Coping by Cutting

The usual approach to people who self-harm is to stop them. David Batty reports on one unit where the response is very different.

Before Sharon Lefevre started cutting herself she could see no way out of her despair. After years of sexual abuse she believed her life was worthless. But her traumas had left here unable to express this distress and in her frustration she punished herself instead. She repeatedly tried to hurt herself, even considering an overdose at one point.

Then one morning six years ago she finally succeeded, gashing open her palm with a broken mug. To her surprise the wounds seemed to release her pent up anxiety. Indeed, she felt a strange sense of achievement at having uncovered the pain she had hidden so deeply.

But Ms Lefevre soon discovered that most health professionals were not interested in the cathartic nature of her self-harm. Nurses and doctors at the local A&E department treated her like a time waster with no apparent concern for her distress.

'On one occasion I was even stitched up without anaesthetic' she recalls. 'It was so painful I didn't realise what was happening at first. I was crying and screaming but the staff ignored me. I was just seeking attention as far as they were concerned. I fact I tried to cut myself only when I was alone and hid my scars under long sleeves.'

After several visits to A&E Ms Lefevre was transferred to a psychiatric unit but encountered similar punitive treatment. 'If I attempted to harm myself I would be shouted at and marched to my room' she said. 'I was forced to agree not to harm myself, as if somehow I could suddenly put a lifetime of trauma behind me and become perfectly well adjusted. No one asked me why I did it, and if I tried to explain they would tell me to shut up. Eventually I decided to act like a "good patient" to get discharged and be able to harm myself again. Of course that soon became a vicious circle.

But in 1993 Ms Lefevre was referred to Dryll y Car, and eight bed support unit in Gwynedd which aims to empower people to take control of their lives. Although encouraged to develop other means of expressing her pain, she was not criticised for cutting herself if she felt unable to cope otherwise. If she did, she was encouraged to use clean razor blades and cut so as to minimise her injuries.

The unit was established five years ago by Gwynedd Community Health Trust and developed an ethos of supporting people to stay well through working in partnership between staff and clients. Around a quarter of its clients suffer from some degree of psychosis, and many engage in self-harm or suicidal behaviour. The approach to people who self-harm was based on the observation that prohibiting people from self-harming did not prevent them from doing so outside hospital.

'In my experience punishing people for self harming behaviour only makes things worse' comments Dryll y Car's Acting Nurse Manager Mike Greenwood. 'Over time I noticed that most people only harmed themselves when extremely distressed and were much calmer afterwards. Talking to clients I realised that self harm was usually a survival strategy to avert suicide. It isn't attention seeking, but an expression of unspeakable truths or feelings of lack of self worth, often linked to traumas like sexual abuse. By forcibly preventing people from self-harming you take away the only control they have over their lives and increase their feelings of helplessness. Instead we should be empowering people by giving them responsibility for their actions so that they can move beyond their victim status and not need our support.'

Mr Greenwood describes Dryll y Car's approach as a structured partnership between clients and staff on mutually agreed purposes. 'We negotiate our objectives rather than prescribing a fixed model of care' he explains ' Clients are offered a series of planned, focused admissions at regular intervals to work on the causes of their distress. If they need our support between admissions they can phone the unit or be admitted for 72 hours. By encouraging clients to contact us before they're in crisis we can prevent them from self harming or needing another lengthy stay as would happen in the conventional system.'

The unit is part of a multi disciplinary community mental health team with nurses working alongside psychologists, psychiatrists, social workers and occupational therapists. Some members of the team are also trained as complimentary therapists. Mr Greenwood explains that this range of therapeutic techniques allows clients to be less reliant on medication. 'They learn new ways of expressing themselves through music and art therapy. Physical exercise and relaxation techniques, such as aromatherapy, help them regulate their emotional state, whilst in individual counselling sessions they try to confront past traumas.

But these methods do not always prevent clients from experiencing further distress, as Mr Greenwood recognises. 'There are no quick solutions, which is why we help people to limit the damage caused by self-harm. This can prevent wounds becoming infected and help reduce scarring.'

