Tuesday, 27 September 2016

Metal Nurse: Self Harm and Suicide Attempts

This isn't a topic that I read an awful lot about until relatively recently. Maybe it's because I've got two daughters and I worry about their well-being especially seeing as one of them is approaching the age where self harming is most common. Maybe it's because as I get older I meet more people who have self harmed one way or another. Whilst this article will mostly focus on self-harm, I will also touch base on suicide attempt since they often overlap. And because of having a personal history of it.

 According to a report by Health Behaviour in School-Aged Children up to 1 in 5 children aged 15 self harm and a large proportion of those are girls. That's not to say that boys don't self harm, they do. But either they are less willing to admit to do doing do or they do in a way that most people don't consider to be self harming. We still don't expect boys to be as emotional mature as girls, so there might be a case of easy dismissal when they feel the need to offload their burdens but can't because they are boys. And boys don't talk about feelings instead they commit suicide.


My interest in writing this particular article was not so much the self harming itself, but the attitude I have come across. The attitude that self-harming is somehow all about attention, that people who attempt suicides are just time wasters, essentially that people who suffer from various mental health issues do not deserve medical treatment. The problem with that attitude is that it invalidates how these patients feel. They need help, we might not always be able to provide that help, but what we should be able to provide them with is environment that feels safe. Where they feel not so much like a burden, somewhere where they don't feel judged by their actions and decisions. As healthcare professionals we are not only responsible for our patients physical well-being but also their emotional well-being.


Quote from Mind

So maybe if we start with the basics.

What is self harm?

It's a fairly self-descriptive phrase. But for those who need it said, it is the act of harming oneself. Self-harm can come in form of intentional overdose, harming yourself by cutting, burning and punching yourself. There are of course other more subtle ways of harming yourself, for example by starving yourself, over eating, practising unsafe sex, binge drinking, etc.

Self harm cycle
We also have to remember is that people who do self-harm are not doing so in order to commit suicide. In most cases this is to assist them with coping with their heightened emotional states. It is a form of distraction. It is a way of coping. It can also be looked as an act of self-preservation, as some people do it as an emotional release.

Bear in mind is that self-harming is usually an indication of a problem rather then the problem. It is mostly a manifestation of that persons personal circumstances, whether they are under unusual amount of stress, depression, past abuse, some form of past trauma, neglect, loss, etc, the list is pretty endless. It is essentially a cycle of self torture. Some people use it as self punishment for when they feel they have done something wrong to someone else. Some patients also plan on their self harm, whilst others do it more spontaneously.



Why do people self harm?

Now then, this is were it gets a little trickier. And for some a little harder to understand. As I mentioned previously, it is essentially a way to cope with external circumstances and internal turmoil. For some it is a form of release. Like opening up a valve full of pent up rage, stress, self-doubt and so on. Others have said that it makes them feel more alive after feeling numb for so long. That the negative emotions they were experiencing before a self harming incident was reduced. For others it feels like the only aspect that they can control in their lives, when there are issues occurring that they feel is out of their control. For some it feels like the closest they can do to suicide without dying, a form of prevention so to speak. These individuals might be feeling low, and do not know how else to cope with pressures that are surrounding them. Whether it's due to social pressure, family, education, etc. There will always be outside stress factors that will contribute to a person self-harming.

How common is self harm?

Well. That is something that is pretty hard to put a finger on. It is in the top five of reasons for acute medical admissions, with over 150,000 attendances per year. The exact figure of how many people self harm is hard to find out, most studies have been done in form of survey's and questionnaires after an admission to hospital due to self harming and/or attempted suicide. But the Royal College of Psychiatrists put the figure somewhere around 400 in 100,000. According to the RCPsych people of all social groups and all ages engage in self-harm and/or suicidal behaviour, but teenagers, veterans and prisoners are at particular risk.

