Working Towards a Harm Minimisation Policy for Self Injury

1. Working Towards a Harm Minimisation Policy for Self Injury Helen Duperouzel Rebecca Fish

2. Staff experiences of working with people who self injure

3. 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.� �There�s a multitude of emotions ...there�s things like failure that you didn�t spot it and it is something that you should have observed, could have, you know, done differently. Em, you then worry about what response you�ll get from the managers about someone self harming, it�s not always supportive, although it is more than it used to be.�

4. 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 you�re filling critical incident forms in, you�ve got to explain what she�s done it�s �Well, how�s she got it?��Why�s she got it?� �How�s she been allowed to get it?� �She�s on a one to one, how�s she managed to get it?� or �She�s on a two to one� or �Why weren�t you watching her?� �It�s still, it�s a case of blaming people there instead of, like, just realizing that the client is the person to blame. I mean there�s no member of staff gonna say �Here you are, cut yourself with that.� Or �Here you are, swallow that.� So it�s not the staff�s fault.�

5. 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.

6. �Cutting doesn�t make you die� (2000)

7. �Cutting doesn�t make you die� �People don�t realize that I want to do it, why can�t I? One day it�ll all stop but not now, it keeps me going. They don�t want to understand, they don�t want to do it my way. Just leave me to it, � cos I�d get bored in the end if no one was doing anything about it, wouldn�t 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 shouldn�t 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 people�s lives, it�s horrible.�

8. �Cutting doesn�t 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.

9. �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

10. �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� �I�ve been on my section for eleven years, so I cut up after my TCP�s and my section renewals. I go off my head that�s why they won�t let me go to this one...I Know what will happen I�ll end up cutting up, and them are the bad ones.�

11. �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 it�s 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 I�m concerned as my self harming.� �...people shouldn�t judge us as they�ve never had to go through what we�ve had to go through.�

12. �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 didn�t cope with it at all they didn�t have a clues what to do with me, they�d take me to hospital get me stitched up and you know, no one would talk to me about it no�

13. �Hurting no-one else's body but your own� H Duperouzel and R Fish Nurse patient interactions and relationship: �I�ll admit I don�t like cutting up, but some say I do it for the attention but I don�t, that gets right up my nose. Usually I don�t tell them till the day after.� �I self harm and that�s all I�ve said. I don�t really go into detail about why I�m self harming and what triggers it off. I don�t really go into that much detail. I feel scared. I don�t think they would understand. I just think they would increase my supervision level.� �It�s like because you pissed them off so much, because they�ve got to do all the ******* paperwork, how�s 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.�

14. �Hurting no-one else's body but your own� H Duperouzel and R Fish Special observation: �Well when I�ve cut up in the past there�s your punishment of putting you on a level three for a few months until things get better. That�s 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..., I�d feel bad, they didn�t trust me, once I�ve cut I�m all-right; I wouldn�t 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 what�s 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!�

15. �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.

16. 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�

17. Why couldn�t I stop her? (2007)

20. 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

21. 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).

22. 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.

23. 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!

24. Harm minimisationSurvey undertaken with staff 2009

25. 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)

26. 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.�

27. 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.�

28. 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.

29. 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? Aren�t 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.

30. 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.

31. 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.

32. 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 patient�s 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 individual�s 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. �

33. 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.

34. 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.

35. Thank you for listening Any Questions?