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Balancing Costs and Benefits: A Clinical Perspective Does not Support a Harm Minimization Approach for Self-injury Outside of Community Settings

9 Feb, 17 | by miriamwood

Guest Post: Hanna Pickard and Steve Pearce

Responding to: Harm may sometimes be a good thing? Patrick Sullivan

Sullivan’s emphasis on the importance of supporting autonomy and independence among vulnerable people who self-injure is fundamental to good clinical practice. This is why some forms of harm minimization, such as encouraging reflection, responsibility, safe cutting and where appropriate self-aftercare, are uncontroversial and already widely practiced within community settings. The situation is different, however, with respect to both secure and non-secure inpatient settings. It is also different when we consider the other forms of harm minimization that Sullivan advocates, namely, the provision of self-harming instruments on wards alongside education about anatomy.

In secure (forensic) inpatient settings, it is neither practical nor ethical to provide implements that can be used as weapons to any patient, for any reason. This would be to severely compromise staff and patient safety.

In non-secure inpatient settings, patients are likely to be detained under the Mental Health Act. This raises the question of the grounds of detention. Typically, patients who self-injure are detained because they are judged to be currently at risk of life-endangering or life-changing injury. As Sullivan notes, it is not clinically or ethically appropriate to provide patients with the means to self-injure when they are in this state of mind. This means that the relevant inpatient population for which a harm minimization approach could even be considered is relatively small: those who have a standing pattern of self-injury and who are detained on non-secure units for reasons other than acute self-injury.

Sullivan suggests that the long-term benefits of facilitating self-injury for such patients may outweigh the costs. He notes that self-injury functions as a way of coping with psychological distress – which restrictions of liberty can heighten – and suggests that harm minimization may improve therapeutic relationships with staff and outcomes for patients over time. However, the potential benefits of a harm minimization approach to a particular patient must be weighed – in clinical and ethical decision-making in a non-secure inpatient setting – not only against the potential costs to that patient but also against the potential costs to staff and other patients. Consider these in reverse order.

With respect to costs to other patients, it is well-established that self-injury can be contagious. Patients who are admitted onto a ward without a history of self-injury may learn to self-injure if they see other patients doing it – this risk may be especially pronounced if self-injury is part of a therapeutic engagement with staff – and patients with a history of self-injury may learn new means. Specialist inpatient units, including one at which SP worked in the 1990s, which have employed a harm minimization approach in the past have had difficulties with patients adopting techniques from one another and self-injury escalating. Put bluntly, witnessing or even just hearing about self-injury increases the chance that people try it themselves. The impact on other patients of facilitated self-injury on wards needs to be factored into any assessment of costs and benefits.

With respect to the costs to staff, it is of course accepted that clinical work requires managing the psychological burden of treating challenging patients like those who self-injure. But facilitating self-injury through the provision of implements in non-secure inpatient settings would significantly increase this burden. Risk assessment is not an exact science and mistakes will occur – especially, perhaps, in the current NHS context where wards are both overpopulated and understaffed. If staff provide implements to people to self-injure in inpatient settings, they not only bear the psychological cost of knowing they have facilitated – and in that sense sanctioned – the process of self-injury. There will also be occasions where patients accidentally or deliberately kill themselves. Staff will then be in a position of having provided the means to this devastating outcome. Obviously by far the most important cost in such a situation is to patients. But the psychological burden of working with this risk – let alone dealing with its actual occurrence – and its potential impact on staff stress levels and burn-out will not be negligible, and again needs to be taken into account.

Finally, consider the potential costs to patients themselves. We do not deny that it is extremely difficult for patients who have a standing pattern of using self-injury as a way of coping with psychological distress to have it curtailed. No doubt, care would be improved by better awareness and attention to the impact this has on detained patients. But people self-injure not only to manage psychological distress. Self-injury is also a communication to others as well as linked to low self-esteem, negative core beliefs, and emotions like shame and self-hatred. It can both express and reinforce a person’s deeply held belief that they are bad, worthless, and deserving of punishment. This is part of its meaning. The impact of staff facilitating self-injury within a therapeutic relationship risks fuelling this mindset by implicitly sanctioning it. This risk might be mitigated in contexts where staff are highly trained and skilled in offering complex psychological interventions with vulnerable patients – as well as expertly supported and supervised – but, again, this is not a realistic expectation on today’s NHS wards.  Long-term self-injury is correlated with suicide. This is one reason why so much effort is made to address it across all mental health settings. Correlation is not causation, and we must acknowledge that mechanisms are as yet unknown, but it is natural to speculate that one reason is that self-injury maintains a negative self-concept –a known risk factor for suicide.

