February 9, 2017

expert reaction to allowing some people to continue to self-injure

An opinion piece published in the Journal of Medical Ethics, from the BMJ Journals group, looks at the ethical and clinical implications of allowing self-harm in mental health units.

Dr Bernadka Dubicka, incoming Chair of the Child and Adolescent Psychiatry Faculty at the Royal College of Psychiatrists said:

“There are significant ethical and clinical concerns surrounding the practice of encouraging self-harm in young people, particularly within inpatient settings where this behaviour can become contagious and also adversely affect other young people.

“Young people who self-harm on adolescent inpatient units should be encouraged by staff to gradually learn less harmful ways of responding to their distress. This can be a difficult and slow process, and young people may need a lot of support to establish new ways of coping. In extreme circumstances staff may need to restrain young people if risks are very high, and outweigh those of restraint, however, this should always be done within a legal framework and it is not routine practice to restrain young people for all episodes of self-harm.”

Dr Martina Di Simplicio, from the Medical Research Council Cognition & Brain Sciences Unit, said:

“I work with young people who self-harm (on a study called Imaginator, funded by NIHR/CLAHRC East of England) who come to the clinic as outpatients, so the premise is that they don’t engage in any life threatening injury or injury that is at high risk of causing permanent damage. Within this context, the aim of the therapy is to help them find alternative strategies to cope with distress instead of self-harming. So the aim isn’t stopping self-harming per se, but managing distress in a more helpful way. This is what the young people we see desire from the therapy.

“In Imaginator we start by making sense of the fact that self-harm has a function and identify how this is different for each individual. We devise a therapy for the individual that empowers the young person: they feel understood and start regaining a sense of control by making sense of what’s going on. There is no judgment and no blame. We also acknowledge that self-harm in general is a potent way to get relief from distress (because of the biological release of endorphins). I think this formulation (where we map an individual’s triggers and assess their specific needs) is often lacking in current care provision – especially with more and more understaffed and under pressure services! – and so agree with the points in the paper that argue for understanding the person’s needs and behaviour and giving them autonomy.

“Within the above therapeutic context, most young people don’t set the goal of stopping self-harm as it’s too scary to stop straight away without coping mechanisms. They usually set a goal to reduce gradually and hopefully ultimately not to need it at all anymore. The key is also to make sure that self-harm isn’t substituted by another unhelpful behaviour (binge eating or drinking for example). So, I would agree that stopping self-harm as the first goal at all costs isn’t actually helpful at supporting those who self-harm, not even those who would like to stop at some point, let alone those who don’t wish to stop at all.

“However, the context of inpatients can be quite different because:

1) Self-harm might be much more severe in inpatients. There is evidence that repetitive self-harm tends to become more severe over time and increases risk of suicide or death by misadventure, and there’s no evidence (as far as I know) that this is secondary to interventions trying to stop it altogether. So, as a general rule, we cannot just let self-harm just take its course – making it safer via sterile razors, for example, won’t stop the risk of escalation, which is more likely in more severe situations e.g. inpatients.

2) Harm-reduction may not work for everyone: most people experience ambivalence between feeling initially better after self-harm and then worse because they’ve done it (guilt, low self-esteem). Some people say that if they don’t have the means, they sometimes end up not self-harming; so learning that they actually can tolerate and cope with distress better than they expected can help.

“Again, it’s about formulating the problem with each individual and then making a management plan which might be different from person to person.”

* ‘Should healthcare professionals sometimes allow harm? The case of self-injury’ by Patrick J Sullivan published in the Journal of Medical Ethics, from the BMJ Journals group, on Thursday 9^th February.

Declared interests

None declared