Guidelines Miss The Reality Of Self Harm (Part 1)

Those who have self-harmed should receive assessment and treatment within 48 hours, new guidelines from the National Institute for Clinical Excellence and the National Collaborating Centre for Mental Health (NCCMH) have recommended in a guideline for the NHS in England and Wales. The guidelines cover acts of self-harm that express personal distress and where the person directly intends to injure themselves, for example through cutting or overdosing. But Phil Barker and Poppy Buchanan-Barker believe there has been a complete lack of imagination in developing these guidelines. In this article they highlight the absence of mental health nursing input and call for new thinking about different ways of responding to problems that have not been successfully dealt with in the past

Self-Harm and Co.

Self-harm has been a hot topic for as long as people have known about it, or been willing to own such knowledge. Now that various 'celebrities' have been included in the self-harmer list - from Princess Diana to Johnny Depp - what once was taboo and disgusting has become almost morbidly fashionable. The virtual avalanche of books published on the subject over the past few years, seems to support this trend towards talking about self-harm, if not actually 'talking it up' (Conterio and Lader, 1999; Levenkron, 1999; Strong, 1999; Turner, 2002).

However, few modern-day practitioners, reared on the psychobabble of 'borderline personality disorder', and related attempts to pigeonhole this phenomenon, might appreciate the complex dynamics - intra-psychic, interpersonal and social - that frame self-harm. It is almost 70 years since Karl Menninger (1938:1985) first discussed the 'war' that humans wage against themselves, for all sorts of different reasons. People who self-harm - especially those who dramatically carve the story of their distress on their bodies - belong to a disparate group of people who use a primitive instinct, designed for self-preservation against others, as a means of defending themselves against an abstract enemy that lies within. Regrettably, many professionals still dismiss people who self-harm as a health care nuisance.

It may be unpopular - and some will say, unscientific - to sketch the membership of such 'self-warring' peoples. However, self-harm seems to have much in common with many people who are suicidal, abuse alcohol and drugs, overeat, starve and purge themselves, or are exercise junkies, many of whom become health care statistics, sooner or later. All such behaviour is, at least indirectly, intentional and results in the 'primary gain' of changing how one feels within the body, if not also about oneself. Regrettably, psychiatry chose to adopt the term 'deliberate', with all its moralising overtones.

At the same time, society cultivates more and more people who are 'unhappy' with the shape or size of some part of their anatomy, or even of their 'self-esteem' or 'self-image' (cf Furedi, 2004). This new breed of 'self-haters' or at least self-dissatisfied people, may well lie at one end of a continuum, which extends through the eating disorders and addictions, to conclude with self-harm and suicide. Some authorities (e.g. Favazza, 1996) would even include all forms of body-modification alongside self-harm - through body piercing etc - although it was not clear whether he was pathologismg the former or normalising the latter.

Taken from a 6 Page Essay written by Phil Barker and Poppy Buchanan-Barker, 2004

Community Psychiatric Nurses Association Nov 2004
Over the next 6 weeks I will post it in parts or you can read the original article here.

Dissociation

Grounding Skills are interventions that assist in keeping a person in the present. They help to re-orient a person to reality and the immediate here-and-now. Grounding skills are useful in many ways.

However, then can be used to help re-orient oneself when experiencing intense and overwhelming feelings and intense anxiety. They help to regain one’s mental focus. These skills usually occur within two specific modalities:
1. Sensory Awareness
2. Cognitive Awareness

Sensory Awareness Grounding Skills
• Keep your eyes open, look around the room, notice your surroundings, notice details.
• Hold a pillow, stuffed animal or a ball.
• Place a cool cloth on your face, or hold something cool such as a can of soda.
• Listen to soothing music.
• Put your feet firmly on the ground.
• FOCUS on someone’s voice or a neutral conversation.

Cognitive Grounding Skills
Re-orient yourself in place and time by asking yourself some or all of these questions:
• Where am I?
• What is today?
• Whatis the date?
• What is the month?
• What is the year?
• How old am I?
• What season is it?

• List as many grounding skills as you can.
• Practice several grounding skills every day
• Construct a list of those which are most helpful and effective.

Goals When Using Grounding Techniques
1. To keep myself safe and free from injury.
2. To re-orient myself to reality and the here-and-now.
3. To identify what I attempted to do to prevent the dissociative experience.
4. To identify skills that I can use in the future to help myself remain grounded.
5. Choose a new response: What action, if any, do you want to take to feel better in the present?

For example, a flashback
may indicate that a person is once again in a situation that is in some way unsafe. If this is the case, self-protective actions should be taken to alter the current situation. On the other hand, a flashback may simply mean that an old memory has been triggered by an inconsequential resemblance to the past such as a certain colour or smell. In such cases, corrective messages of reassurance and comfort need to be given to the self to counteract the old traumatic memories.

