Self-harm in adolescent in-patients

AIMS AND METHOD

Self-harm among adolescent in-patients exercises all who workwith them. The UK has an exceptionally high prevalence of thisbehaviour compared with the rest of Europe. However, in onein-patient adolescent unit, in-patient self-harm was significantlyreduced. Details of our rationale and intervention are presented,together with a retrospective data analysis.

RESULTS

Using a range of practical and psychological interventions,the alarmingly high level of self-harm was almost completelyeliminated and this level has been maintained to the present.

CLINICAL IMPLICATIONS

Our results suggest that self-harm in in-patients can be managedand reduced without adverse effects on the patients. Our methodsmay be applicable to other settings, although some staff mayinitially feel uncomfortable with such policy.

Introduction

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Introduction

Research into self-harm in adolescents has been heavily weightedtoward the study of suicide and behaviours related to it. Thoseepisodes of self-harm which owe little or nothing to consistentor lasting suicidal intent are recognised, but mostly studiedin relation to young adults. Studies include women with borderlinepersonality disorder, incarcerated men with antisocial personalitydisorder, people with an intellectual disability and other organic conditions, and those with psychoses or gender identity disturbanceswho engage in major self-mutilation (Favazza, 1989; Pies & Popi, 1995).

The incidence of non-suicidal self-harm in adolescents has beenrising year on year and the UK now has the highest rates ofthis behaviour in Europe (National Institute for Health and Clinical Excellence, 2004),although rates of depression do not show similar geographicor cultural variation. It is estimated that one in ten adolescentsin the UK will self-harm (Hawton & James, 2005), althoughthe actual number may be much higher. These behaviours leadto 24 000 hospital admissions per year (Samaritans & Centre for Social Research, 2002).The report Truth Hurts (Mental Health Foundation, 2006) urgesus all ‘to hear the voices of the young people’and commit to playing an active part in ‘transformingthe experience of the 1 in 15 young people in the UK who arein such pain that they are harming themselves’.

Particular groups at risk include girls (with seven times theincidence in boys), prisoners and young Asian women (National Institute for Health and Clinical Excellence, 2004).Reasons for self-harm include relationship problems with peers,family and school, depression, bullying, alcohol and drug misuse,and low self-esteem (Fox & Hawton, 2004; Hawton & James, 2005).

A number of explanations are offered for the behaviour, includinga release of tension, frustration and anger, and using self-harmto communicate difficult feelings. Self-harming may begin inadolescence, but it frequently persists into adulthood andcan become addictive (Favazza & Conterio, 1989).

It is clear that such behaviour, when it occurs within definedcommunities, for example at hospital in-patient units, canbe followed by fellow in-patients (Taiminen et al, 1998).

Interventions designed to reduce or eliminate self-harm havebeen researched mostly in young adults, with a scarce numberof studies that include adolescents. The literature on self-harmin adults suggests that whereas medical interventions havean impact on some of the associated factors, such as low moodand low self-esteem, few lead to lasting success in reducingthe incidence of self-harm.

Oakwood Young People’s Centre

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Oakwood Young People's Centre

Oakwood Young People’s Centre is a sub-regional in-patientand day-patient National Health Service (NHS) adolescent unitwith 13 beds and 12 day places, although staffed for only 3beds at weekends and public holidays. Like most similar units,we have moved from operating as a therapeutic community atthe centre’s inception in 1981 to an acute general psychiatricadolescent ward. We continue to utilise the therapeutic opportunitiesafforded by having a managed group of adolescents under our care.

The mean length of stay in the centre is 6 months. The centreis open 365 days per year and a third of total admissions areacute emergency admissions. The centre’s admission criteriaspecifically exclude those with a moderate or severe intellectualdisability.

In the last 3 months of 2002 the generally steady backgroundlevel of self-harm on the unit (mean number of episodes perweek 1.2, s.d.=1.3) escalated to alarming proportions (meannumber of episodes per week 8.1, s.d.=4.0). Here, we definedself-harm as making cuts on one’s body or over-dosingon purchased prescription drugs. The acute management of self-harm was detracting from other therapeutic work and teenagers whohad not previously self-harmed were learning and practisingthese behaviours during their admission. Those who were notself-harming, as well as their parents, clearly expected staffto protect them from the distressing sights and repercussionsof self-harm occurring on the unit.

