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Expert argues harm minimization for self-injury

A recent paper in clinical ethics argued the validity of harm minimization practices for self-injury and suggested that letting individuals continue to self-harm may be part of a beneficial therapeutic process.

“Self-injury is a common occurrence in many mental health units and there is no agreed and empirically supported means of reducing its occurrence. Self-injury raises ethical and clinical challenges,” Patrick J. Sullivan, a PhD student at the School of Law, University of Manchester, United Kingdom, wrote. “There are moral questions regarding prevention of harm, especially as the behavior often involves individuals who appear to understand the nature and consequences of their actions. There are also complex clinical issues regarding what interventions do and do not work.”

Standard practice in hospitals in the United Kingdom has been to stop self-injury from occurring, according to Sullivan. This practice includes searching individuals and their possessions, removal of potentially harmful implements, and continuous observation.

More challenging cases can include intensive interventions such as seclusion, sedation and physical restraint.

“These measures are characterized by restrictions, attempts to increase control and on occasions the use of force,” Sullivan wrote.

In lieu of these practices, Sullivan suggested harm minimization.

This approach may include providing access to sterile self-injury implements for personal use and education on how to injure “more safely.”

“These interventions form part of a longer-term strategy to reduce the likelihood that the person resorts to self-injury,” according to Sullivan. “Access to psychological therapies designed to support individuals explore the meaning and function of their behavior and help promote change must also occur; this is an essential component of harm minimization. Self-injury is being allowed, in order to maintain its role as a coping mechanism, based on the understanding that this occurs safety. Without the access to psychological therapies designed to facilitate change the arguments supporting harm minimization are weakened significantly.”

Sullivan cited several objections to harm minimization, including the requirement of patient consent and allowing self-injury to occur in a clinical setting.

“The problem with this objection is that individuals, for whom harm minimization is a possibility, have already accepted the use of self-injury as a routine and necessary part of their life. The risks associated with the behavior do not constitute a deterrent,” Sullivan wrote. “Although not necessarily addictive, the behavior has some similarities with addictive behavior and is difficult to stop. Allowing some degree of self-injury is a realistic and pragmatic approach to addressing the issue and in some cases may be the only option the individual is willing to accept.”

In an accompanying editorial, two researchers refuted Sullivan’s claims regarding allowing self-injury as a preventative means.

“Deliberate self-injury is rarely if ever part of a life of flourishing. It is high risk and serves to maintain a negative self-concept,” Hanna Pickard, DPhil, of the University of Birmingham, United Kingdom, and Steve Pearce, MRCPsych, of Oxford Health NHS Foundation Trust, Oxford, wrote.

“But from a clinical and practical ethical perspective, the devil is always in the details. Of all the various measures that could in principle be adopted to help them, the forms of harm minimization that Sullivan advocates in inpatient settings do not strike us as the measures we ought to promote. For self-injuring patients themselves — let alone when we factor in the potential impact on other patients and staff — the balance between costs and benefits of these forms of harm minimization for self-injury does not tip in their favor.”– by Amanda Oldt

Disclosure: The researchers report no relevant financial disclosures.