Indeed, even something as seemingly innocuous as education about anatomy carries risks that Sullivan does not acknowledge. In this respect, it is noteworthy that the medically trained population has higher suicide completion rates than the general population. Sullivan seems to presume that teaching someone about, for example, the important structures in the wrist, will enable them to cut with less risk. But we cannot assume knowledge is benign: rather than being used to self-injure more safely, it can, instead, be used to enable people to cut more dangerously and effectively.

The abstract principles of harm minimization are laudable, but from a clinical and practical ethical perspective, the devil is in the details. Apart from uncontroversial measures already practiced in community settings, we do not believe that – for self-injuring patients themselves, let alone when we factor in the potential impact on other patients and staff – the balance between costs and benefits tips in its favour.

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  • Patrick Sullivan

    I would like to thank Hannah Pickard and Steven Pearce for their considered response to my blog and to my paper. I do however feel it is important to be clear about my argument. As a result I would like to make a number of points in order to clarify my position. I will number these in order promote clarity:

    1. It is important to me clear that I am in no way advocating the use of harm minimisation as a routine measure across inpatient facilities. I am arguing that there are a small number of inpatients that may benefit from such an approach.

    2. When I talk about harm minimisation I am not merely describing the use of sterile cutting instruments and education about anatomy. This alone would achieve little. I make pains in my article to emphasise that harm reduction methods are a component of a sophisticated therapeutic programme that must include access to psychological interventions based on a detailed assessment of a persons needs and wishes.

    3. If the prevention of infection is taken seriously then access to sterile cutting implements must be considered a possibility. It would not be appropriate in all cases and if permitted would have to occur in a safe and controlled way. In addition, it is important to note that the overall approach does not necessarily involve the use of sterile cutting instruments. Elastic bands and ice cubes have been used as alternatives.

    4. I agree entirely with the point that in secure settings (and other inpatient facilities) the open availability of implements that can be used as weapons is not an option. I do not and have not advocated such a position. The approach is far more sophisticated than this. Having made this point it is important not to exclude the use of harm reduction techniques in secure environments as work has been undertaken supporting the use of harm reduction techniques. These are discussed in the Department of Health Self Harm Expert Reference Group (SHERG) publication Safe and Secure. Working constructively with people who self injure. A Guide for staff working in secure mental health units. May 2012.

    5. I am not advocating the use of harm minimisation for acutely Ill people detained under the Mental Health Act who are actively suicidal or may injure in life threatening ways. This would be neither feasible nor right.

    6. The fact that this limits my argument to a small group of individuals does not invalidate it. This is in fact an essential element of my argument, as like Pickard and Pearce I realise there are limitations on adopting the approach in many inpatient clinical environments. Participation in such a programme would need to be based on an informed consent.

    7. An important part of my argument is to weigh the costs and benefits of current regimes against a harm minimisation approach. Sadly the alternative option for some people (not all people) is currently high levels of observation and restrictions of movement with little in the way of therapeutic support and sometimes no psychological input. If harm minimisation is not an option then some alternative means of promoting engagement and improving the persons experience is required. The status quo is not an option.

    8. I would accept that self-injury is contagious and that people who have no history of self-injury may learn such behaviours in an inpatient setting. Drawing on my own experiences (I have worked in mental health services in some capacity since the 1970’s), I would argue that this phenomenon also occurs in units that do not adopt a harm minimisation approach and take active measures to prevent such behaviour occurring.

    9. I acknowledge Pickard and Pearce’s comments about the impact the adoption of such approach may have on staff. However, it is important to note that this situation may also arise in units, which attempt to prevent self-injury through quite restrictive means and do not make use of harm reduction techniques.

    10. I note Pickard and Pearce’s comments on the current position in NHS facilities and would agree entirely but the pressures on these units may be a fact but that does not make it right. I think we would both agree there is a need for more resources and the development of a more positive therapeutic ethos supported by more highly skilled and appropriately supervised staff. Although I accept the point self-injury is a form of communication and I take the point and there are risks associated supporting self-injury. I am not convinced however current interventions in an inpatient environment are successful. For example many inpatients have no access to psychological therapy.

