mht insight

Harm-minimisation for self-harm

your guide to today’s mental health issues

Traditionally, the main principle for treating self-harm has concentrated

on prevention or cessation, but has the time come to focus instead on
harm-minimisation techniques?

By Clare Shaw BA (Hons), MA, PGC, director of harm-ed, a self-harm training organisation that delivers
training courses to staff working in a variety of different services across the UK.

I
n my work for harm-ed I’m informed not just has been agreed with the service user and the wider
by my academic grounding in the issue, but multidisciplinary team.”
also by my years of personal experience of In doing so, they add to the number of guidelines
self-harm. Six years of frequent admissions to advising the use of harm-reduction strategies, including
inpatient services instilled in me a passion for Mainstreaming Gender and Women's Mental Health
improving services and a specific commitment to the (Department of Health, 2003); NICE guidelines for The
harm-minimisation approach. In this article, I focus on Short-term Physical and Psychological Management
the NICE guidelines for longer term management of and Secondary Prevention of Self-Harm (2004); the
self-harm (2011) and their conclusions on the issue Royal College of Psychiatrists’ Better Services for
of harm-minimisation; drawing also on wider research People who Self-Harm: Quality standards (2006) and
and theory, and the accounts that we commonly hear the Department of Health Self-Harm Expert Reference
during training. Group guide for staff working in secure mental health
Many people working in health and social care have units (Douglas & Marriot, 2012, draft).
already heard of harm-minimisation – the term has They also add to the small but growing body of
been around since the 1980s (Newcombe, 1987); evidence in support of harm-minimisation for self-
and as an alternative to zero-tolerance approaches, harm, including formal evidence (Holley et al, 2012;
its principles have been in evidence since at least Pengelly et al, 2008) based on practice and research,
the 1920s (Rolleston, 1926). The approach has its and perhaps most importantly, first-hand evidence
strongest history in the field of substance misuse, drawn from experience (Pembroke, 2000; Shaw &
where, despite initial controversy, needle exchanges Shaw, 2006).
and drug awareness programmes are now accepted
as mainstream practice. Coping strategies
Not so for self-harm, where prevention or Thought experiment: visualise a difficult day that
cessation remains the dominant principle upon leaves you feeling stressed out. Now identify what
which interventions are based and where harm- coping strategies you would usually draw on to make
reduction techniques – such as imparting basic yourself feel better. Which of these are actively or
anatomical knowledge to people who self-harm – potentially harmful to the self? Can you identify any
are still regarded as marginal practices, surrounded other common coping strategies that involve actual or
by controversy, obscured by anxiety, and heavily potential harm to the self?
resisted at organisational and managerial levels. But It’s a safe guess that most people will recognise how at
this may be about to change. least one of their coping strategies – smoking, drinking,
In consideration of harm-minimisation approaches comfort food etc. – is actively or potentially harmful
to self-harm, the NICE guidelines observe: “The to the self. Self-harm exists as part of a much wider
resistance to employing harm reduction techniques spectrum of common and socially accepted behaviours
in this context (i.e. working with self-harm) had no that cause (often significant) harm to the self.
evidential support – whilst there was significant Guided by a body of research and literature
evidence supporting harm-reduction techniques in extending back over decades (Favazza, 1987; Tantam
other areas of healthcare.” & Huband, 2009) it is now widely accepted that self-
NICE therefore makes the following harm is a coping strategy, rooted in difficult feelings
recommendation to those working with people who and experiences, which functions by restoring calm,
self-harm: “Consider discussing less destructive or expressing distress, releasing tension, experiencing
harmful methods of self-harm with the service user, comfort and grounding a person in reality (Arnold,
their family, carers or significant others where this 1995; Hawton et al, 2003; MHF & Camelot

