"Assisted" self harm

I came across this article via a friend on Facebook and have a bit more to say about it than would fit in the comment box. The article, which can be found here, details approaches being used in psychiatric hospitals to try to reduce harm brought about by self injury and enable service users to self injure more safely. Many of these strategies are not new, though they're probably unheard of in most mental health establishments. I think some of those described are very helpful, others quite dubious, and it may surprise you to find out which I think are which.

Everyone who's admitted to a mental health unit has a care plan drawn up, usually with their participation. That is a standard procedure and copies should be held by both the staff and the patient. A good care plan for someone who self injures should include a section on how self injury might be managed. The general aim is to reduce the incidence of self injury, though that aim may not be shared by the patient. That's because self injury can be a life-saving coping strategy and removing a person's means of coping can put them at risk. However, self harm reduction strategies do need to be put in place because they may provide an alternative and more effective way of coping at some times. For example, being given the opportunity to talk to a trusted member of staff can be helpful in managing self harm, though staffing limitations on the ward often make this unworkable.

In addition to looking at reducing self harm, however, this article details ways for patients to continue to self injure but to do so more safely. The provision of dressings on wards is usual, though they are not usually directly accessible to patients, being kept in a locked room. Usually dressings will be provided as needed, and sometimes additional dressings will be provided, ostensibly for when dressings need to be changed, but effectively they can be used for new wounds too. The contraversial aspect is the provision of clean blades. The rationale is that, deprived of their usual means of self injury, people will look around for something else to use, and that something else will be more likely to cause infections than the clean blade they might have used otherwise. This is completely true. I have known people use broken glass off the pavement outside the ward, used blades discarded by others, even staples from magazines when on 1-1 supervision. None of these items are clean and some may carry serious health risks. A clean blade would certainly be preferable to any of these. There are, however problems, which I will come to shortly.

Some years ago I encountered this dilemma myself. I was in hospital for several months and self injuring frequently at the time. It was general practice for staff to remove blades from us if they found them on us, but there are many ways to hide a blade if you're determined enough. I had a friend who also self injured and she knew I had blades. I had been to the shop earlier and bought a pack of five. She asked me to give her one of them. I was unsure what to do. On one hand I felt that she had a right to self injure and shouldn't have had her means of doing so removed. I was also aware that she was trying to contain her stress and that she might do something more life-threatening if she was unable to cut. I also felt that it was somewhat hypocritical to stop her cutting when I was doing the same. On the other hand I didn't want to be responsible for her hurting herself, especially as this particular kind of blade was different, and probably sharper, than what she was used to using. I was worried that she might injure herself more severely than she intended with this unfamiliar blade. But it was clean and new and therefore preferable to what she might resort to using otherwise. I gave her the blade. I told her it was sharper, I made her promise to use it safely, and was very relieved that she did.

I do worry that hospital issue blades might escalate the severity of some people's injuries. If someone is admitted having been cutting with a penknife, and is issued a supply of razor blades they're not going to go back to using the penknife when they get home. On the other hand it was when in hospital that I started what became years of burning myself because my blades had been taken away.

It seems to me that by far the most sensible thing is for staff to supply the dressings but let people keep their own blades. If they weren't taken off us in the first place the whole issue of whether to replace unhygeinic salvaged "weapons" with hospital issue blades would go away. That measure in itself would probably reduce the level of self injury because it would reduce the build up of anxiety and the desperation it leads to.

Now onto the part of the article that really worried me; that being the practice of nurses sitting with patients while they self harm. Maybe this is some sort of covert prevention strategy because I can't imagine myself or anyone I know self injuring when anyone else is there. This is an intensely private activity, not to be seen by anyone, whoever they may be. One of the big reasons people don't seek help for injuries and learn to do their own dressings is because they don't want anyone to see the wounds, let alone the act itself. In my view the main preoccupation would be how to get rid of the nurse so I can get on with the self harm! I can't see how encouraging a patient to self harm in front of a nurse is going to help anyone, in fact I had not been prepared for the degree of horror I experience just by writing about it. Maybe sitting with the nurse before, or, even better, after self injuring, would help. But during? Ugh!

So my conclusion: let us keep our blades, help us to use them less if you can, give us the dressings we need when we need them and don't even think about sitting there while we're cutting.