    11. I agree entirely that in dealing with people who self injure the risks must be mitigated by highly trained staff with a high level of psychological skill that provides the relational security and therapeutic containment that is required to support people who self injure. Only then could harm minimisation (or for that matter other types of intervention) be a possible option.

    12. I accept that education may increase the risks, the point about health care professionals is well made, but unfortunately the alternative is not to educate people and they may suffer serious harm that is not intended. The proposal is not just about teaching people to self injure safety; it is also about explaining the dangers of the persons current behavior. This area raises particularly complex moral questions.

    I would like to thank Hannah Pickard and Steven Pearce for their considered response to my blog and to my paper. I do however feel it is important to be clear about my argument. As a result I would like to make a number of points in order to clarify my position. I will number these in order promote clarity:

    1. It is important to me clear that I am in no way advocating the use of harm minimisation as a routine measure across inpatient facilities. I am arguing that there are a small number of inpatients that may benefit from such an approach.

    2. When I talk about harm minimisation I am not merely describing the use of sterile cutting instruments and education about anatomy. This alone would achieve little. I make pains in my article to emphasise that harm reduction methods are a component of a sophisticated therapeutic programme that must include access to psychological interventions based on a detailed assessment of a persons needs and wishes.

    3. If the prevention of infection is taken seriously then access to sterile cutting implements must be considered a possibility. It would not be appropriate in all cases and if permitted would have to occur in a safe and controlled way. In addition, it is important to note that the overall approach does not necessarily involve the use of sterile cutting instruments. Elastic bands and ice cubes have been used as alternatives.

    4. I agree entirely with the point that in secure settings (and other inpatient facilities) the open availability of implements that can be used as weapons is not an option. I do not and have not advocated such a position. The approach is far more sophisticated than this. Having made this point it is important not to exclude the use of harm reduction techniques in secure environments as work has been undertaken supporting the use of harm reduction techniques. These are discussed in the Department of Health Self Harm Expert Reference Group (SHERG) publication Safe and Secure. Working constructively with people who self injure. A Guide for staff working in secure mental health units. May 2012.

    5. I am not advocating the use of harm minimisation for acutely Ill people detained under the Mental Health Act who are actively suicidal or may injure in life threatening ways. This would be neither feasible nor right.

    6. The fact that this limits my argument to a small group of individuals does not invalidate it. This is in fact an essential element of my argument, as like Pickard and Pearce I realise there are limitations on adopting the approach in many inpatient clinical environments. Participation in such a programme would need to be based on an informed consent.

    7. An important part of my argument is to weigh the costs and benefits of current regimes against a harm minimisation approach. Sadly the alternative option for some people (not all people) is currently high levels of observation and restrictions of movement with little in the way of therapeutic support and sometimes no psychological input. If harm minimisation is not an option then some alternative means of promoting engagement and improving the persons experience is required. The status quo is not an option.

    8. I would accept that self-injury is contagious and that people who have no history of self-injury may learn such behaviours in an inpatient setting. Drawing on my own experiences (I have worked in mental health services in some capacity since the 1970’s), I would argue that this phenomenon also occurs in units that do not adopt a harm minimisation approach and take active measures to prevent such behaviour occurring.

    9. I acknowledge Pickard and Pearce’s comments about the impact the adoption of such approach may have on staff. However, it is important to note that this situation may also arise in units, which attempt to prevent self-injury through quite restrictive means and do not make use of harm reduction techniques.

    10. I note Pickard and Pearce’s comments on the current position in NHS facilities and would agree entirely but the pressures on these units may be a fact but that does not make it right. I think we would both agree there is a need for more resources and the development of a more positive therapeutic ethos supported by more highly skilled and appropriately supervised staff. Although I accept the point self-injury is a form of communication and I take the point and there are risks associated supporting self-injury. I am not convinced however current interventions in an inpatient environment are successful. For example many inpatients have no access to psychological therapy.

    11. I agree entirely that in dealing with people who self injure the risks must be mitigated by highly trained staff with a high level of psychological skill that provides the relational security and therapeutic containment that is required to support people who self injure. Only then could harm minimisation (or for that matter other types of intervention) be a possible option.

    12. I accept that education may increase the risks, the point about health care professionals is well made, but unfortunately the alternative is not to educate people and they may suffer serious harm that is not intended. The proposal is not just about teaching people to self injure safety; it is also about explaining the dangers of the persons current behavior. This area raises particularly complex moral questions.