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Foundation, 2006; Heslop & Macauley, 2009). We Table 1 below lists, in the left-hand column, helpful
can reflect on our personal experiences to recognise responses to self-harm as identified in research
how these functions are shared with most common (Royal College of Psychiatrists, 2006; Arnold, 1995;
coping strategies. However, self-harm is marked out, Newham Asian Women’s Project, 2007). In the right-
not just by the directness, immediacy and physicality hand column are examples of common practices
of the harm caused – which sets it apart from smoking, informed by a preventative approach to self-harm.
or unhealthy eating, for example – but also by Let’s examine the alternative. I work in a training
social attitudes that are, even according to the most partnership that defines harm-minimisation as “an
conservative of measures, predominantly negative alternative to preventative approaches which aim
(NICE, 2011). primarily to prevent people from self-harming.
Thought experiment: visualise yourself at the end of Harm-minimisation approaches accept that
that difficult day, about to use your coping strategy. someone may need to self-harm at a given point,
Someone tries to prevent you from having your glass and focus instead on supporting that person to
of wine, cigarette, walk with the dog etc. How do you reduce the risk and the damage inherent in their
feel? What do you do? self-harm.” (harm-ed, 2010).
Feelings commonly reported by training Take the example of self-cutting: in the left-hand
participants include: distress, frustration, despair, column of table 2 are listed some of the risks, and in
anger and a loss of control; leading many people to the right, steps that may be taken to reduce those risks.
respond by withdrawing, becoming aggressive, “doing To see these strategies in practice we can look to a
it anyway” and “doing it even more”. number of organisations that have worked using this
Evidently, a primary emphasis on the prevention or approach for years, including:
cessation of an important coping strategy is unlikely ■■ S t George’s Hospital in South Staffordshire
to be the most helpful response. Ask a drugs worker NHS Trust
or a teenage sexual health worker why they don’t ■■ The Crisis Recovery Unit at Maudsley Hospital,
‘just say no’ to their clients. You might anticipate London
answers like, ‘it’s unrealistic and patronising’; ‘it would ■■ Royal Edinburgh Hospital
ruin the therapeutic relationship’; ‘it increases risk ■■ Calderstones NHS Trust
by driving the problematic behaviour underground’; ■■ Guild Lodge in Lancashire Care NHS trust
‘it undermines the potential for services to facilitate ■■ 4 2nd Street, which supports the emotional
lasting change.’ And so we are alerted to the distinct wellbeing of children and young people
possibility that, when working with self-harm, a focus in Manchester
on prevention or cessation may be the exact opposite ■■ Scottish mental health charity Penumbra
of helpful. ■■ The Leeds Survivor Led Crisis Centre.

Table 1: Preventative and zero-tolerance approaches

Helpful responses to self-harm Preventative approaches to self-harm
Positive, non-judgmental attitudes Punitive responses eg. insufficient anaesthetic;
withdrawal of leave
Choice and involvement Detention and restraint
Optimistic and hopeful approaches Exclusion from treatment on the grounds of continued
self-harm
Compassion, comfort, caring The withdrawal of care and comfort following an incident
of self-harm
The opportunity to talk/express feelings ‘No self-harm’ contracts or promises
Individualised care Collective restrictions
Provision of information Withholding information

Table 2: Possible risks and harm-minimisation measures

Possible risks Harm-minimisation measures
Severing arteries, nerves or tendons Basic anatomical information about bodily structures,
access to medical attention etc.
Risk of infection Using clean implements, keeping wounds clean, access
to first aid and medical care etc.
Scarring Wound care, issues surrounding site of cutting, access to
specialist services etc.
For more information about practical strategies for reducing harm see Dace (1998) and National Self Harm
Network (2000), which can be downloaded from www.harm-ed.co.uk.

