Lets start by saying that I self harm. I self harm regularly in a way that society tends to approve of. Most Saturdays I strap on my rugby boots and on a good day, for 80 minutes large, hairy men will charge at me while I try to knock them over. On other days I am punched, stamped on, scraped with studs, or just hurt. Over the years I have broken my nose, chipped my teeth, ripped the skin under my chin open, split my forehead and all last week, sported a big purple eye. I play rugby every week, not seeking pain but knowing full well that it is inherent in this activity. The pain and damage that it gives me is worth it in terms of the other benefits that I receive. Now obviously playing rugby isn’t the same as cutting lines in my thigh, but I’m arguing that that both activities are on a spectrum of things that damage you but come with some reward that makes it worthwhile.
Now its interesting that nobody cares about my self harm in the slightest. In work I spend a lot of time with people who regularly self injure, where others aren’t that bothered about their self harm either. At work I try to point out the link between self harm and suicide, offer to help and support people who want to stop and encourage them to care for themselves in ways that don’t involve hurting or punishing themselves. I never forcibly stop them. The people I work with all live in the community and can make informed decisions about how to live their lives. If they want to stop self harm I’ll do my best to help. If they don’t I’m still there (although I might let them know how I’m affected by it). Self harm is their understandable way of coping which they do because it works.
On the ward, it is a different story. The people I work with tend to have long standing thoughts of suicide. When that chronic risk becomes acute they might be admitted. What is interesting is that it becomes an unspoken part of someone’s care on the ward that they must immediately stop all forms of self harm. It doesn’t matter that self harm wasn’t a factor in their admission, it has become one now. Usually the acute period of suicidality passes fairly quickly, but because those who have self harmed for years have suddenly lost their only way of coping the risks go through the roof. Those who cut carefully with blades are ripping cans open, smashing crockery, banging their heads on the wall and (potentially most lethally) tying things around their neck in a quest to get whatever benefit they usually receive. It is at this point the person tends to want to get out of hospital asap and it is at this point that the enforced self harm abstinence really comes into its own. While the client articulately tells people they don’t want to die and just wants to go home, we can’t let them go until they fit our model of wellness, which tends to involve them presenting with healthier coping methods than they have used in years.
With people who don’t want to stop self harming (and weren’t admitted to do so) psychological intervention to help them stop rarely works. Instead we prescribe different intensities of observation ranging from being checked on once an hour to being followed constantly by 1 or more staff. At times we can administer a PRN dose of heavy staff to physically stop whatever behaviour we find intolerable. As the risks increase the number and weight of the staff rises proportionally and eventually we decide that the only solution is large staff in an environment far away from us.
We can wonder about why MDTs need someone who has no intention of stopping self harm to be self harm free before they are discharged. We can spend even longer wondering how a period of stability can be achieved when long standing coping mechanisms are forbidden, everything is scrutinised, no leave or time alone is allowed, any emotional response to this treatment is written off as part of the diagnosis and if you do try to hurt yourself in a way that no one would have batted an eyelid at in the community, 3 heavy men will hold you on the floor in a vague reanactment of one of your most traumatic experiences.
Looking at this rationally we can see that if you want to seriously upset and disregulate someone, following the above “care”plan might well be the perfect way to do it.
Its worth thinking about why situations like this come about. I hear others say that they are kicked off the ward as soon as they self harm but for some clients, ward based self harm is more effective at keeping you on the ward than locking yourself in the nursing office. It makes sense that we let people make their own decisions about how to manage their distress in their own homes, but why do we have to forcibly prevent them on the ward?
There’s two main factors at play for me. The first is that the majority of mental health staff come to work to make people better. Our training prepared us for people who would come in with simple problems, we would dispense our wisdom and they would recover and be grateful. It is almost impossible for staff to look at someone under their care bleeding profusely and feel they are doing a good job. Stopping self harming is a kind of recovery and if people won’t get better, we will make them better. I’m sure this starts out with the most caring and compassionate motivations but after a few weeks of wrestling much of the empathy will have evaporated.
The second is how painful it is to see someone hurting themselves. There is the immediate visceral impact of seeing damage occurring, the emotional reaction to seeing someone in so much distress and the psychological trauma of watching someone causing damage to themselves. When we combine people who see their role as preventing harm with people who use harm as a way of coping we manage to whip up a perfect storm where the more we help, the more abusive we are perceived. Given no obvious other way of helping we do everything we can to prevent harm occurring and lose sight of how much added distress, trauma and risk our help is causing. Regardless of the clients wishes, we will join the long list of other people in their lives who forced them to do what we wanted.
I see the above frequently and I suspect it is replayed across the country. I worked with a man recently who was only ever violent when he was in hospital. He was no longer suicidal but couldn’t be let off the ward until the behaviour that only occurred on the ward had stopped occurring on the ward.
My solution is for organisations to have a team to think about these complex dynamics that are so hard for us to see when we are caught up in them. The NICE guidelines for borderline personality disorder describe teams who support the organisation to formulate, assess and respond to complexity and risk in thoughtful ways. A 3rd mind that can ask the question “Why do we keep doing this when it makes it worse?” can be invaluable.
So often I find that staff caught up in these situations are utterly miserable. They can see that they are actively harming someone with their help but feel powerless in a system that knows only higher levels of restriction in response to risk. In my ideal world admission would rarely be used and when it was, the benefits/costs would be thought about beforehand. At the very least on every care plan we would rubber stamp “do not detain in hospital for behaviour we wouldn’t consider detention for in the community”. In models of organisations that work with people, a strong emphasis is placed on the value of a thinking space. I regularly hear that this can’t happen and that action is valued much more. If staff can’t be given space to think and reflect then specialised teams might need to do their thinking for them. This might involve changing the culture of the organisation so that risk is thought about in a different way. I have 2 fears. One that this will only begin to happen after someone who is far more dangerous as an inpatient accidently kills themselves on the ward. My other fear is that this happens time after time and we still can’t learn from it.
Now blanket approaches to managing risk are rarely successful and its most beneficial to think about everyone individually. I’m not advocating for inpatient environments where anything goes, but for thoughtful consideration of how people respond to an environment and how we respond to their presentation. If nothing else, let’s think about our role in someone’s change in presentation. Most importantly, lets ensure we are never a part of someone being sent miles from home to be forced to stop something that was never a factor in their admission.
All thoughts appreciated @keirwales
Keir is a Lead Therapist in an NHS Specialist Service and provides training, consultation and therapy around complex mental health problems through beamconsultancy.co.uk
Much of this was inspired by a conversation with @graffiticymraeg who’s blog https://themainoffenderblog.wordpress.com/ is far better than mine
All the above reflects themes expressed much more articulately in The Ailment