  • Miriam Wood

    Response by Patrick Sullivan: Sometimes, not always, not never. Some additional comments on harm minimisation and self-injury.

    I would like to make some additional comments relating to my pervious blog“ Harm: could it sometimes be a good thing “ and to also respond to the very helpful response to that blog by Hanna Pickard and Steven Pearce titled; “Balancing costs and benefits: A clinical perspective does not support a harm minimization approach outside of community settings.

    The paper that links to my original blog has resulted in some media coverage and much of that coverage misrepresents (in my view) my underlying argument. For that reason I would like to restate my position briefly to be clear exactly what it is. It is important my position is not misunderstood, as this is an important issue.

    There are a number of people who self injure as a means of coping with feelings of overwhelming distress. By preventing such individuals injuring themselves it is possible to increase such distress with the result that the desire to self injure becomes overwhelming. This may result in more extreme attempts at self-injury. Harm minimisation involves allowing individuals to self injure safely whilst working with them to develop alternative coping strategies. The approach would not be suitable for routine use and It cannot be used with individuals who are suicidal or whose self injury is so dangerous it may become life threatening. My paper considers a number of ethical issues that arise in considering the viability of such an approach within an inpatient setting.

    In such a setting the normal approach to working with people is to try and stop the individual acting in this way. In hospital settings this will involve restricting access to harmful implements and on occasions the use of continuous observation to try and ensure the persons safety. I argue that paradoxically this may increase the risks, although I accept that in some cases these more restrictive approaches are both necessary and proportionate and harm minimization would ‘never’ be used or even considered. I suggest that ‘ sometimes’ allowing harm may be a good thing. I note that the approach is both controversial and counter intuitive and accept there are real questions regarding the implementation of the approach. I do however believe that it brings into focus the complex issues relating to autonomy and paternalism and the need to take positive risks to achieve positive therapeutic outcomes. In the final analysis I remain committed to the view that harm minimisation may ‘sometimes’ be a good thing.

    In their blog and accompanying paper Hannah Pickard and Steven Pearce provide a considered but different perspective. In reading their response I was concerned that parts of my argument could be misunderstood by readers of the blog or paper. I would like to make a number of points in response. I will number these in order promote clarity:

    1. It is important to me clear that I am in no way advocating the use of harm minimization as a routine measure across inpatient facilities. I am arguing that there are a small number of inpatients that may benefit from such an approach.

    2. When I talk about harm minimization I am not merely describing the use of sterile cutting instruments and education about anatomy. This alone would achieve little. I make pains in my article to emphasise that harm reduction methods are a component of a sophisticated therapeutic programme that must include access to psychological interventions based on a detailed assessment of a persons needs and wishes.

    3. If the prevention of infection is taken seriously then access to sterile cutting implements must be considered a possibility. It would not be appropriate in all cases and if permitted would have to occur in a safe and controlled way. In addition, it is important to note that the overall approach does not necessarily involve the use of sterile cutting instruments. Elastic bands and ice cubes have been used as alternatives.

    4. I agree entirely with the point that in secure settings (and other inpatient facilities) the open availability of implements that can be used as weapons is not an option. I do not and have not advocated such a position. The approach is far more sophisticated than this. Having made this point it is important not to exclude the use of harm reduction techniques in secure environments as work has been undertaken supporting the use of harm reduction techniques. These are discussed in the Department of Health Self Harm Expert Reference Group (SHERG) publication Safe and Secure. Working constructively with people who self injure. A Guide for staff working in secure mental health units. May 2012.

    5. I am not advocating the use of harm minimisation for acutely Ill people detained under the Mental Health Act who are actively suicidal or may injure in life threatening ways. This would be neither feasible nor right.

    6. The fact that this limits my argument to a small group of individuals does not invalidate it. This is in fact an essential element of my argument, as like Pickard and Pearce I realise there are limitations on adopting the approach in many inpatient clinical environments. Participation in such a programme would need to be based on an informed consent.

    7. An important part of my argument is to weigh the costs and benefits of current regimes against a harm minimisation approach. Sadly the alternative option for some people (not all people) is currently high levels of observation and restrictions of movement with little in the way of therapeutic support and sometimes no psychological input. If harm minimisation is not an option then some alternative means of promoting engagement and improving the persons experience is required. The status quo is not an option.

