SELF HARM

1. SELF HARM

2. Treatment Approaches What Works

3. The aim of this presentation is: Introduce and define self harm Brief history of previous interventions and attitudes to self harm Motivation to change Therapeutic approaches and changes in attitude Way forward (sharing good practice) and implication for practice A patients perspective

4. The Dynamics and Motivation Underpinning Self Harm Identifying therapeutic alternative approaches whilst risk managing within a safe environment

5. The issue of self harm is a very complex one and we must firstly understand the dynamics of self harm and why do people self harm.

6. SELF HARM Any harmful act to the self, or omission, in which the direct intent is not to die (Smith 2003) Self injury is an act which involves deliberately inflicting pain and/or injury to one�s own body, but without suicidal intent (Babiker and Arnold (1998) Any behaviour engaged in by an individual, regardless of intent, that results in deliberate harm to their body or interference with their vital functioning (Beasley 1999)

7.  There are numerous definitions of self injury/harm which are available, all of which we can agree involves harm to the individual and that self injury is seen as a maladaptive coping strategy that enables individuals to express themselves in one way or another and can manifest in varying forms.

8. Forms of Self Harm Cutting Burning Self hitting Hair pulling Bone breaking Picking (at wounds/skin) Swallowing (foreign objects)

9. HISTORICALLY �Self harmers in psychiatric services were seen as attention seeking, are disliked by staff and were seen as being in control of manipulative behaviour� Self injurious behaviour is complex and costly to services, and can cause concern and distress amongst professionals. A survey in 1997 by (Liebling et al) on women who self harm in a secure setting, reports half of the women stated that their urge to self harm was prompted by their surroundings and the attitudes of staff. Staff frustration, empathy, distressed, maybe control and restraint to stop patients from self harming if no alternative. Staff frustration, empathy, distressed, maybe control and restraint to stop patients from self harming if no alternative.

10. Motivation to Change A positive attitude and sound knowledge base about our client group (female forensic patients) A greater familiarity with risk assessment procedures Changes is staff team members Gain an understanding of why individuals self harm and why they go to such lengths. Reduce the incidents of self harm Work towards improving attitudes towards self harming patients, for example through training aimed at increasing knowledge. Work towards recommendations from the NICE Guidelines 2004 around key priorities Changes in staff team. People who wanted to and were happy to work with women. Regular supervision, appraisals, staff meetings, debriefing. New treatment files with person centred care plans. Staff training in depth in self harm, personality disorder, OCD etc to give staff a better understanding of all patient issues.Changes in staff team. People who wanted to and were happy to work with women. Regular supervision, appraisals, staff meetings, debriefing. New treatment files with person centred care plans. Staff training in depth in self harm, personality disorder, OCD etc to give staff a better understanding of all patient issues.

11. Within the Female Forensic Services at Northgate Hospital (part of Northumberland, Tyne & Wear NHS Trust) a positive therapeutic approach to self harm has been developed in order to educate staff to enable them to safely manage individuals who self harm within a safe and secure setting.

12. Therapeutic approaches and changes in attitude. Involved the service user Provided staff training Held regular patient meetings. Individual one to one sessions. Research Recording of incidents Looked at approaches that could be adopted to assist in minimising self harm and increasing self esteem. Involvement with the service user is paramount, to engage them in all aspects and build up trust and encourage self monitoring following an incident with support, to see what we could do to improve and offer alternatives. Ideally to provide them with an awareness of how and why we understood about them and their feelings. One to one sessions allowed the patients an opportunity to talk to staff of their choice who they felt comfortable with. Regular patient meetings were held to encourage appropriate open conversation about self harm. Approaches adopted to assist in minimising self harm were awareness groups, self esteem groups, healthy lifestyle groups, relationship groups working as an MDT.Involvement with the service user is paramount, to engage them in all aspects and build up trust and encourage self monitoring following an incident with support, to see what we could do to improve and offer alternatives. Ideally to provide them with an awareness of how and why we understood about them and their feelings. One to one sessions allowed the patients an opportunity to talk to staff of their choice who they felt comfortable with. Regular patient meetings were held to encourage appropriate open conversation about self harm. Approaches adopted to assist in minimising self harm were awareness groups, self esteem groups, healthy lifestyle groups, relationship groups working as an MDT.

13. Staff Training Definitions of self harm Understanding self harm both from a patient perspective and those who support them. Self harm seen as a way of communicating rather than manipulating. Risk Assessment Supporting staff to support individuals who self injure Infection advice. Clinical supervision Debriefing following any self harm incident Identifying a harm minimisation approach rather than one which looks at exclusive prevention. Alternative therapies including : the holding of ice cubes, use of henna tattoos, use of elastic bands, use of red marker pens, playing loud music to distract, using other alternatives for hitting (pillow etc) This list is not exhaustive. Exploring what works for who? Communication � Important for staff to realise that self harm was a way of communicating and not historically attention seeking or manipulating. Debriefing � Allowed for evaluation of incidents and enabled it to be more person centred to that individual i.e how could we improve or further support. Ensured that staff were aware of patients history in terms of possible abuse etc. Trigger factors. By giving definitions of self harm it gave rise to conversation about this topic and got people to think differently and discuss past experiences and concerns.Communication � Important for staff to realise that self harm was a way of communicating and not historically attention seeking or manipulating. Debriefing � Allowed for evaluation of incidents and enabled it to be more person centred to that individual i.e how could we improve or further support. Ensured that staff were aware of patients history in terms of possible abuse etc. Trigger factors. By giving definitions of self harm it gave rise to conversation about this topic and got people to think differently and discuss past experiences and concerns.

14. Way Forward Sharing good practice. Implications for practice. Evaluating incidents of self harm before and after. Maintaining positive attitudes and knowledge. Continuing research and new approaches. Improve the clients quality of life. Continue to manage risk. There will never be a risk free environment or risk free situation. Monitor legislation and nursing guidelines Work together as a MDT From the onset it should noted that there can never be a risk free environment or situation. To talk of risk management in terms or risk removal is unhelpful and raises expectation to levels which are impossible to achieve. We risk managed with the definition as the minimisation of dangers.From the onset it should noted that there can never be a risk free environment or situation. To talk of risk management in terms or risk removal is unhelpful and raises expectation to levels which are impossible to achieve. We risk managed with the definition as the minimisation of dangers.

15. A positive attitude and a sound knowledge base about this client group (female forensic patients) together with a greater familiarity with risk assessment procedures has enabled nurses to provide the necessary emotional support in times of self harm.

16. Within the female service (Longhirst Villa 15) we have been able to provide the support, training and guidance for nursing staff who work within the service with patients who self harm and feel we have therefore moved a step closer to fulfilling out aim of reducing the incidents of self harm. Recent statistics following the new intervention has shown a decrease in episodes of self harm by 70%.

17. Incidents of Self Harm 1st March 2005 � 28th February 2006

18. MISUNDERSTOOD Since the day I was abused Nobody would listen This is difficult for me to explain But I�ll try and tell you about my position I love talking, but the pain stops me I feel numb I love being honest, but the pain stops me I feel dumb Sometimes I feel really low Thinking about my past The tears fall down by face, and I shake And I wonder how long this will last. To take away the pain I will cut myself with anything I can find I�m angry with myself So wound up I�ve let him win But please understand this gives me piece of mind!!