Self-harm within inpatient psychiatric services: most episodes are among women, involve breaking the skin and take place in private
- Director, VA National Center for Patient Safety Field Office, White River Junction, Vermont, USA and Adjunct Associate Professor of Psychiatry, The Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- Correspondence to
: Dr Peter D Mills
VA National Center for Patient Safety, VAMC (10A 4E), 215 North Main Street, White River Junction, VT 05055, USA;
Implications for practice and research
Focusing on the method, antecedents and level of openness of self-harm can inform clinicians and researchers about the possible motivators and goals of the behaviour and lead to a more clear understanding of possible interventions.
The majority of self-harm does not appear to represent an attempt to manipulate others or gain their attention; rather it is more often a private act with other internal motivations.
More research is needed to determine the most effective interventions for different types of self-harm in the inpatient setting. Targeted intervention for specific types of self-harm may be a more effective methodology.
In this important study, the authors differentiate between self-harm and attempted suicide and consider the characteristics of self-harm that do not represent an attempt or intent to die. While other studies have looked at inpatient suicide attempts and completions,1 ,2 this is the first to focus solely on inpatient self-harm in a national healthcare system.
The authors analysed reports of self-harm from inpatient psychiatric patients in the UK during 2009. They randomly selected 500 cases from 14 271 reports in the National Patient Safety Agency database. Cases were coded for ‘openness’ or level of privacy during the self-harm, demographic characteristics, type of psychiatric service, severity of harm, method of harm, location, object-use and timing of the action. Associations between variables were analysed using conservative and appropriate statistical methods to determine where possible relationships exist.
This study makes several important points. Most patients in inpatient psychiatric care conduct self-harming behaviours in private. The method of self-harm is associated with the level of privacy and may be motivated by different goals such as the alleviation of dissociative states or distraction from painful emotions. In addition, forensic units had higher rates of self-harm that were more public in nature. Women had three times more episodes of self-harm than men; men used methods that were more open and aggressive.
Self-harm or ‘parasuicide’ has been the subject of research since the mid-1970s. As the authors point out, non-suicidal self-harm is often seen as manipulative or attention-seeking by staff. This perception can lead staff to have a negative attitude towards patients who self-harm. In fact, one of the primary foci of the most empirically supported treatment for self-harm, dialectical behavioural therapy,3 is helping therapists to remain emphatic and supportive of their patients. It is helpful, therefore, that the current study finds that most self-harm occurs in private with little attempt to influence or manipulate others. In our study of the physical locations in which patients tend to harm themselves, we also found that the most common areas on mental health units are bedrooms and bathrooms4 suggesting that patients are conducting self-harm in private. The privacy may be an artefact of avoiding discovery, but the primary reason for conducting the self-harm in the first place appears to be a response to internal needs and/or mood states.
Although it makes sense that staff may feel manipulated by patients who self-harm, it is important to find the true reasons for the behaviour to help patients find other methods of meeting their needs. In this study, the antecedents to the self-harm were reported in only 24% of the cases but the results support the idea that the self-harm was a response to internal stimuli such as difficult emotions or hallucinations or frustration resulting from negative interpersonal interactions. Another important finding is that it is possible to distinguish self-harm that is more open and public from self-harm that is private. Making this distinction in a clinical setting will help staff to form more nuanced and targeted responses to patients in order to help them heal. More research is need to determine the best clinical responses to open versus private self-harm in the inpatient setting, and using the scale developed by the authors will further this endeavour.