managing self-harm among mental health service users
Joy Koroma
11B (Mental Health)
Adopting Best Practice
Who has come across a service user who has self harmed?
The rational in ‘Practice experience’
In all my placements, both mental health and adult, I came across several services users who self harm or had history of self harm.
Planning and managing the care of those service users was challenging at times
Myths about self harm and at times negative attitudes towards those who self harm
My interest is ‘How to effectively manage the care of service users who self harm’ as this may result in reduced suicide rate.
Outline of presentation
Definition and incidence of self harm
Self harm and suicide relationship
Risk factors associated with self harm
Policies and guidelines on managing self harm
Conclusion
Self harm
Deliberate self harm is any act by an individual with the intent of harming himself or herself physically and which may result in some harm.
(Isacsson & Rich, 2001)
Generally, individuals who engage in deliberate self harm are in a lot of emotional pain and they do not have healthy methods for coping to manage the pain. (Pearrow, 2004)
Methods of self harm
65% more likely to cut themselves.
30% poisoning/overdose
More violent & less common methods: Asphyxiation,
Hanging,
Suffocation
Jumping
Substance misuse (illicit drugs)
Burning
(Dennis et al, 2007 & Fox et al, 2007)
Self harm statistics
It is estimated that around 1 in 130 people (nearly half a million across the UK) self-harm a year
A survey of 6,000 teenagers found that 11% of females and 3% of males have self-harmed
In a study of 398 participants who reported acts of self harm, only12.6% of episodes had resulted in presentation to hospital.
One of the top five causes of acute medical admission in the UK – BUT, most people who self-harm do not attend Accident & Emergency.
(Hawton et al 2007)
self harm and suicide
They are not the same: motivation and intent may be different
Suicide is considered as death cause by intentional self-harm or injury/poisoning of undetermined intent.
40-50% of completed suicides have histories of deliberate self harm
Deliberate self harm is the most high risk group for suicide. 100 times greater than the general population
Suicide is now the second most common cause of death amongst young people.
Main cause of premature death in people with mental
(Office of National Statistics, 2011)
psychological and risk factors associated with self-harm
People who self-harm tend to:
Experience low mood
Misuse substances
Be impulsive
Have poor coping strategies to regulate their emotions
Be hypersensitive to rejection
Lack warmth in relationships
Suppress angry feelings
Do not feel in control of how they cope with life
Suffer chronic anxiety
Tend not to plan for the future
(Bhugra, et al 2002; Dennis et al, 2007; Hawton et al 2009; Hawton et al 2007)
quiz
reality or myth
“People who self-harm are attention seeking or manipulative”
Answer: Myth
The reality:
For many people it is a very private act, and kept secret for years. For others it is the only way of communicating at a time when they are deeply distressed.
‘Rejection and feeling bad about oneself may be a cause of someone’s self-harm. Further rejection is likely to lead to further self-harm’
Answer: Reality
The Myth
It’s best to ignore someone when they have self-harmed – they are less likely to do it again
If people who self-harm cause themselves pain, they don’t need pain relief when their injuries are being treated
Answer: myth
Reality:
Sometimes people are conscious of pain when they self-harm, at other times they are not. Once the self-harm is over, pain is very much a reality!
People who self-harm have a personality disorder
Answer: Myth
The reality:
A person’s self-harm may not relate to any specific mental health condition
Policies
Although World Health Organisation (WHO 2004) recommends that all nations develop mental health policy, there is no specific policy on the management of self harm
The European mental health strategy (with four core strategic objectives: equal opportunity, human rights; mental health services are accessible and affordable, and people receive effective and respectful treatment.) has no guideline on the management of self-harm
The Department of Health’s New Horizons programme replaces the National Service Framework for Mental Health (1999). New Horizons is a comprehensive programme of action for improving the mental wellbeing of the population and improve the quality and accessibility of the services that care for people with poor mental health by 2020.
