VOL: 98, ISSUE: 20, PAGE NO: 40
Charlotte Lewis, BNurs, is a staff nurse at Northgate Clinic (Senior), Edgware, MiddlesexProviding nursing care for people who self-harm is a challenge for nurses because they feel responsible for their patients' safety. Nurses report feeling a range of emotions in relation to self-harm, including horror, sadness, betrayal and even incompetence. Yet they often have to work without training, guidelines or support (Babiker and Arnold, 1997; Pembroke, 2000).
Providing nursing care for people who self-harm is a challenge for nurses because they feel responsible for their patients' safety. Nurses report feeling a range of emotions in relation to self-harm, including horror, sadness, betrayal and even incompetence. Yet they often have to work without training, guidelines or support (Babiker and Arnold, 1997; Pembroke, 2000).
Professionals usually try to convince people to stop self-harming and end up in a fruitless cycle of arguing. In a bid to address this problem at Northgate Clinic (Senior), patients asked for a self-harm support group. It was decided that efforts would be made to provide one.
The clinic is an inpatient unit for emotionally and behaviourally disturbed people aged between 16 and 21. It runs several psychotherapeutic groups, as well as individual therapy sessions, and there is an established culture of groups in the unit. Each day begins with a community meeting that everyone attends and there are small psychotherapy, art therapy and psychodrama groups.
Why have a support group?
Most of the self-harming adolescents at the clinic are women. Self-harm is a coping strategy that they use regularly and, at times, severely. By the time they come to the clinic they have often experienced extremely negative responses to the issue of self-harm. This can have serious consequences for the adolescents involved.
People who self-harm report that negative responses from services have a cumulative effect, making them feel worse about themselves and therefore more likely to self-injure again (Pembroke, 2000).
Research suggests that services should aim to provide an alternative response, ensuring that patients' negative beliefs about themselves are not reinforced (McVey and Murphy, 2001).
It was in this context that the patients identified the need for a self-harm support group. The fact that the clinic's staff listened to what they were asking for was, in itself, one way of offering a response that was very different to those they had previously received.
Setting up the group
Staff considered what shape such a group should take and used literature from The Basement Project (Arnold and Magill, 2000) to inform much of the structure. Some of the questions considered were:
- How will people be invited to join the group?
- Will the group be open or closed?
- Over what period of time will it run for?
- Where in the building should it take place?
- What format should the meetings take?
Arnold and Magill (2000) define a closed group as one in which the participants make a commitment to the group which remains fixed over an agreed period of time. An open group differs in that new members are free to join it at any time. At Northgate, strict criteria for entry to the group were avoided and a broad definition of self-harm was used, encompassing any act of self-inflicted injury except those with the intention of committing suicide.
An empowering approach
By definition, a self-harm group includes people with a common problem. It may also mean that they share common experiences and backgrounds (see Box 1). Self-injury often communicates a person's pain and feelings of powerlessness associated with maltreatment. Services, treatment or any therapeutic interventions can increase these feelings of disempowerment and 'add insult to injury' (Barker, 2001).
The literature on working with people who self-harm suggests that the services and treatment they receive should be empowering (Babiker and Arnold, 1997; Pembroke, 2000).
The clinic's aim was to provide a forum in which a group of patients who find it difficult to express themselves verbally could be heard. At the meetings, staff took the stance of being curious about self-harm and interested in hearing the patients' views. This approach aimed to empower people to take responsibility for their self-harming behaviour. The general principles of the group are summarised in Box 2.
Hopes and fears
The group started with participants sharing information on self-harm and, on occasion, developed into what felt like a working group. At other times it has been a forum in which people have explored extremely personal feelings and experiences.
It took a long time to build up enough trust within the group for individuals to be able to explore their personal experiences. This is a consequence of self-harm being a taboo subject: one that many people had not previously expressed their feelings about.
Staff were concerned about being seen as 'the experts' in the group and about how patients would react to them. This led to many discussions on how self-harm could be managed more effectively in the clinic.
The fact that the patients asked for the group to be set up meant that staff members taking on this task needed to give careful consideration to the potential for divisions in the staff team. It was therefore important to maintain open communication between the group and the wider community in the clinic.
A focus group was set up to disseminate information on the work of the group throughout the clinic so that the future of self-harm programmes could be jointly discussed and planned.
The establishment of this group was initially a daunting task but, with the patients moving into the role of 'experts', it has been possible to open up new ways of looking at and understanding self-harm. Before the group was set up, the consequences of an act of self-harm would have been explored in a community meeting after an incident had occurred, but there was little time to consider the motives behind it.
Babiker and Arnold (1997) have warned against the potential for a self-harm group to lead to copycat behaviour, elitism and the acting out of behaviours. It is still too early to comment on whether or not this group has had any effect on the incidence of self-harm in the clinic, so further research is needed.
However, Northgate Clinic has always been a place where self-harm has been discussed in an innovative way. The need for a clinic policy, which can incorporate the ideas raised in the group, has been identified. This should include the experience and knowledge of the patients and empower them as people in the management of their self-harm, while providing structure, support and guidance for nurses.