Understanding Self Harm Salena Williams Senior Psychiatric Liaison Nurse, BRI

What are your feelings when confronted with a self-harmer? How do you feel when confronted with a patient with self harm? Please write a word or sentence which describes how you feel when someone present with self harm behaviour. This is confidential – write whatever comes to mind!!! Try and recall such a situation when the department is very busy and all of the staff are already committed and note down the issues, feelings and what could have resolved the issue

The “Oh no!” factor Lack of knowledge of self harm how can we safely assess? Stigma: People who cut their wrists /arms over and over again are wasting NHS resources Potential for violence Confounding issues with deliberate self injury Time/Staffing difficulties? Facilities? Conduits of referral? Security issues?

What is self harm? Self assault Ingesting Gouging Fluids Punching walls Foreign Facial punching bodies Biting Medication  Insertion Ligature Forcing foreign bodies neck cord Into wounds/cavities hanging  Picking Laceration Wounds/sutures Cutting the body  Head banging Misc Chafing Immersion Burns Electrocution Rubbing

Quotes ‘I felt a warm sense of relief, as though all the bad things about me were flowing out of me, and it made me feel alive, real’. ‘People often link self harm to suicide, but for me it was something very different; it was my alternative, my way of coping even though sometimes I wished that my world would end!’

Who Self Harms? - strong self dislike - hypersensitivity to rejection Psychological characteristics common in self-injurers: -       strong self dislike -       hypersensitivity to rejection -       chronic anger (usually towards themselves) -       suppress and direct anger inward -       high levels of aggressive feelings, which they disapprove of -       impulsive – lacking in impulse control -       act in accordance with their mood -       lack plans for the future -       depressed/suicidal (1/4 all suicides DSH w/in last year) - chronic anxiety sufferers, suffer irritability -       poor coping skills/no flexibility of skills -       avoidant -       unempowered

Self Harm: Not a suicide attempt Not manipulative – “attention seeking” Usually private – go to great lengths to hide it Not necessarily associated with personality disorder or severe mental illness Key risk factor for suicide

TREATMENT OBJECTIVES 1. Assess suicide risk 2. Assess for mental illness   3. Obtain a detailed picture of why the patient undertook self harm at this particular time 4. Medical support: immediate, plus advice on self care 5. Communication with community support 6. Helplines, support networks and treatment

NICE: General Principles Respect and privacy Choice of staff: male/female Explain treatment Capacity and consent Include family/friends/support Offer treatment Offer sedation/anaesthesia

When you are with the patient Be aware they are experiencing strong emotions – anger, fear, sadness Be clear – simple instructions, write things down Keep boundaries clear – precise information Behaviour is the problem not the person Be genuine, honest and listen but set limits on time Stick to facts Encourage social support not medical support Document decisions Get team support

Open questions “What’s led up to the tablets/cutting yourself?” “What’s been happening lately?” “How have you been feeling in yourself lately?” “Can you tell me about any recent difficulties/upsets?” “Tell me about your circumstances at home” – e.g. who do you live with? “What is the biggest problem at the moment?”

‘Top Tips’: helping the self harming patient : Harm minimisation Non-destructive self harm - punch bag, ice cube Medical awareness Peaceful environment  Following self harm Information sharing Encourage self-help group – control Information giving - Resources in area Therapist/key worker contact

Summary Understanding the differences between self harm and suicide Recognising our own feelings Who to refer and how to refer