‘No health without mental health’ (2011) Supersedes The new horizon (2010)
The six shared objectives are as follows:
More people will have good mental health
More people with mental health problems will recover
More people with mental health problems will have good physical health
More people will have a positive experience of care and support
Fewer people will suffer avoidable harm
Fewer people will experience stigma and discrimination
NICE Guidelines management of self harm (2004)
Key points:
People who self harm should be treated with the same care, respect and privacy as any other patient
Clinical and non-clinical staff in contact with people who self harm should have appropriate training
Assessment of service users should be comprehensive and include risk assessment.
When someone self harm: steps for management
Physical assessment
Physical treatment:
Mental health assessment
Treatment for mental health problems
Psychosocial intervention
Benchmarking and Audits
recommended by NICE (2004)
Benchmarking:
NICE (2004) developed nine (9) standards as best practice guide used as a benchmarking tool by local NHS services which can be audited to demonstrate improvement in services provided to people who self harm.
Audits:
Objectives for the audit is to ensure that:
Individuals who self-harm are involved in their care
Treatment options are appropriately offered and provided in the best practical way.
A single audit could include all individuals who self-harm or individual audits could be undertaken on specific groups of individuals such as: people who self-poison or self-injure a sample of people from particular populations in primary care.
Local policy
A local mental health trust use the principles of NICE guidelines to develop local polices on preventing and managing self harm within secondary mental health care settings.
The purpose of this policy is to provide a flexible and reflective approach to the assessment and management of service users who present with previous or current self-harming behaviour.
Service users can present to A&E or contact mental health services who may refer to advice service user to go to A&E depending on the severity of the self harm
The trust is responsible for the provision of clinical care and are also responsible for having training in place for clinical staff in relation to the care and treatment of service users who self-harm.
Psychosocial assessment following self harm could mean service user can be admitted for brier periods (lest than 5 days) in one of two local mental health assessment units
Conclusion:
Interventions for managing self harm should emphasise human values:
Non-judgmental
Dignity
Advocacy
Empowerment
Any questions?
references
Bhugra, D; Singh, J; Fellow-Smith, E; Bayliss, C. (2002) Deliberate self-harm in adolescents. A case study among two ethnic groups. European Journal of Psychiatry , Vol 16(3), 145-151.
Dennis et al (2007) A study of self-harm in older people: Mental disorder, social factors and motives Aging & Mental Health, 11(5): 520–525
Department of Health (2011) No health without mental health: a cross-government mental health outcomes strategy for people of all ages http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_123766
Department of Health ( 1998) Saving Lives – Our Healthier Nation. A Contract for Health. A Consultation Paper. London: Department of Health.
Department of Health ( 1999) The National Service Framework for Mental Health. Modern Standards and Service Models. London: Department of Health.
Fox, C. & Hawton, K. Deliberate self Harm in adolescence Jessica Kingsley Publishers: London.
Hawton, K., Rodham, K., Harriss, L. (2009) How adolescents who cut themselves differ from those who take overdoses. European Child & Adolescent Psychiatry, DOI 10.1007/s00787-0009-0065-0.
references
Hawton, K., Rodham, K. & Harriss, L. (2007) Deliberate self-harm in young people: characteristics and subsequent mortality in a 20-year cohort of patients presenting to hospital. Journal of Clinical Psychiatry, 68, 1574-1583.
Isaacson, G; Rich, C. L. (2001) Management of patients who deliberately harm themselves. BMJ: British Medical Journal , Vol 322(7280), 213-215.
NICE (2004) Self-harm: The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care http://www.nice.org.uk/CG16 :
ONS, 2011: Statistical Bulletin, Suicide rates in the United Kingdom 2000-2009)
Pearrow, M. (March, 2004). Self-mutilation and the Role of the School Psychologist. Mini-skills workshop conducted at the annual meeting of the National Association of School Psychologists, Dallas, Texas.
WHO. (2004a). Promoting mental health: Concepts, emerging evidence, practice. Available: hnp://who.int/mental_health/evidence/en/promoting_mhh.pdf
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