repeatedly self harm and who are
  likely to repeat self injury, clinicians may
  consider advice to the client on harm
  minimisation techniques, alternative coping
  strategies, self-management of superficial
  injuries, and how best to deal with scarring.
  (NICE 2004)
• One of the aims of a harm minimisation approach
  is for staff to actively support and encourage
  individuals to take steps to contain their self
  harm within reasonable limits while working with
  them to replace self-harming with other, more
  positive, means of coping and expressing
  themselves which are primarily user-led. (DH,
  2003)

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Staff Responses

• 87 of staff were in favour of a harm
  minimisation policy being in place - This would
  be a break through, it would allow clients to
  take more responsibility for their self injury
  and move away from being totally controlled,
  which can perpetrate the behaviour.
• The self injurer feels that their way of coping
  is 'bad'. Staff feel duty bound to prevent it
  which often results in unnecessary conflict,
  which then detracts from the real issue of what
  is causing someone to use self injury.
• In the past I have seen clients admitted who
  have self harmed and we have managed to create
  monsters - with some clients it has become a game
  you take away everything i.e. pot cups etc so the
  second a cup is left out they use it.

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Staff Support needs

• Having worked in a situation where a client was
  allowed to self harm I know how intense and
  demanding it is to be in that type of
  environment. I therefore feel maximum support is
  required and every person must feel a valued
  member of the team. I feel staff should be able
  to express how they feel after something has
  happened and they should be occasion for time out
  if it is needed.

• Support groups and networks discussion groups,
  good practice.
• Compulsory clinical supervision.
• Clear and accessible guidelines.
• Training wound care, personal perspectives of
  self-injury, how to respond when someone
  self-injures.
• Clear roles and full support from all managers.

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Support for Clients

• User-friendly guidance or contract for people
  to sign up to.
• Education about safer self-injury, wound care.
• Non judgemental and empathic environment
• Working through reasons and finding safer
  alternatives.
• Therapy and support groups.

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Staff fears about Harm Minimisation

• Infection control issues where equipment is
  kept, how to clean equipment.
• Danger of serious injury.
• Duty of care to client who takes
  responsibility? Arent staff supposed to protect
  clients?
• Staff should not be forced to work under this
  regime.
• Ambiguity and flexibility of guidelines knowing
  when to implement the policy.

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Developing a dedicated harm minimisation policy

• The policy
• Harm minimisation means that clients who want to
  self-injure would be allowed to, but in a safer
  way.
• The introduction of a harm minimisation policy at
  Calderstones would include permitting habitual
  self-injury (behaviours which clients were
  already using) but incorporating support systems
  such as education about life threatening
  injuries, how to care for wounds, and with the
  ultimate goal of introducing alternative coping
  strategies.
• The policy would not include providing people
  with implements with which to harm themselves.

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Developing a dedicated harm minimisation policy

• Robust assessment and be supported by a reasoned
  considered opinion at the time of the assessment
  which balances risk with the most appropriate
  response for the individual service user.

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• To provide a seamless responsive service to
  people who self injure and provide a framework
  for staff to support the decision making process.
• Rationale
• To reduce clients/patients/service user distress
• To provide a needs led service
• To support clients/patients/service users in a
  widely accepted way of coping with distress,
  whilst supporting in the development of
  alternative coping strategies.
• To support and guide professionals in the
  management of care.
• To support a patients responsibility for
  improving and maintaining their health
• To respect a persons right to reach decisions in
  partnership about their treatment and care
• To ensure that the individuals capacity has been
  established
• To respect the privacy and dignity of
  clients/patients/service users and other staff
  members
• To ensure that decisions made in partnership with
  a person which involves harm minimisation have
  been endorsed by the full multidisciplinary team
  and recorded formally.
•  

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Legal Implications

• Although the Mental Health Act Code of Practice
  (1999) instructs that patients must be protected
  from harming themselves when the drive to do so
  is the result of a mental disorder NICE
  guidelines (2004) suggest that staff consider
  giving advice and instructions on harm
  minimisation issues and techniques. The Bolam
  test (1957) which would be defensible under
  common law, asks whether the practice is in
  accordance with a practice accepted as proper by
  a responsible body of clinical opinion skilled in
  that particular discipline.
• A number of services are piloting this practice,
  including Maudsley and Penumbra, and South
  Staffordshire NHS Trust, no precedent has yet
  been set within the legal framework re self
  injury.

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A slow start

• Three clients within the service now have
  treatment and care plans for a harm minimisation
  approach
• For one client who has had years of physical
  intervention this has been difficult, for the
  others new to the service they readily accept and
  appreciate this approach leading to less
  physical intervention and helping them maintain
  relationships with staff.

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• Thank you for listening
• Any Questions?