Intervention

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Intervention

Discussion

Conclusions

References

We addressed the self-harm problem directly and drew up a newpolicy to guide staff. We introduced this to the in-patientsin December 2003, allowing time for discussion and questionsand indicating that the new policy would take effect afterthe New Year holiday.

The essence of the policy was to emphasise that we recognisethat many struggle with self-harm and have used it in the past.We offer a range of support and alternative coping techniques,for example the use of ice, rubber bands and marker pens insteadof sharp objects, diaries, relaxation and distraction, as wellas a wide range of therapeutic interventions to address thepatient’s underlying distress and problems. We would viewself-harm on the unit as analogous to the use of alcohol orillicit substances - completely unacceptable and resultingin immediate suspension from the unit. Following suspension,a person would return to a meeting, in which their care giverswould participate, to consider and renegotiate their therapeutic contract with us. Such contracts are rarely written and signed,although the care plans are. Any repeated self-harm would begrounds for discharge.

We recognised the need to make rare exceptions to the policy,for example behaviour stemming from genuine and persistentsuicidal intent.

Results

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Results

Monitoring and reporting incidents is rigorous on the unit andgives us confidence that few, if any, episodes of self-harmwould go undetected.

There were three distinct periods in data collection.

The background level from April 2002 until the end of September2002.
The 3-month period when the self-harm escalated (OctobertoDecember 2002).
The period following policy implementationup to the present(February 2003 to the present).

The rates of self-harm for the 2 weeks following implementationwere similar to those in the 3 months before implementation.Initially, many in-patients did not believe that the policywould be implemented or that it would be followed consistently.Thereafter, the rates fell and have remained low to the present(Table 1).

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Table 1. The number of self-harm episodes on the unit before and after intervention

Managing self-harm on the unit is no longer a task which detractsstaff from other aspects of their work (Fig. 1).

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Fig. 1. The number of self-harm incidents on the unit before and after the policy was implemented. Data were collected monthly; last self-harm incident recorded in April 2006.

There were no differences in the levels of occupancy or in the patients’ diagnoses in the three periods identified,namely at baseline, in the 3 months before the Christmas holidays2002 and after the policy was implemented.

Our policy is explained to all individuals being assessed foradmission to the unit. To date, we have not discharged anypatient as a consequence of the policy, nor has anyone refusedadmission as a direct result of being unable to comply withthe policy. Rather, patients and parents at admission generally welcome and support the efforts made to maintain the safetyof the individual and the community of patients. We monitorpatients’ weekend activities by telephone or face-to-facecontact with carers upon return to the unit on Sunday evening;we have not noted any increase in self-harm at weekends. Rigorousincident reporting procedures support our impression that self-harm behaviours have not been replaced by alternative injuriousacts not specifically included in the policy.

Discussion

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Intervention

Discussion

Conclusions

References

During the drafting of the policy, not all the unit’sstaff supported the initiative. Some feared that it might beperceived as punitive or judgemental and suggested we oughtto accept these behaviours or ‘work with them’.Nevertheless, the danger posed by these behaviours and their disruptive and distressing effect was clear to staff and otherin-patients. Through a prolonged period of consultation, staffwere helped to realise the lack of alternative, effective therapeuticinterventions available to us and the need to act consistently.This helped stem the tide of opinion suggesting that we shouldmaintain a very flexible response to self-harm behaviours.

The policy is specifically limited to addressing behaviourson the unit and does not include weekend activities off theunit.

In retrospect, the commitment of the in-patients to their placeon the unit is evident in their efforts to stem behaviourswhich might result in their discharge.

This approach depends upon the staff’s ability to offermeaningful sanctions for self-harm, while continuing to offersupport, alternative coping strategies and therapies. Suchan approach is not necessarily directly applicable to non-institutionalsettings, for example in the community. However, the contagiousnature of self-harm is well recognised in schools, where considerationof the model may prove useful.

Conclusions

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Intervention

Discussion

Conclusions

References

There is an obvious and pressing need for more research intothe area of self-harm, in particular non-suicidal self-harmin adolescents, not least in the areas of intervention andtreatment. We cannot rely with confidence upon extrapolationof adult findings to support our work with teenagers.

There is a risk that a need to understand the behaviour (forself-harm is not an illness) may be confused with an apparentacceptance, condoning or even fostering the behaviour. Sinceviolence towards others is unacceptable, perhaps we might considerviolence towards oneself, at least, in a similar vein. We mayaccept the continuation of self-harm behaviours when workingwith adults, but I view it as an inappropriate response whenworking with adolescents.

References

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Intervention