    8. I would accept that self-injury is contagious and that people who have no history of self-injury may learn such behaviours in an inpatient setting. Drawing on my own experiences (I have worked in mental health services in some capacity since the 1970’s), I would argue that this phenomenon also occurs in units that do not adopt a harm minimisation approach and take active measures to prevent such behaviour occurring.

    9. I acknowledge Pickard and Pearce’s comments about the impact the adoption of such approach may have on staff. However, it is important to note that this situation may also arise in units, which attempt to prevent self-injury through quite restrictive means and do not make use of harm reduction techniques.

    10. I note Pickard and Pearce’s comments on the current position in NHS facilities and would agree entirely but the pressures on these units may be a fact but that does not make it right. I think we would both agree there is a need for more resources and the development of a more positive therapeutic ethos supported by more highly skilled and appropriately supervised staff. Although I accept the point self-injury is a form of communication and I take the point and there are risks associated supporting self-injury. I am not convinced however current interventions in an inpatient environment are successful. For example many inpatients have no access to psychological therapy.

    11. I agree entirely that in dealing with people who self injure the risks must be mitigated by highly trained staff with a high level of psychological skill that provides the relational security and therapeutic containment that is required to support people who self injure. Only then could harm minimisation (or for that matter other types of intervention) be a possible option.

    12. I accept that education may increase the risks, the point about health care professionals is well made, but unfortunately the alternative is not to educate people and they may suffer serious harm that is not intended. The proposal is not just about teaching people to self injure safety; it is also about explaining the dangers of the persons current behavior. This area raises particularly complex moral questions.

  • Miriam Wood

    Patrick Sullivan

    Sometimes, not always, not never. Some additional comments on harm minimisation and self-injury.

    I would like to make some additional comments relating to my previous blog “Harm: could it sometimes be a good thing “ and to also respond to the very helpful response to that blog by Hanna Pickard and Steven Pearce titled; “Balancing costs and benefits: A clinical perspective does not support a harm minimization approach outside of community settings.

    The paper that links to my original blog has resulted in some media coverage and much of that coverage misrepresents (in my view) my underlying argument. For that reason I would like to restate my position briefly to be clear exactly what it is. It is important my position is not misunderstood, as this is an important issue.

    There are a number of people who self injure as a means of coping with feelings of overwhelming distress. By preventing such individuals injuring themselves it is possible to increase such distress with the result that the desire to self injure becomes overwhelming. This may result in more extreme attempts at self-injury. Harm minimisation involves allowing individuals to self injure safely whilst working with them to develop alternative coping strategies. The approach would not be suitable for routine use and It cannot be used with individuals who are suicidal or whose self injury is so dangerous it may become life threatening. My paper considers a number of ethical issues that arise in considering the viability of such an approach within an inpatient setting.

    In such a setting the normal approach to working with people is to try and stop the individual acting in this way. In hospital settings this will involve restricting access to harmful implements and on occasions the use of continuous observation to try and ensure the persons safety. I argue that paradoxically this may increase the risks, although I accept that in some cases these more restrictive approaches are both necessary and proportionate and harm minimization would ‘never’ be used or even considered. I suggest that ‘ sometimes’ allowing harm may be a good thing. I note that the approach is both controversial and counter intuitive and accept there are real questions regarding the implementation of the approach. I do however believe that it brings into focus the complex issues relating to autonomy and paternalism and the need to take positive risks to achieve positive therapeutic outcomes. In the final analysis I remain committed to the view that harm minimisation may ‘sometimes’ be a good thing.

    In their blog and accompanying paper Hannah Pickard and Steven Pearce provide a considered but different perspective. In reading their response I was concerned that parts of my argument could be misunderstood by readers of the blog or paper. I would like to make a number of points in response. I will number these in order promote clarity:

    1. It is important to me clear that I am in no way advocating the use of harm minimization as a routine measure across inpatient facilities. I am arguing that there are a small number of inpatients that may benefit from such an approach.

    2. When I talk about harm minimization I am not merely describing the use of sterile cutting instruments and education about anatomy. This alone would achieve little. I make pains in my article to emphasise that harm reduction methods are a component of a sophisticated therapeutic programme that must include access to psychological interventions based on a detailed assessment of a persons needs and wishes.

    3. If the prevention of infection is taken seriously then access to sterile cutting implements must be considered a possibility. It would not be appropriate in all cases and if permitted would have to occur in a safe and controlled way. In addition, it is important to note that the overall approach does not necessarily involve the use of sterile cutting instruments. Elastic bands and ice cubes have been used as alternatives.

