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Self-harm training

Self-harm is one of the top five causes of acute medical and surgical admission in UK hospitals. Distressing, but what has that to do with Security? Healthcare – and other – security officers, on campuses for example, are often called to ‘safeguard’ patients who are known to be at risk of self-harming, says trainer Jim O’Dwyer, of AEGIS, featured in our February issue on healthcare security-specific guard training. Here he goes into more detail on self-harming – which has been escalating alarmingly, he writes.

Consider this scenario: you are a security officer on duty in a hospital A&E Department. It’s a typically busy evening and about 20 people are in the reception-waiting area. A woman approaches you and draws your attention to a 14-year-old girl, who has learning difficulties. The woman tells you that she is very concerned about the girl, not just because she seems to be very upset and distressed, but also because for the past five minutes she has seen the girl rubbing a steel tail-comb hard across the top of her left wrist, causing it to bleed – and she was still doing it. The woman insists that you act immediately to stop the girl from continuing to injure herself and, when you hesitate for a fraction, she adds that unless you do it right now, her husband (a very large man) will do it. So, you approach the girl and say, “What’s wrong with you? Why are you doing that to yourself? You must stop doing it right now.”

The girl says: “You just don’t understand. I need to do it!” The girl then says that she knows she has a legal right to cut herself and won’t stop until she wants to. Does she have a legal right to self-harm? Is she right, that you don’t understand why she needs to do it? She continues to rub the comb across the top of her hand. You notice there is blood on her hands and on her jeans. However, in your opinion, the injury she has caused herself is non-life threatening and it also does not appear that her intention is to commit suicide. You order her to stop cutting herself and instruct her to put the comb down on the floor, but when you take a step closer, the girl warns you that if you try and stop her she will stab you with the tail of the steel comb. As a security officer, you have a duty to protect against harm happening. But, do you have legal authority to physically stop her from continuing to self-harm? Does her age or the fact that she has learning difficulties mean that in these circumstances she lacks ‘capacity’ to decide for herself? What is the NHS trust’s policy on use of physical force and restraint? She has threatened to stab you and is ‘armed’ with a weapon. What does the trust’s policy say about challenging someone who is armed with a weapon? Would it be best to allow her to continue to harm herself? What else could you do? As you are thinking things through, the husband of the woman who originally informed you about the girl gets up from his seat and begins moving towards the girl. As he does so, he says: “Out’ta my way. I’m gonna put a stop to this right now. You need to understand discipline young lady.” What are you going to do?

Luckily, the mental health nurse has recognised what’s going on and she intercepts the man and, thanking him for his interest, invites him to re-take his seat and let her deal with the situation. He complies without any fuss. The nurse then invites the girl to the privacy of a side room saying: “I understand where you are at. Don’t worry! Please come with me.” The girl then gets up and follows the nurse into the side room. The nurse (discreetly) signals to you to wait outside in case you are needed. The nurse then spends quite some time talking with the girl. The next thing that happens is that you see the nurse un-package a surgical scalpel blade and give it to the girl who begins to cut herself on her arm with it. You can see that the cut has drawn blood. You are horrified! You think: “What on earth is going on here?” What are you going to do?

Without suitable training and lacking an understanding about a ‘harm minimisation’ approach it would be easy to just follow your basic instincts and end up doing completely the wrong thing and making the situation worse! And, that’s the reason why a unit on ‘self-harm awareness’ has been incorporated in the National Association for Healthcare Security (NAHS) endorsed Healthcare Security Officer training course. The alarming escalation in self-harming over the past few years, especially amongst teenagers – and the challenges it presents – make this element of training essential for healthcare security officers and relevant to all security professionals, which is why we have also made it available as a ‘stand-alone’ e-learning CPD course.

The most recent survey (due to be published in 2015) is expected to confirm that there has been a threefold increase in the number of teenagers who self-harm in England over the last decade. Of the 6,000 young people aged 11, 13 and 15 surveyed across England – up to one in five 15-year-olds said they self-harm and 43pc said they self-harmed at least once a month.

About the training
The ‘Self-Harm Awareness’ training informs about the nature and extent of self-harming in the UK; identifies vulnerable groups; develops understanding of why people may self-harm and common methods used. It also introduces the concept of a ‘harm minimisation’ approach and provides guidance on how best to support patients who have self-harmed or are considered ‘at risk’ of doing so. The overall aim is to instil learners with a suitable understanding about self-harm and develop professional ability to support patients who may be at risk.