Image: Out of Body Experience by ~parallelspaces

Link: NHS (pdf)

Medical Treatment For Self Harm

There may be sometimes when the individual requires medical treatment for their self harm. If this is the case the individual should expect to be treated sensitively and with the same level of care and attention as any other patient. (There are a set of guidelines produced for NHS staff to advise them how they should treat people who self harm.)

Unfortunately this is not always the case, and it will help if you are prepared and able to advocate for the person who has harmed themselves. Be aware that going to a GP or A & E for treatment of self harm is most likely going to be a very difficult experience for someone who self harms as this is a very public arena for a very private act.

Try to ensure the individual is given a private area to speak to the health care professional and that they are given a choice in their treatment - even if their choice is one you disagree with.
Any individual who has self harmed has the right to pain relief and thorough treatment for their harm, and should not be exposed to judgment or criticism by the healthcare professional.
If the person is bleeding heavily, has taken an overdose or ingested a substance, take the person to A & E as this could be life threatening. We are not healthcare professionals and cannot give advice on first aid.

A majority of cases of self harm are not serious enough to warrant medical intervention so individuals may never come into contact with healthcare services for their self harm. In these cases it is often beneficial for the individual to manage their own first aid by dressing their wounds and keeping them clean and dry.

[taken from Harmless]

A & E

New Guidelines to Standardise Care for People Who Self Harm.

The National Institute for Clinical Excellence (NICE) have issued new guidelines to standardise care for people who self harm in England and Wales.

Firstly, the new guideline makes recommendations for the physical, psychological and social assessment and treatment to be offered to people in the first 48 hours after a self harming incident. This covers all acts of self harm.

• Everyone who it is believed to have self harmed, should be offered a preliminary psycho-social assessment when at the triage stage.
• Proper care of a physical injury should not reflect a patients willingness to undergo psycho-social assessment or psychiatric treatment.
• Self harmers should receive the same care, dignity, respect and privacy as is offered to any other patient. Healthcare professionals should be supportive and take into account the distress of the self harm patient, over and above the nature of the injury.
• Accident and Emergency departments should have activated charcoal available at all times for self harm patients who have self-poisoned or overdosed.
• Always use proper anaesthesia and/or analgesia if treatment for self injury is painful.
• All staff who come into contact with people who self harm should receive appropriate training.
• All people who have self harmed should be assessed for future risk of self harm or suicide.
• Health professionals should take account of emotional distress as well as physical distress.
• Medical staff should not delay treatment because it is self inflicted.
• Acts of self harm by the elderly should be regarded as evidence of suicidal intent until proven otherwise.
• The key phychological characteristics associated with risk, in particular, depression, hopelessness and continuing suicidal intent, should be identified.

Dr Tim Kendall, a consultant psychiatrist and co-director of the National Collaborating Centre for Mental Health, is reported to have said: "Self harm and suicide have now become the third leading cause for life years lost after cancer and heart disease in all age groups. Few people providing care in casualty understand why people self harm and don't know how to help them effectively.

"Hopefully, this statement won't be true for much longer!

[taken from: Distant Healer.Co.UK]

A & E

It is estimated that around 170,000 people each year deliberately harm themselves. Of these, around 80,000 of those who attend the casualty department never receive a phychological assessment or follow-up. This is despite the fact that the risk of committing suicide after self-harming is 100 times greater than the average risk in the rest of the population.

You'd think that self harmers would be 'in safe hands' at hostpial, but there is growing concern and evidence (and I can back this up with personal experience) that self harmers sometimes receive a poorer standard of NHS care than other patients that were deemed to have sustained their injuries by accident. Self harmers are classified with drug addicts, drunks, glue sniffers and other groups who are in the same vicious cycle of tranquilizing their anxiety by inflicting harm and pain to themselves.

There is a deep seated feeling among some health care staff that self harmers of all kinds, clog the system, and consume resources that should be allocated to the 'deserving'. Charactistically, this goes with a general lack of patience when dealing with self harmers, right alongside the sarcastic or cutting remarks, that demean the self harmer, and sap their already low self esteem. Indeed, Professor Paul Lelliott, the director of the Royal College of Psychiatrists Research Unit, is reported as saying; "There are still examples of people having wounds stitched without anaesthetic, the idea being 'well you cut yourself without anaesthetic, so why should we use it?'"How barbaric is that??

This is not to say this sort of thing happens in all hospitals, and is not representative of the feelings of all staff. Many casualty staff are highly sympathetic and understand there is an underlying cause to the actions of a self harmer, which may require the efforts of other fields of medicine to resolve.

[taken from: Distant Healer.Co.UK]