20 September/October 2012 mentalhealth

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We can also look to prominent individuals such as Rather, with adequate support and supervision,
psychologist Sam Warner, psychiatrist Pat Barker, those concerns can help to inform a thoughtful,
and nurse consultant Suzie Marriott, alongside many individualised response to self-harm, one which fits
anonymous frontline workers whose practice has more closely with the core principles of a helpful
been informed by harm-minimisation principles, often response as identified by people who self-harm,
without the backing of their organisation. and the people who care for them. Service users,
activists and committed professionals have worked
Conclusion for years to move this approach from marginal
“The resistance to employing harm reduction to mainstream. With the backing of the NICE
techniques in this context had no evidential support” guidelines, and with a body of evidence behind it,
(NICE, 2011). However, I’m guessing that there will now is the time.
be significant resistance among this readership,
and that this resistance is based in some very real
Arnold L (1995) Women and Self-Injury: A survey of 76 women.
experiential evidence. This goes a long way to
Bristol: Bristol Crisis Service for Women.
explaining why prevention or cessation of self-harm
Dace E (1998) The Hurt Yourself Less Workbook. Nottingham:
is the goal of many services, and why the NICE
National Self Harm Network.
(2004 & 2011) guidelines themselves use cessation
Department of Health (2003) Mainstreaming Gender and Women’s
as the golden rule in measuring the effectiveness
Mental Health. London: DH.
of interventions. But in addition to that there are
Douglas N & Marriott S (2012) Safe and Secure: Working
other significant challenges, including high levels of
constructively with people who self-injure – a guide for staff working in
anxiety around suicide and severe injury, alongside secure mental health units. London: Department of Health Self-Harm
fears of transgressing codes of conduct and ‘duty of Expert Reference Group.
care’, and subsequent criminal or civil proceedings. Favazza A (1987) Bodies under Siege: Self-mutilation in culture and
These anxieties are heightened in a context of lack psychiatry. (reissued 1996 and 2012) Baltimore: Johns Hopkins
of organisational policy and guidelines or of back-up University Press.
from management and colleagues. Harm-ed (2010) Harm-minimisation for self-harm: a reading pack.
However, informed by the excellent work of staff at Unpublished.
St George’s in South Staffordshire – including the late Hawton K, Rodham K & Evans E (2003) Youth and Self-harm:
(and much missed) Chris Holley – the Royal College Perspectives. A report. Oxford: Samaritans; University of Oxford
of Nursing’s Learning Zone (2009) resources go some Centre for Suicide Research.
way to addressing and allaying these concerns, setting Heslop P & Macaulay F (2009) Hidden Pain? Self-injury and people
out basic principles for how harm-minimisation might with learning disabilities. Bristol: Bristol Crisis Service for Women.
be employed in practice: Holley et al (2012) Self-injury and harm-minimisation on acute wards.
■■ Every person who self-harms is unique, therefore Nursing Standard 26 (38) 51–56.
assessment, care-planning and care must Mental Health Foundation/Camelot Foundation (2006) The Truth
be individualised Hurts: a National Inquiry into self-harm amongst young people.
■■ T he capacity to engage in harm-minimisation London: MHF

might vary. The level of risk must be reviewed Newcombe R (1987) High time for harm reduction. Druglink 2 (1)
10–11.
regularly and the care plan should be altered
accordingly for an agreed period of time Newham Asian Women’s Project (2007) Painful Secrets: A qualitative
study into the reasons why young women self-harm. Available from:
■■ The boundaries of self-harm must be negotiated
http://www.nawp.org/
fully and documented
National Institute for Clinical Excellence (2004) The Short-term
■■ The care plan must be detailed. It should describe
Physical and Psychological Management and Secondary Prevention
what nurses need to do in a given situation of Self-harm in Primary and Secondary Care CG16. London: NICE.
■■ T h e c a r e p l a n s h o u l d h a v e b e e n a g r e e d
National Institute for Clinical Excellence (2011) Longer Term Care and
between the patient, nursing staff and the whole Treatment of Self-Harm CG133. London: NICE.
multidisciplinary team (this may include the
National Self Harm Network (2000) Cutting the Risk: Self-harm, self-
legal department) care and risk-reduction. Nottingham: National Self-Harm Network.
■■ The care plan must include strategies for nursing
Pembroke L (2000) Damage Limitation. Nursing Times 96 (34) 34–35.
staff and the patient when the person is no
Pengelly et al (2008) Harm-minimisation after repeated self-harm:
longer feeling safe and not able to manage their
development of a trust handbook. The Psychiatrist 32 (2) 60–63.
self-harming safely
Rolleston Report (1926) Department Committee on Morphine and
■■ T his approach must be thoroughly based on
Heroin Addiction. London: HMSO.
the agreed organisational risk assessment
Royal College of Nursing (2009) Learning Zone: Self-harm module,
and documentation must be fully consistent
RCN May 2009. Available from: http://www.rcn.org.uk/newsevents/
with regulations. news/article/uk/self_harm__new_online_learning_resource_launched
Royal College of Psychiatrists (2006) Better Services for People Who
Despite this, and the growing body of evidence Self-harm: Quality Standards for Healthcare Professionals. London:
and guidance in support of a harm-minimisation RCPsych.
approach, real and justified concerns remain. But, Shaw C & Shaw T (2006) A Dialogue of Hope and Recovery. In:
as the NICE 2011 guidelines make clear, these Warner S & Spandler H (eds) Beyond Fear and Control: Working with
concerns should not obstruct a readiness to learn young people who self-harm. Ross-on-Wye: PCCS Books.
from the example of other health services, especially Tantum D and Huband N (2009) Understanding Self-Injury: a
substance misuse services. Multidisciplinary Approach. London: Macmillan.

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