Just thought I'd throw this out to the group ... Last week I got into a rather heated debate with my team in regard to a client who self mutilates. It was my opinion that a mutilator did not pose as serious a safety threat as say a suicidal client.
This discussion developed over the decision to physically restrain the client when he began self harm behaviours. My training in physical restraints has always focused on the fact that attempting to intervene on a person who internalizes his anger (such as a self mutilator) in the end winds up being more dangerous to the staff than to the client himself (assuming that the client has a weapon in hand at the time).
True, the client is causing harm to himself yet should there be a high concern for his safety especially if his pattern is to deescalate after doing this type of thing? I say NO.
This is bound to become a heated debate with people on either side, but I thought I'd take a few minutes to give you some of my views and experience around this issue. Firstly I agree with your judgement, and wish I could recall where I took training that clearly defined self mutilation as not a suicidal behavior. It was at least 7 years ago and I was working in a residential facility for young girls, we had serious problems with mutilation becoming almost " copycat" in the residence. After being trained on separating this from suicidal behavior and treating it as such ( no inordinate attention, child cleans up wounds, matter of fact questions about the event i.e. no shock value), the behavior dramatically decreased. After seeing so many instances where one instance lead to another, it was amazing with this no attention type response that the mutilation behaviors were seldom duplicated or copied.
Ever since then I have written this into residential policies for my own staff, and provided them with similar training, and am happy to report instances of mutilation are extremely rare perhaps one per year. As for restraining a self mutilator, I would see this as extremely " inordinate attention" and more likely to increase the need to " gain control" than decrease it. I do not agree with restraint as a behavior modifier at anytime, but in this case it seems the absolute worst response.
I have just encountered a youth whom self mutilates as a way of getting staff attention in our home. When he is in the time out room he bangs his head into the wall and cuts his arms with his finger nails and tries to strangle himself with his hands and makes threats of killing himself.
The way we have got him to level the behavior is we
don't treat bumps and bruised knuckles from time out pounding right away and
let the youth deal with his self inflicted pain. (Unless it warrants
immediate medical attention). When the youth is in this space staff monitor
him but ignore behaviors when it is an obvious play for attention. When the
youth tries to harm himself by cutting or makes suicide threats, staff treat
it as an attempt which means the youths entire room is stripped and he is
placed on safety checks every ten minutes until our therapist assesses that
he is no longer at risk. This has happened twice in the two months he has
been with us and his behaviors have greatly calmed down as he has found that
when he does this it buys him more attention then he bargained for.
First, I have to say that I have only had experience with one teen girl who is a self-mutilator, so I don't want to generalize. I realize that this is an area I need to learn more about. That said, I do agree that this is a serious issue and that some sort of intervention needs to take place. I know some people who have the belief that self-mutilation is not masking an underlying emotional issue, that it is just a sort of fad amongst today's youth. I just can't quite accept this. All behaviour is purposeful, in my mind.
Having said that, I do agree restraint is not the way to go. It is just addressing the symptom of the problem. But it is a serious problem - there may come a day where the kid doesn't de-esclate after an incident. There may also come a day, as has already been suggested, where the kid inflicts more harm than intended.
I am still pretty new to the field and I am currently encountering a roadblock and thought I would come here to see if anyone could give me any ideas. I am currently working with a girl who is 16 and self-abusive. She is a cutter. I don't want to make this extremely long, but basically she has shown us at the group home that she can maintain control when she wants to, when there is something to look forward to (i.e.planned outing, home visit) but it is more often that she chooses to cut. She also has out of control behaviours preceding the cutting, then cuts, cries, briefly talks with staff then is okay. This only happens at night as she is a victim of sexual abuse and naturally this is a hard time for her. Staff have tried numerous ways of trying to de-escalate her behaviours before that point, but it seldom works in our favour. This young lady has many issues to deal with but is not yet ready to accept our help. She has been in our care in the past but this she has been there for 6 months this time. I was just hoping that somebody could give me any ideas on what methods to use with her. I hope I provided enough information. Anything would be helpful.
I am a first year student at the Medicine Hat College, I noticed that you said that this only happens at night. Is there some activity that she can go to (movie, bowling, cards with yourself ,etc ). I feel that the sexual abuse was at night and the memories are too much for her. Maybe if she had something to pass the time with, those memories may go away for the time being. Maybe if she had one staff member counseling and spending time with her she may open up. She has to have someone that she can trust, so maybe ask her if she would like to play a game of cards, it may be a ice breaker. This girl does have many issues to deal with, but you have to take it one day at a time and with someone she can confide in and who shows interest in her she may open up. I am just a first year student and I thought I would put some input in. Good Luck !!