In America for example the suicide rate amongst 15-19 year old has doubled since the 1960's, in the UK self-harm is largest cause of death amongst 20-24 year olds. As I stated earlier, girls are more likely to self-harm and contemplate about suicide. But boys are more likely to commit suicide. Sadly some research from Australia has shown that the younger the patient who presents with self harm and/or suicide ideation, the lower priority they are given compared to those who are aged between 35-44, this is broken down even more in terms of method. Patients who self harmed with blades are deemed as less of an emergency compared to those who expressed the idea of self harming, with a greater preference also being given to male patients.

What can be done?

There is plenty of improvement that needs to be done regarding the care of patients who present with self-harm. Generally the lack of documentation is pretty shocking to start with. In 2009 a small retrospective study pulled 25 patient records from various A&E. These patients had presented into Emergency Departments with self harm. None of those records had documented mental state examinations. Suicide risk and risk factors had either been poorly documented or not at all. So obviously documentation needs to be improved upon, but mostly what is probably more important in my opinion is to raise the staffs awareness of the importance of those details. Yes, some of these patients will be calling for help and that is something that should not be ignored. Why are they crying for help? What is their story? What has lead to them presenting with self harm and/or suicide attempt? NICE provide excellent guidelines on initial management of patients who present in A&E with self harm. Which includes assessment of physical and mental health well-being, as well as safeguarding status. To be taken to a place of safety, or at least taken care of in a place of safety.

The biggest difference we can make is not to take self harm lightly. Which is what majority of these patients express their disappoint about. We need to stop, look and listen. But it is getting harder and harder to give these patients the treatment they need and deserve. Funding for Mental health services continue to be cut down. Waiting time for counselling is sadly going up. According to this report by MIND, 1 in 5 have been waiting for over a year to receive some sort of treatment and 1 in 10 have waited for over 2 years. This is not acceptable.  As general nurses who work in A&E and Medical Assessment Units, we do not get enough time to help. Generally we end up taking care of up to eight patients, each who have varying degrees of acuity. Most of the time we end up neglecting those with mental health problems because they appear physically healthy.

If in our care what we can do, or at least should make an attempt to is to talk. I know I keep on repeating myself. But this is important. If they don't want to talk, but want to continue self harm instead, with blades for example. Then at the very least we should be able to make sure that they use clean blades and have equipment ready to clean their wounds and put on clean dressings on. Teach them how to dress the wounds properly. Teach them how to perform first aid. Provide them with a safe space. And then be available to talk, or make sure there is someone there that they can talk to and/or want to talk to. We can provide paper and pens if that helps, so that they can write out their thoughts and frustrations. We can provide a marker pen for them to use on their skin instead of a blade. We can give them ice cubes, elastic bands, etc etc. If we can't prevent the damage, we should limit it.

In recent years we have become very good at bereavement and know who to contact for those type of situations. We have become very good at comforting relatives when we know that that their loved ones are getting closer to leaving the realm of the living. But we haven't become so good at referring people to counselling, there doesn't seem to be a way to refer patients straight from ED or Medical Assessment straight to counselling. Or IAPT. We also either deny ourselves the time or just plainly don't have the time to sit down and talk to them. What they do get often is a referral to mental health services, they get to speak to mental health practitioners about their initial problems. But then they get put on a waiting list. And more often than not, they return. And they return again. And in the long term if this cycle isn't stopped will lead to more potentially preventable deaths.

Taken from SANE
The point is that we shouldn't judge people because they self-harm, because we don't know what lead to that decision. We don't know what kind of experiences would lead to someone to put a knife on themselves and slice over and over again, or take XX amount of paracetamol, or stub out cigarettes on themselves. As nurses it is not for us to decide that they are weak, or seeking attention. In fact if they are seeking attention then we should do our best and find out why they are doing so. We are there to assist people at their weakest moment, whether that be physical or mental. We are there to care for those who need it. We are there to support and hopefully heal our patients.










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