1. Understanding Self Harm
Salena Williams
Senior Psychiatric Liaison Nurse, BRI

2. 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

3. 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?

4. 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

6. 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!’

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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?”

13. ‘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

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