#talkingharmreduction #selfharm

Transcription

1 #talkingharmreduction #selfharm

2 Harm reduction and self harm: the research evidence Dr Karen James

3 Supporting people who self harm Prevalence: 4% of adults and 10% of young people but probably higher Between 4% and 70% of people self harm during an inpatient admission (Bowers, Simpson & Alexander, 2003; Swinton, Hopkins & Swinton, 1998) What works?? (Hawton et al., 2016) CBT seems to be effective DBT reduces frequency of self harm, but not numbers of people who self harm No evidence for pharmacological interventions What should good nursing care look like? No comprehensive, evidence based, models Evidence for containment measures is mixed (Bowers et al., 2003; Bowers et al., 2008, Lindgren et al., 2011; Duperouzel & Fish, 2008)

4 Harm reduction?? Policies, programmes or interventions that aim to reduce the health-related harms of a behaviour (European Monitoring Centre for Drugs and Drug Addiction, 2010) Focus on reducing the adverse effects of a behaviour, not prevention or cessation of the behaviour itself Well established within sexual health, alcohol and substance support services, and has been shown to improve people s physical health and wellbeing (Midford et al, 2014; Rekart, 2006; Wheeler et al, 2010) Examples include: Prescription of methadone maintenance to people dependent on opioids Promotion of strategies to reduce the risk of HIV transmission during unprotected sex Needle exchange programmes and supervised injection sites for people who inject drugs

5 Harm reduction for self-harm is about accepting the need to self-harm as a valid method of survival until survival is possible by other means. this does not condone or encourage self-injury but is about facing the reality of maximising safety in the event of self-harm (Louise Pembroke, 2007)

6 Clinical guidance The Guidance Development Group (GDG): Found no evidence to support or to contradict a harm reduction approach for people who self-harm. However, took the view that the resistance to employing harm reduction approaches in this context had no evidential support. Recommend tentative approaches to harm reduction for some people who self-harm. Considered the role of the inpatient unit in harm reduction, and whilst the GDG recognised that for some individuals admission may reduce self-harm, for others, this may exacerbate it. The GDG therefore decided to make no recommendation about the use or the role of inpatient units in harm reduction.

7 Clinical guidance

8 Evidence?? a primary emphasis on the prevention or cessation of an important coping strategy is unlikely to be the most helpful response. Ask a drugs worker or a teenage sexual health worker. You might anticipate answers like, it s unrealistic and patronising ; it would ruin the therapeutic relationship. Claire Shaw (from Mental Health Today, September/October 2012) Ros gave me my first lesson in anatomy & physiology [she] taught me how to recognise the symptoms of infection and how to minimise the risk of it occurring this non-judgemental and practical approach was imparted without any lecturing or catastrophising and had a profound impact on me Louise Pembroke (from Beyond Fear and Control, Spandler & Warner, 2007)

9 Impact on rates of self-harm Forensic women s service Collected (incident) reports of self-harm: 6 year period, 45 women, 533 episodes of selfharm Rates of self-harm were significantly lower before discharge than at admission

10 Some reports from practice

11 Clinician perspectives Calderstones Trust, Forensic Learning Disability Service Questionnaire, 71 staff: 85% in favour, not for all clients Concerns about witnessing self harm Concerns about duty of care Staff should be able to choose

12 Self harm antipathy scale nursing staff, 31 wards, 15 hospitals Percentage Agree Disagree Undecided 0 People should be allowed to self harm in a safe environment An individual has the right to self harm

13 Staff veiws by ward People should be allowed to self-harm in a safe environment 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Ward number

14 Interviews: Managing risk Concerns about risk: They ll ask for knives, cans, razors, I think it would increase it I d be scared that they could die, they could bleed out and die. How do we measure the scale of self harming that they re allowed to do? Where do we stop, where do we draw the line? Questioning perception of risk: I think in my head I m feeling this is high risk. At the same time when we see people that self harm, often they don t consider it as a high risk event. They consider it as just something to relieve themselves Benefits may outweigh risks: That desire is so intense that by taking away their stuff, you make it worse I think it would minimise infection We had that plan, and it worked, because over a gradual period of time, I think we observed that the frequency of her self harming was less When he felt accepted, that had a very positive reaction within himself that s when he started showing his motivation and all these plans

15 Interviews: Roles and responsibilities we always have to adhere to prevention of harm, harm to self and to others because they re upset that s not a good enough reason for me I mean to me its professional neglect they might as well not be in hospital A challenge to role of hospital and nurse A moral duty will there ever be anybody there to say, you know, you shouldn t be doing that. You can t do that? It s not up to us to get them there, it s up to them who, really, are we to stop them? Rights based approach Can we stop selfharm? Do we have enough tools in our tool belt?. I don't know if any of us do. we have to acknowledge an individual's need and sense of self I don t think you can ever really stop them

16 Ethical analysis Practitioners are justified in allowing self-harm in the short term as long as the person can engage with therapeutic strategies which aim to help them manage their distress in alternative ways in the future. In the long-term, this will allow people to recover, and so allowing injury (with precautions) may not be harm, all things considered

17 Conclusions Harm reduction for self harm is being implemented in services Anecdotal evidence from lived and professional experience that it is helpful A growing body of (limited) research evidence for its effectiveness: Safer self harm Reduced incidence of self harm Therapeutic effects: acceptance, understanding, empowerment Complex practical, ethical and legal challenges: How do you decide who is eligible? How do you manage risk? How do you manage strong and opposing views within teams? Is it covered by professional codes of conduct? Who is clinically and legally responsible? Currently no comprehensive clinical/best practice guidance

18 Resources NICE guidance Mind & National Self Harm Minimisation Group Guidance: me Hurt Yourself Less Workbook: Coping with self-harm: a guide for parents Rethink guide to self-harm

19 SELF-HARM & ME Isaac Samuels

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22 10 SUMMARY OF RECOMMENDATIONS 10.1 GENERAL PRINCIPLES OF CARE How is this possible when most services are risk averse? Working with people who self-harm Health and social care professionals working with people who self-harm should: aim to foster people s autonomy and independence wherever possible

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25 Risk??

26 It s all about how you view self-harm

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