    4. I agree entirely with the point that in secure settings (and other inpatient facilities) the open availability of implements that can be used as weapons is not an option. I do not and have not advocated such a position. The approach is far more sophisticated than this. Having made this point it is important not to exclude the use of harm reduction techniques in secure environments as work has been undertaken supporting the use of harm reduction techniques. These are discussed in the Department of Health Self Harm Expert Reference Group (SHERG) publication Safe and Secure. Working constructively with people who self injure. A Guide for staff working in secure mental health units. May 2012.

    5. I am not advocating the use of harm minimisation for acutely Ill people detained under the Mental Health Act who are actively suicidal or may injure in life threatening ways. This would be neither feasible nor right.

    6. The fact that this limits my argument to a small group of individuals does not invalidate it. This is in fact an essential element of my argument, as like Pickard and Pearce I realise there are limitations on adopting the approach in many inpatient clinical environments. Participation in such a programme would need to be based on an informed consent.

    7. An important part of my argument is to weigh the costs and benefits of current regimes against a harm minimisation approach. Sadly the alternative option for some people (not all people) is currently high levels of observation and restrictions of movement with little in the way of therapeutic support and sometimes no psychological input. If harm minimisation is not an option then some alternative means of promoting engagement and improving the persons experience is required. The status quo is not an option.

    8. I would accept that self-injury is contagious and that people who have no history of self-injury may learn such behaviours in an inpatient setting. Drawing on my own experiences (I have worked in mental health services in some capacity since the 1970’s), I would argue that this phenomenon also occurs in units that do not adopt a harm minimisation approach and take active measures to prevent such behaviour occurring.

    9. I acknowledge Pickard and Pearce’s comments about the impact the adoption of such approach may have on staff. However, it is important to note that this situation may also arise in units, which attempt to prevent self-injury through quite restrictive means and do not make use of harm reduction techniques.

    10. I note Pickard and Pearce’s comments on the current position in NHS facilities and would agree entirely but the pressures on these units may be a fact but that does not make it right. I think we would both agree there is a need for more resources and the development of a more positive therapeutic ethos supported by more highly skilled and appropriately supervised staff. Although I accept the point self-injury is a form of communication and I take the point and there are risks associated supporting self-injury. I am not convinced however current interventions in an inpatient environment are successful. For example many inpatients have no access to psychological therapy.

    11. I agree entirely that in dealing with people who self injure the risks must be mitigated by highly trained staff with a high level of psychological skill that provides the relational security and therapeutic containment that is required to support people who self injure. Only then could harm minimisation (or for that matter other types of intervention) be a possible option.

    12. I accept that education may increase the risks, the point about health care professionals is well made, but unfortunately the alternative is not to educate people and they may suffer serious harm that is not intended. The proposal is not just about teaching people to self injure safety; it is also about explaining the dangers of the persons current behavior. This area raises particularly complex moral questions.

  • M Wood JME

    Patrick Sullivan: Sometimes, not always, not never. Some additional comments on harm minimisation and self-injury.

    I would like to make some additional comments relating to my pervious blog“ Harm: could it sometimes be a good thing “ and to also respond to the very helpful response to that blog by Hanna Pickard and Steven Pearce titled; “Balancing costs and benefits: A clinical perspective does not support a harm minimization approach outside of community settings.

    The paper that links to my original blog has resulted in some media coverage and much of that coverage misrepresents (in my view) my underlying argument. For that reason I would like to restate my position briefly to be clear exactly what it is. It is important my position is not misunderstood, as this is an important issue.

    There are a number of people who self injure as a means of coping with feelings of overwhelming distress. By preventing such individuals injuring themselves it is possible to increase such distress with the result that the desire to self injure becomes overwhelming. This may result in more extreme attempts at self-injury. Harm minimisation involves allowing individuals to self injure safely whilst working with them to develop alternative coping strategies. The approach would not be suitable for routine use and It cannot be used with individuals who are suicidal or whose self injury is so dangerous it may become life threatening. My paper considers a number of ethical issues that arise in considering the viability of such an approach within an inpatient setting.

