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Harm: Could It Sometimes Be a Good Thing?

9 Feb, 17 | by miriamwood

Guest Post: Patrick Sullivan

Response: Hanna Pickard and Steve Pearce, Balancing costs and benefits: a clinical perspective does not support a harm minimization approach for self-injury outside of community settings

BBC news recently reported on the approval of plans for facilities to support self-injection rooms to allow drug users to inject safely under supervision in Glasgow. Needless to say the initiative is  controversial and as yet is  only approved in principle. The plan would involve addicts consuming their own drugs and in some cases being provided with medical-grade heroin. The move aims to address the problems caused by an estimated 500 or so users who inject on Glasgow’s streets. This initiative again brings into the public eye the issue of harm minimisation.

The concept of harm minimisation has been widely applied in a number of areas such as drug misuse where needle exchange programmes are the obvious example. The basic idea is that where we are unable to stop people engaging in dangerous activities we may sometimes have to settle for the fact that the best outcome possible is that the harm associated with the activity can be reduced. Many day-to-day activities are associated with harm reduction; seat belts on cars, motorcycle helmets, safety measures to reduce risks in extreme sports, advice on safe drinking levels. People will drive, ride motorbikes, engage in dangerous sporting activity and drink alcohol. If they do these things then it is important that they are done safely. Basically this is what harm minimisation is about.

A controversial application of these ideas has been in the area of self-injury. The fundamental idea is that people are allowed to harm themselves safely in the short term, whilst longer-term change is facilitated through access to psychological support. In my recent paper  ‘Should health care professionals be allowed to do harm? The case of self-injury’, I revisit the ethical issues associated with using harm minimisation to support people who self injure. This idea is controversial and counter intuitive given the health care professionals obligation to do no harm.  I challenge this perspective, suggesting that many clinical interventions do in fact involve harm. For example anyone who has experienced surgery or even dental treatment will acknowledge this fact quite readily.

Now it is important to be clear that I am not supporting the routine use of this approach in clinical practice. There is a place, in my view, for paternalism and the ethical case can be made in a number of scenarios. For example the prevention of suicide in people with a psychotic depression. Furthermore, I do not underestimate the risks associated with implementation in a mental health care inpatient setting. I do, however, believe it provides an alternative perspective that could be adopted with some people who self injure.

There are a number of factors that inform my perspective. First, this approach is an expression of what people who self injure say works for them particularly given the alternatives. No one who has listened to the stories of people who self injure can fail to be concerned by the picture it paints of a system that just fails to understand. Second, attempts to stop people acting in this way are often tenuous and in some cases just do not work. Third, the approach respects a person’s autonomy and choices. Finally, on balance it results in a net reduction in harm and there are some examples of success using this type of approach.

My paper is prefaced on the idea that self-injury is often linked to an individuals ability to cope with overwhelming distress. I also take the view that there are people who act in this way who do so autonomously and where autonomy is absent then a whole range of different arguments come into play. In my paper I pay particular attention to the importance of linking the focus on reducing harm with the need to promote change through access to appropriate psychological therapy. Harm minimisation is not a treatment in its own right but an adjunct to such treatment and must be seen in this way.

There are major challenges in adopting such an approach but it brings into focus the tension between autonomy and paternalism that pervades mental health care provision. In spite of the challenges, perhaps a harm minimisation approach provides a source of hope for people like Alison (the fictional case study in my paper), who may currently experience services in a negative and unhelpful way. If nothing else it helps us to begin to think about the limitations of current services for people who self injure based on first person narratives about why individuals act in this way and what does and does not work in even the best services.

You can read a response to this blog: Balancing costs and benefits: a clinical perspective does not support a harm minimization approach for self-injury outside of community settings, Hanna Pickard and Steve Pearce





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  • Patrick Sullivan

    My paper 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 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. 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.

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