The RCN's Mental Health Advisor Tom Stanford said that while treatment outcomes for prohibitive self-harm services are very poor, harm minimisation programmes still need careful evaluation. 'Our understanding of self-harm is still very limited so we need to be cautious. Harm minimisation raises important questions about nurses' accountability. I'm anxious that they might find themselves in practice situations where their action could make them vulnerable if not clearly recorded by the multi-disciplinary team.'

Mr Greenwood recognises that giving clients more responsibility can be difficult to deal with. 'People sometimes increase their level of self-harm initially' he admits 'It can be a way of testing whether staff can be trusted not to remove the control. This isn't always easy for nurses to cope with, but taking over relieves your anxiety but not the client's.'

' To work in this way we have to have a closely knit team with good communication and an atmosphere of mutual trust between colleagues.' Mr Greenwood continues. 'We have to be clear that our aim is always to reduce self harm as much as possible by supporting people and by dealing with their distress, not their behaviour. But if people do self harm it is not our place to sit in judgement of them.'

Two units like Dryll y Car have opened in Bron Haul on the North Welsh coast and Coedlys in Anglesey, but elsewhere in the health service there is little acceptance of self harm. The National Self Harm Network, which campaigns for more understanding of people who intentionally injure themselves, hopes that a new workbook inspired by Dryll y Car's methods will change professionals' attitudes. Working with Self Harm is a collaboration between the network's co-ordinator Louise Pembroke and Andy Smith and Nurse Mike Smith, winner of the Nursing Standard nurse 97 award, and his colleague Ron Coleman.

The workbook advises people who self harm to prepare guidelines for hospital staff describing what treatment they want; whether they would prefer to see a social worker, a psychiatrist or a psychiatric nurse, for example. 'When people are admitted to A&E we'd like them to have access to an advocate and a private assessment room.' Ms Pembroke said. 'Under the present triage system you usually have to show staff your injuries at an open desk where anyone can come and have a gawp. This heightens your stress and anxiety. And self-harmers generally don't possess the self-worth to ask for even basic comforts.'

Ms Pembroke added that’s he would like to see outreach projects for self-harmers developed in the community. I'd like to see "safe houses" where people can collect first aid kits and clean blades. These could contain "rage Rooms" for you to express you distress through smashing objects rather than hurting yourself.

To support its campaign for reform the network is compiling an incident report of cases where hospitals refuse to treat self-harmers and plans to pass its findings to the department of health. "We already have letters from managers and consultants telling people they will not tat self inflicted injuries.

The Network believes that greater liaison between users and professionals can help to change existing practices. Mike Greenwood shares this view and has run several training groups on self-harm with Ms Lefevre. 'If we're really committed to moving mental health care out of the asylums and into the community then we must learn to relinquish control and treat people as individuals and not diagnoses' he said. 'It may be harder work, but it's also far more rewarding.

Ms Lefevre admits she can see why self-harm can be hard for nurses to deal with. 'For the professionals self-harm seems like a failure on their part, they couldn't prevent the client from hurting themselves. But for the sake of all professionals, I'd like to say that you cannot fail something that you have not begun. You do fail when you ignore that person's open wounds, or when you treat this person as though they have no sense or rights and deny their experience, or turn away in disgust.

Since 1996 Ms Lefevre has run her own workshops at hospitals and conferences across Britain. She is currently writing a new workbook with Mr Smith, exploring therapeutic interventions to self-harm which will be published this summer.

Ms Lefevre admits that self harm is not easy to live with but believes that it has long been her salvation. 'Although there is still a long way to go before I can say I've recovered, learning to manage my experience and minimise my injuries has enabled me to get on with my life. I've finished a drama degree and started a PhD at Aberystwyth University, and I don't feel like a failure any more.

This article appeared in:

Nursing Standard

April 8-14 1998 Number 29 Volume 12

Different versions appeared in a number of national newspapers at the time, and were features in news programmes on BBC Wales and Channel 5

Nurse Manager Mike Greenwood