On Wednesday, 28th August 2019 we had our monthly online journal club session and we discussed the paper “These Things Don’t Work.” Young People’s Views on Harm Minimization Strategies as a Proxy for Self-Harm: A Mixed Methods Approachethics” by Ruth Wadman, Emma Nielsen, Linda O’Raw, Katherine Brown, A. Jess Williams, Kapil Sayal & Ellen Townsend.
Here are some notes from thoughts shared in our discussion, kindly summarised by Jessica Leather.
- We started by discussing the informal nature of harm minimisation guidance, and the dearth of evidence for these strategies.
- Clinicians/therapists are reliant on informal lists of harm minimisation strategies (HMS) which are “cheaper, easier, quicker” than actual guidance. It is likely that clinicians/therapists make them up, so they are non-standardised. Tend to be coping and distraction techniques, so there is overlap. Seem sensible on the surface, but not necessarily useful in practice.
- The nomenclature around harm minimisation is non-standardised. Most are quite broad ideas around restricting access, replacing processes of self-harm or replacing sensation in ways that are considered safer. There are differences between what clinicians, researchers and the public think is meant by ‘harm minimisation’. The authors found it challenging to communicate these different meanings to participants and other researchers, but it helped to make a distinction between discrete categories of harm minimisation (sensation proxies and process proxies).
- Of the minority of participants who found HMS useful, they only appear to be so in the immediate, or very short-term. They may be useful for some people as part of a broader therapy ‘package’ that seeks to bolster more positive coping. However, the authors had reservations about their use, particularly in emergency settings and their role in long-term care. Since some HMS encourage repetitive or constant behaviours, there is a risk of they might escalate into self-harm (for example, some participants used elastic band snapping, a commonly cited HMS, as a means of self-harm). As such, there is a risk of promoting a maladaptive coping route.
- The promotion of these strategies outside of care environments such as the internet and social media may be particularly maladaptive for people who do not have any existing supervision or contact with services, because these people are not being encouraged to progress to more adaptive means of coping.
- The authors were surprised by the small number of participants who were exclusively positive about HMS: they were expecting a more mixed bag of support. Consistently the message was that things weren’t working.
- There were queries raised about whether participants perceived certain behaviours as dangerous or not dangerous, such as self-poisoning. The authors noted that some participants perceived overdoses of over-the-counter medication to be different from ‘swallowing dangerous substances’ – suggesting these respondents believed there was a safe way to overdose. It would be useful to explore young people’s knowledge about intent, lethality, and potential outcomes of self-harm.
- In terms of suggestions for what could work in the future, there was more interest in fostering positive relationships (with professionals, personal relationships and even pets). Interpersonal dynamics can make a difference when progressing to more positive coping methods. This questions the use of HMS in place of building safe relationships.
- Future self-harm interventions might address intent rather than the behaviour. For example, collaborative interventions for young people might focus on bolstering positives (such as relationships and the wish to live), which may affect self-harm outcomes without addressing self-harm directly. These might also tackle transition periods for young people, where relationships change, roles become more nuanced and environments become inconsistent. Clinical influence might help young people to build relationships and peer support, but it depends how these issues come out in help-seeking behaviours (which tends to be through peers).
- Unsure how to take the findings to the next step – how to get the information out and implement it. As there is no alternative to offer, what can be recommended? Potential for a qualitative study to ask young people what has helped them and how they would want things to change? A move to service quality over tick-boxes.
- Guidance from ‘authority’ figures goes unchallenged. So the next step might be to edit existing guidance in light of new findings, instead of trying to get rid of HMS entirely. By encouraging people to amend what they have, it would help to get the message out there.
- There is also a need to get the voices of young people heard, since they had such clear reasons about why things did or did not work (e.g. HMS not addressing underlying problems). Would need to identify services that recommend HMS, who have regular contact with their young patients/clients. If the clinician is sceptical, they could be told to ask their patient when they next see them: what they think of HMS, and why they think that. This would be valuable data from first hand sources. We need to listen and believe patients.
- Fundamental question – if you are concerned about someone, what do you do (e.g. seek information? If so from where: Google, Mind website, forums?)? What does that look like (e.g. do they go to one source or amalgamate information)? Do people appraise the information they read? Do people then act on what they have read? To what extent do people do these things?
- Young people: what do they consider to be a good source of information compared to older people? How can we account for their concerns about confidentiality and privacy? Adults tend to be more receptive to face-to-face therapy; idea of going spending time with a stranger can be alienating for young people.
- Considered an app to provide guidance, but the evidence for app-based self-harm interventions is unclear, and there tend to be issues with recruitment and feasibility. Have to strike a balance between providing good information, and forging bonds with people.
- At the end, we referred to EDASH and Reboot. Some issues around recruitment have been to do with risk management. A population with people around them (such as care co-ordinators and gatekeepers) supports engagement with trials.
Jessica Leather (@JessZLeather) has a masters in Health Psychology and is a PhD student at the University of Manchester (firstname.lastname@example.org). Her project is funded by the NIHR Greater Manchester Patient Safety Translational Research Centre.