Mental health articles

Understanding – mechanism and meaning

The first stage in nursing someone who has self-harmed is to understand what meaning the act has for them. In order to do this we have to ask about and explore with the client what happened and how they felt, before, during and after they self-harmed. This requires us to have an attitude, and use language, that is non-judgemental. Showing that we are interested in the client as an individual and that we do not blame them for self-harming will help to establish a therapeutic relationship through which we can help the client to identify what they would like to change and how they can change their behaviour.

Therapeutic assessment

Case study:

Jenny Jenny is a 21-year-old music student training as a classical violinist. She attended the emergency department in the early hours of the morning having made ten 4 cm cuts in a row along the length of her forearm. She had played in an end-of-term concert that evening and been for a drink with her fellow students, consuming approximately 12 units of alcohol. Upon her return home she had felt an overwhelming desire to release a feeling of tension, which she described as being located in her arm. Having cut herself she felt an immediate release of tension, but very quickly felt her anxiety levels rise again as she began to fear lest she had damaged her arm, worry about what her friends, teachers and family would think, and was angry that the tension seemed to be returning. She told one of her flatmates what she had done, and was persuaded to attend the emergency department. Although this was the first time that Jenny had cut herself, she had taken an overdose one year ago and from the age of 13 had starved herself when feeling stressed. When she was 7 years old her father, who was also a professional musician and her first teacher, left her mother. Jenny excelled at school and gained a place at the university of her choice, but always felt that she was somehow ‘scraping by’. Since arriving at university she had struggled, and although passing her course, felt she was near the bottom of the class. She described in her own words a ‘love–hate’ relationship with her peers. Performing at university motivated her, but she resented doing it. As the end of her course approached she feared what would happen and was angry that she had failed to get onto a postgraduate course. Jenny seemed able only to see things as poles apart: she would either become a professional musician or she would be a failure; her teachers loved or hated her. During her assessment with a psychiatric liaison nurse, Jenny was able to identify that when things went wrong she ‘blamed’ and ‘hated’ herself. She had a belief that she wasn’t good enough for her father, her school or her university, and only felt better if she ‘punished’ herself by starving, taking an overdose or cutting herself. Jenny agreed that she wanted to do something to change this pattern of behaviour. She identified that drinking alcohol when she was feeling distressed made it more likely that she would do something to harm herself, or starve herself the following day because she felt guilty at having had too many calories in the alcohol. She also felt that she was ‘testing’ her body, and to some extent that she wanted ‘it’ (her body) to fail her so that she would be able to justify not becoming a professional violinist. The nursing intervention as a result of this assessment was essentially pragmatic. Jenny was educated about the risks of binge drinking, and given some written information to back this up. Jenny identified that it would be helpful to speak to the careers office at her university to see if she could identify a realistic option that fell between her ideal career and her view of failure. A ‘crisis plan’ was devised including what Jenny would do if she felt like harming herself again. This included trying to think of a middle-ground between her extreme beliefs and feelings, asking a friend to come round rather than going to the pub, calling a student helpline, and how to access emergency mental health services. Jenny was offered a referral for psychotherapy. However, she felt it would be ‘too much to deal with’ at that time, but would consider it as an option for the future. Jenny gave permission for her case to be used as an example. Her name and other details have been changed to protect her anonymity. The case study of Jenny illustrates the importance of this first stage. During the assessment of her self-harm, Jenny was able to formulate her own ideas about how she had come to a point where she used cutting as a coping mechanism. Even if this is your only contact with someone who has selfharmed there are treatment options available: psycho-education, solutionorientated interventions, distraction or harm-reduction techniques can all be employed in the context of a therapeutic assessment. Anyone who self-harms and has capacity has the right to refuse treatment. In Jenny’s case she did not feel able to cope with psychotherapy at that time, and so chose not to take up the offer of referral. The nurse’s role includes ensuring that treatments remain accessible to their clients and acknowledging that people change their minds over time. If Jenny repeatedly attended the emergency department, the nurse could suggest to her that she needed more support to change her behaviour and re-offer the referral to psychotherapy.

Harm minimization

In the fields of health promotion and addictions nursing the concept of harm minimization is well established. For example, in addictions, by acknowledging that someone is going to continue to use if they are in the precontemplative, contemplative or preparation stages of change, the risk of infection, accidental overdose, not knowing what they are ingesting, can be reduced by needle-exchange programmes, health education and methadone maintenance programmes. The client engages with services while still using so that the therapeutic relationships and hopefully the client’s confidence in a service is established at the time they do want to change their behaviour. It may be particularly challenging to engage with someone who is selfharming. It is possible that your client may have had previous negative experiences of health care. If you make nursing care conditional on not selfharming, you will communicate to your client that you blame them. Service users report that signing ‘no self-harm’ contracts is unhelpful, and that short-term tolerance of risk leads to increased honesty about deliberate self-harm (South London and Maudsley 2001). While ensuring that the responsibility for self-harm remains with the client, nurses should accept that the behaviour will continue into treatment. Specific harm-minimization techniques such as distraction are widely used. Some people have suppressed the need to cut by snapping elastic bands against their wrist, holding ice in their hands, or punching pillows. In the short term these may reduce the risk involved in deliberate self-harm. However, they perpetuate the client’s need to experience an immediate physical response to psychological distress. Positive distraction techniques that engage the client in creative rather than destructive behaviours, such as exercise, listening to music, watching television, drawing/painting, etc. are more likely to change their behavioural response to self-harm. In Jenny’s case, examining the role alcohol may have to play as an antecedent to her self-harm could be considered a harm-reduction strategy. Educating Jenny about the risks of binge drinking and finding an alternative to going to the pub may help to reduce the potential frequency and severity of her self-harm.

Tags: nursing, self-harms