Approach
The intensity of an urge to self-harm can be overwhelming and irresistible. It has been likened to the levels of craving that heroin addicts endure when they need a ‘hit’. At such times, being prevented from self-harming can cause a person extreme distress and anxiety. The consequent internal ‘desperation’ they suffer can induce them to take extreme measures and drastic action to secure ‘relief’. This, with the legal ‘right’ to self-harm, can make it impractical if not impossible for others (such as hospital staff and security) to successfully impose and enforce a ‘zero tolerance’ approach to self-harming, especially where the nature of the self-harming is not obviously life threatening. So, managing the care of a person who self-harms may require a ‘harm-minimisation approach’ instead of ‘zero tolerance’. Harm-minimisation will accept that someone may need to self-harm; and focus instead on supporting that person to reduce the risk and the damage inherent in their self-harm. An example of ‘harm-minimisation’ in action could be (as in the scenario) providing a self-harmer with surgical blades to use to cut themselves if they want to cut and can’t be persuaded not to; so as to avoid infection. This is akin to the provision of methadone hydrochloride, with hypodermic needles and syringes to heroin addicts and the provision of contraceptives to (illegal) sex workers. Because it seems to directly conflict with their duty to prevent harm and loss, ‘harm-minimisation’ may be difficult for some healthcare security officers to initially accept. However, it is the only ‘practicable’ way to manage some self-harmers.

Co-operation
Think about it. Even if you had the resources (and legal authority) to keep a person totally immobilised, to prevent them self-harming, they could still accomplish it by biting their own tongue off (or their lips or cheeks), or simply refusing to eat and starving themselves! So, getting the self-harmer’s co-operation is essential.

Interrupting the cycle
There isn’t yet good evidence to show which therapies work well for people who have self-harmed. However, what evidence there is, suggests that problem solving therapy and cognitive behavioural therapy are useful. Distraction strategies can help a person to defer self-harming. When the urge to self-harm arises, distracting their attention away from it by occupying themselves with an alternative non-harmful task to focus on can really help to reduce the intensity of the urge to self-harm and enable them to decide to defer harming themselves. Making this decision is the first step towards stopping self-harming completely.

Examples of non-harmful ‘distractions’ that can help include:

• Having a really cold shower.
• Hitting a cushion or pillow against a wall.
• Eating something with a strong taste like chilli or peppermint.
• Sniffing something with strong odour (such as rubbing liniment under your nose)
• Flicking an elastic band on their wrist
• Holding an ice cube in the crook of their elbow, or the back of their knee (or, on the area they intend to cut) until it completely melts.

If a person is struggling with an irresistible urge to cut themselves, this can really help them to defer doing so, because allowing the ice cube to completely melt on the skin has the effect of producing the same kind of endorphins that cutting would but, without causing the physical damage. This can mean that the urge to cut becomes less intense and more manageable for them.

• If the sight of blood is important, they could try dyeing an ice cube with red food colouring to visually simulate blood, or alternatively, they could try drawing or painting lines on the skin where they are proposing to cut, using a red lip liner pen, or tempera paint, or red food colouring straight from the bottle.

How can healthcare security officers support people who self-harm?
Self-harmers will usually only seek medical assistance when their injury is greater than intended (or parental intervention occurs). If a person has self-harmed to the extent that they need to attend a hospital, they can be expected to be embarrassed, distressed and scared that they are going to be deprived of their ‘method of release’. For them it is a crisis! The sight of a uniformed officer may induce them to panic. They need and deserve to be greeted by ‘informed’, caring and supportive staff.

Healthcare security officers should:

• Be prepared for rejection – and not take it personally when it happens. Be aware that social networking via the internet/mobile phones has given rise to a sub-culture of self-harmers that has its own language, idioms and phrases, as well as, conceptualisations and philosophies. Members of this sub-culture may consider that ‘outsiders’ who fail to use the right ‘language’ don’t and can’t understand anything!
• Demonstrate interest in helping them and better understanding their reasons for self-harming.
• Help them to think about their self-harm not as a shameful secret, but as a problem to be sorted out. (Self-harming is a definite sign of an underlying problem and, if it gets out of hand, they could risk accidentally killing themselves.)
• Guide them towards the help and support that is available.
• Not try to be the person’s therapist – therapy is complicated. Leave it to the experts.
• Not make them promise not to do it again. Understand that they may be scared of stopping if they use it as a way of coping. Don’t expect them to stop self-harming immediately or overnight – it’s difficult and takes time and effort.

Before speaking:
T – is it true?
H – is it helpful?
I – is it inspiring?
N – is it necessary?
K – is it kind?

Don’t bother saying: “Why are you doing this to yourself?” because “I don’t know” and “F**k you” are the most common answers to this question. Don’t say: “Harming yourself is bad. You mustn’t do it.” They already know this and don’t need reminding! Instead, try saying: “How can I help you?” If they don’t want your help, ask: “Who could help you?” If they look upset, try: “You look upset. Would you like to talk about it?” Be supportive: Try saying: “I’m not medically qualified but, I promise you this – I will listen and I will care.” and “I’m here if you need me”.

The most important thing is to listen to them without judging them or being critical. If you can help the person to feel safe and secure, you can make a real difference to how the person behaves – and you may even save their life!


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