Self-harm or self-mutilation is a distressing subject which many child care workers encounter in the course of their work. I append a short resource list, mostly of UK sources, which may be of interest to some of you:
Arnold, Lois 1997 Working with people who self-injure: a training pack. Bristol Bristol Crisis Centre for Women
Arnold, Lois Magill, Anne 1998 Hurting inside: a book for young people Bristol Basement Project
Arnold, Lois Magill, Anne 1998 The self-harm help book Bristol Basement Project
Arnold, Lois Magill, Anne 1996 Working with self-injury: a practical guide Bristol Basement Project
Babiker, Gloria Arnold, Lois 1997 The language of injury: comprehending self-mutilation Leicester British Psychological Society
Basement Project Arnold, Lois Magill, Anne 1997 What's the harm? a book for young people who self-harm or self-injure Bristol Basement Project
Bifulco, Antonia Moran, patricia 1998 Wednesday's child: research into women's experience of neglect and abuse in childhood, and adult depression London Routlege
Coleman, John Lyon, Juliet Piper, Roz Piper, Dorothy, Eddi 1995 Teenage suicide and self-harm Brighton Trust for the study of adolescence Tapewise
Dace, Eleanor et al. 1998 The Hurt Yourself Less workbook London National Self-harm network
Elliott, Julian Place, Maurice 1998 Children in difficulty: a guide to understanding and helping London Routlege
MacDermid, Alan Walker, Sophie Sinclair, Keith 1997 The suicidal generation Glasgow
Miller, Dusty 1994 Women who hurt themselves: a book of hope and understanding New York Basic Books
Smith, Heather 1995 Unhappy children: reasons and remedies London Free Association Books
Spandler, Helen 1996 Who's hurting who? Young people, self-harm, and suicide [Manchester] 42nd Street
Who Cares? Scotland Friday, Eve 1998 Listen up: young people talk about mental health issues in residential care. Who Cares? Scotland Mental health project report Glasgow Who Cares? Scotland
Thompson, Audrey; Miah, Humerah. Wounds that never heal Community care, 18-24 Nov 1999, 18-20
Most of us recoil from the idea of self-harm and those who inflict it on themselves. Unfortunately, many health and care professionals have the same reaction. Report and description of how it feels to be so desperate that you harm yourself.
Wrate, R M Suicidal tendencies Scottish Child, November/December 1995, 8-11
Analyses the reasons behind the increase in suicide and attempted suicide among children and adolescents.
Teenage girls are more likely to harm themselves Professional Social Work, Sept 1996, 2
A study of admissions at the Warneford Hospital in Oxford has found that teenage girls are more likely to inflict harm on themselves than boys, and that self-harm is rare under the age of 12.
Francis, Joy. Hurting only myself Community Care, 1053, 2-8 Feb. 1995, 10
Disturbing evidence suggests practitioners are not equipped to meet the growing challenge of adolescent self-harm. Report on a Hackney initiative to address the needs in this small and under-researched area.
Harrison, Diane. Scarred by pain Community care,1135, 29 Aug-4 Sep 1996,17
A young woman inflicts pain on herself because she feels it is the only part of her life over which she has any control. For that young woman and others like her, self-harm is a way of expressing the unspeakable.
Hartman, David. Cutting among young people in adolescent units Therapeutic Communities, 17/1, Spring 1996, 5-17
Discussion of deliberate non-suicidal cutting by adolescents in psychiatric units.
Colthup, Neil. Prison initiative reduces juvenile custody numbers Community care, 1115, 11-17 Apr 1996, 14
Letter from the Delinquency management co-ordinator for Humberside SSD regarding methods adopted to prevent self-harm in juvenile remand centres.
Downey, Rachel. Young and alone Community care, 1111, 14-20 Mar 1996, 23
The author goes behind the walls of Hull Prison to assess a radical new method of preventing self-harm and suicide among juveniles on remand.
Librarian and Information Officer
Centre for Residential Child Care
Michelle, try reading I Hate You, Don't Leave Me
by Jerold J.Kreisman. Great book re: borderline personality disorder.
I was a wee bit concerned by Michelle Duffields recent contribution on the subject of self-harming. My main concern is that Michelle gave us a significant amount of personal information about a specific 'client' with whom she is currently working. Although she did not give the persons name she gave such specific information that I'm sure anyone who knew the young people in the unit she was referring to would feel they could indentify the person described. I was also concerned by her shorthand/ casual use of the phrase 'she is a cutter'. Is this is in effect a derogatory way of referring to someone.
I am sure that Michelle has made her contribution with the best of intentions but I do feel she has been rather thoughtless on this occasion.
I hope I am not being over-critical. It may be that different cultural perspectives are coming into play here. I am from Scotland and am used to a more reserved approach to many matters than appears to be the case in North America with its 'Oprah/Jerry Springer' approach to personal information.