Risk and responding to self injury: is harm minimisation a step too far?

Date14 January 2019
Published date14 January 2019
AuthorPatrick Joseph Sullivan
Subject MatterHealth & social care,Mental health,Mental health education
Risk and responding to self injury: is harm
minimisation a step too far?
Patrick Joseph Sullivan
Purpose The purpose of this paper is to consider some of the legal implications of adopting a harm
minimisation approach in supporting people who self-injure within inpatient mental health units. It is argued
that a focus on risk and the increasing influence of the law and legal styles of thinking often associated with the
allocation of blame have produced a more risk adverse clinical environment. As a result health professionals
are more likely to err on the side of caution rather than engage in practices that although potentially
therapeutic are not without their risks.
Design/methodology/approach The analysis draws on the clinical, philosophical and legal literature to
help understand how harm minimisation may support people who self-injure. It considers some of the
complex medico-legal issues that arise in a clinical environment dominated by risk.
Findings A focus on risk and accountability has produced an environment where the law and legal styles of
thinking have come to influence practice. This is often associated with blame in the minds of the health
professional. Given the legal obligation to prevent suicide, health professionals may take a conservative
approach when working with people who self-injure. This makes the adoption of harm minimisation difficult.
Originality/value This paper provides a legally informed analysis of some of the challenges associated with
using harm minimisation techniques with people who self-injure. It adds to the literature regarding this area of
clinical practice.
Keywords Suicide, Risk, Self injury, Harm minimization, Rabone
Paper type Conceptual paper
Self-injury is a serious health issue; the long-term outcomes for people who repeatedly self-injure
are often poor (Morgan et al., 2017)and the demands on both general hospital and mentalhealth
services are high(Tsiachristas et al., 2017). The causesof self-injury are complex and multifaceted
and its treatment involves a range of different approaches and no specific intervention that is
supported by a valid and reliable body of evidence (Hawton et al., 1998; National Collaborating
Centre for Mental Health, 2004). The dynamics of the relationship between the patient and the
health care professional is complicated and clinical staff often struggle to know-how to care
appropriately for people who self-injure (Morales and Guarnero, 2014).
Self-injury is common in mental health units; research undertaken in mental health inpatient
settings indicates that the percentage of patients who harm themselves during the course of their
admission varies from 4 to 70 per cent. The rate of self-injury in adult inpatient units being 2.54
per 100 available bed days ( James et al., 2012). In such units it is often normal practice to try and
stop the person hurting themselves and a range of restrictive practices may be implemented in
pursuit of safety (Sullivan, 2017; Morrissey et al., 2018). People who self-injure perceive these
approaches negatively (Duperouzel and Fish, 2010). Harm minimisation has been proposed as
an alternative way of supporting some individuals who self-injure (Gutridge, 2010; Edwards and
Hewitt, 2011; Inckle, 2017; Sullivan, 2017).
Harm minimisation accepts that someone may still need to self-injure at a given point in time.
Therefore, instead of trying to prevent self-injury, the focus is on supporting the individual in
Received 11 May 2018
Revised 16 August 2018
30 September 2018
18 October 2018
Accepted 18 October 2018
Patrick Joseph Sullivan is a
Postgraduate Student at the
Centre for Social Ethics and
Policy, School of Law,
University of Manchester,
Manchester, UK.
DOI 10.1108/JMHTEP-05-2018-0031 VOL. 14 NO. 1 2019, pp.1-11, © Emerald Publishing Limited, ISSN 1755-6228

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