    In such a setting the normal approach to working with people is to try and stop the individual acting in this way. In hospital settings this will involve restricting access to harmful implements and on occasions the use of continuous observation to try and ensure the persons safety. I argue that paradoxically this may increase the risks, although I accept that in some cases these more restrictive approaches are both necessary and proportionate and harm minimization would ‘never’ be used or even considered. I suggest that ‘ sometimes’ allowing harm may be a good thing. I note that the approach is both controversial and counter intuitive and accept there are real questions regarding the implementation of the approach. I do however believe that it brings into focus the complex issues relating to autonomy and paternalism and the need to take positive risks to achieve positive therapeutic outcomes. In the final analysis I remain committed to the view that harm minimisation may ‘sometimes’ be a good thing.

    In their blog and accompanying paper Hannah Pickard and Steven Pearce provide a considered but different perspective. In reading their response I was concerned that parts of my argument could be misunderstood by readers of the blog or paper. I would like to make a number of points in response. I will number these in order promote clarity:

    1. It is important to me clear that I am in no way advocating the use of harm minimization as a routine measure across inpatient facilities. I am arguing that there are a small number of inpatients that may benefit from such an approach.

    2. When I talk about harm minimization I am not merely describing the use of sterile cutting instruments and education about anatomy. This alone would achieve little. I make pains in my article to emphasise that harm reduction methods are a component of a sophisticated therapeutic programme that must include access to psychological interventions based on a detailed assessment of a persons needs and wishes.

    3. If the prevention of infection is taken seriously then access to sterile cutting implements must be considered a possibility. It would not be appropriate in all cases and if permitted would have to occur in a safe and controlled way. In addition, it is important to note that the overall approach does not necessarily involve the use of sterile cutting instruments. Elastic bands and ice cubes have been used as alternatives.

    4. I agree entirely with the point that in secure settings (and other inpatient facilities) the open availability of implements that can be used as weapons is not an option. I do not and have not advocated such a position. The approach is far more sophisticated than this. Having made this point it is important not to exclude the use of harm reduction techniques in secure environments as work has been undertaken supporting the use of harm reduction techniques. These are discussed in the Department of Health Self Harm Expert Reference Group (SHERG) publication Safe and Secure. Working constructively with people who self injure. A Guide for staff working in secure mental health units. May 2012.

    5. I am not advocating the use of harm minimisation for acutely Ill people detained under the Mental Health Act who are actively suicidal or may injure in life threatening ways. This would be neither feasible nor right.

    6. The fact that this limits my argument to a small group of individuals does not invalidate it. This is in fact an essential element of my argument, as like Pickard and Pearce I realise there are limitations on adopting the approach in many inpatient clinical environments. Participation in such a programme would need to be based on an informed consent.

    7. An important part of my argument is to weigh the costs and benefits of current regimes against a harm minimisation approach. Sadly the alternative option for some people (not all people) is currently high levels of observation and restrictions of movement with little in the way of therapeutic support and sometimes no psychological input. If harm minimisation is not an option then some alternative means of promoting engagement and improving the persons experience is required. The status quo is not an option.

    8. I would accept that self-injury is contagious and that people who have no history of self-injury may learn such behaviours in an inpatient setting. Drawing on my own experiences (I have worked in mental health services in some capacity since the 1970’s), I would argue that this phenomenon also occurs in units that do not adopt a harm minimisation approach and take active measures to prevent such behaviour occurring.

    9. I acknowledge Pickard and Pearce’s comments about the impact the adoption of such approach may have on staff. However, it is important to note that this situation may also arise in units, which attempt to prevent self-injury through quite restrictive means and do not make use of harm reduction techniques.

    10. I note Pickard and Pearce’s comments on the current position in NHS facilities and would agree entirely but the pressures on these units may be a fact but that does not make it right. I think we would both agree there is a need for more resources and the development of a more positive therapeutic ethos supported by more highly skilled and appropriately supervised staff. Although I accept the point self-injury is a form of communication and I take the point and there are risks associated supporting self-injury. I am not convinced however current interventions in an inpatient environment are successful. For example many inpatients have no access to psychological therapy.

    11. I agree entirely that in dealing with people who self injure the risks must be mitigated by highly trained staff with a high level of psychological skill that provides the relational security and therapeutic containment that is required to support people who self injure. Only then could harm minimisation (or for that matter other types of intervention) be a possible option.

    12. I accept that education may increase the risks, the point about health care professionals is well made, but unfortunately the alternative is not to educate people and they may suffer serious harm that is not intended. The proposal is not just about teaching people to self injure safety; it is also about explaining the dangers of the persons current behavior. This area raises particularly complex moral questions.

    Patrick Sullivan

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