Safer self-injury or assisted self-harm?

Abstract

Psychiatric patients may try (or express a desire) to injure themselves in hospital in order to cope with overwhelming emotional pain. Some health care practitioners and patients propose allowing a controlled amount of self-injury to occur in inpatient facilities, so as to prevent escalation of distress. Is this approach an example of professional assistance with harm? Or, is the approach more likely to minimise harm, by ensuring safer self-injury? In this article, I argue that health care practitioners who use harm-minimisation can be considered to be helping physical injury to occur, although they do not encourage the act. I consider why there are compelling reasons to believe that a patient who self-injures is not maximally autonomous in relation to that choice. However, I then move onto argue that allowing a degree of self-injury may enable engagement with psychotherapy (enhancing autonomy) and behavioural change. In these circumstances, allowing injury (with precautions) may not be harm, all things considered.

Safety in psychiatric inpatient care: The impact of risk management culture on mental health nursing practice

“…Taking up responsible subversion in the psychiatric inpatient setting creates an alternative safety culture in which relative risks are critically evaluated in an iterative process, acknowledged appropriately when present and mitigated thoughtfully. An example of responsible subversion is explored by Gutridge (), in a “harm‐minimization” approach to self‐harm. Gutridge presents an ethical inquiry of health care providers’ responsibilities relating to patient self‐harm in the psychiatric inpatient setting and suggests an approach in which health care providers acknowledge that some self‐injury may occur on an individual's trajectory towards wellness.…”

“…Gutridge () states, “development of judgement and self‐worth [is] being afforded the freedom to act” (p. 90), yet our current safety frameworks preclude this freedom. A shift in autonomy and responsibility for care is needed not only for reducing blame placed on those we are purporting to treat, but also for supporting autonomy itself as a therapeutic intervention.…”

Should healthcare professionals sometimes allow harm? The case of self-injury

“…Edwards and Hewitt,2 for example, have argued that among all options open to healthcare professionals, prevention is the least plausible and supervising self-injury the most appropriate form of intervention. While Gutridge3 also supports safer self-injury she argues that the individual who self-injures is not fully autonomous and she supports harm minimisation based on its therapeutic benefits.…”

Accentuate the positive, eliminate the negative? The variable value dynamics of non-suicidal self-hurting

“…At the same time, their engagement with downsides, not always articulated in the social science literature, offers suggestions as to how education, health and social services might engage more constructively with self-hurting. Firstly, services can offer a more structured approach to reducing medical risks associated with self-hurting (Davies et al, 2011), although harm reduction strategies can be criticised for legitimating behaviour which is often ultimately self-defeating (Gutridge, 2010). Secondly, through documenting the risks of self-hurting turning sour over the longer term, service providers can help individuals to consider possible futures which they might not otherwise be able to envisage, as argued by Slovic (2012).…”