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Senior Lecturer, Health Studies, University of South Africa, Pretoria, South Africa
SANDY P.T. (2013) Motives for self-harm: views of nurses in a secure unit. International Nursing
Review 60, 358365
Background: Self-harm is a widespread behaviour among people with mental health problems. Although
guidance on how to manage self-harm is offered, it is still a behaviour that is misunderstood by many nurses.
Such misunderstanding is generally attributed to the perceived motives for self-harm and lack of specialized
education to manage the behaviour. As a consequence, the care provided is usually inadequate and
inappropriate. Yet, research concerning nurses reasons of users self-harming behaviours is limited.
Aim: This paper reports on a study that explores nurses explanations of the motives for self-harm in a secure
adolescent unit in England.
Methods: The study utilized a phenomenological methodology with semi-structured individual interviews
(n = 25). The data were analysed thematically using interpretative phenomenological analysis.
Results: The findings indicate that the behaviour of self-harm has multiple motives. Examples of these include
affect regulation, coping with distress, averting death, regaining control and attention seeking.
Discussion: Self-harm is a complex behaviour commonly experienced in secure environments. Nurses assume
that users who self-harm are motivated by a desire to seek attention and manipulate others. Users may find
these beliefs humiliating. Such feelings may increase users risks for further self-harm. Most adolescents who
self-harm experience unbearable emotions because of their past sexual abusive encounters. They self-harm to
regulate these emotions. These affect regulatory functions may act as reinforcers of self-harming behaviours.
Conclusions: Improved understanding of self-harm and its motives may result in improved nurseuser
relationships and thus safer and more effective care provision.
Keywords: Adolescents, Motives, Nurses, Secure Environment, Self-Harm
Introduction
Self-harm is a long-standing and extremely widespread behaviour that has occurred even before recorded history and
observed to occur at all levels of society in many parts of the
Correspondence address: Dr Peter Thomas Sandy, Health Studies, University of
South Africa, 6-184 Theo van Wijk, Muckleneuk Ridge, Pretoria 0003, South
Africa; Tel: +27(12)429-8224; +27(17)202-715; Fax: +27(12)429 3361; E-mail:
sandypt@unisa.ac.za
Funding: This research received no specific grant from any funding agency
in the public, commercial or not-for-profit sectors.
Conflict of interest: No conflict of interest has been declared by the authors.
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Background
Self-harm is a growing problem in secure environments, as it is
a behaviour that is often repeated by users in these settings
(Dickinson et al. 2009). Secure environments have the highest
incidence of self-harm (Gough 2005; Tantam & Huband 2009).
But the statistics indicating this are likely to be an underestimate, as the majority of cases of self-harm usually remain a
secretive act that can go on for a long time without being discovered (Mental Health Foundation 2006). If detected, users
may provide excuses that may mislead healthcare professionals
into believing, for example, that their injuries are the result of
accidents or attacks from others (Long & Jenkins 2010). It is
therefore difficult to accurately determine its incidence. Despite
this, its growing rate is a significant indicator of the scale of the
problem.
Self-harming behaviour is common among adolescents in
secure environments and the literature indicates that they are
the most prolific self-harmers in these settings relative to their
adult counterparts (Dickinson et al. 2009). A cursory glance at
available research in Europe, Australia and the USA revealed a
prevalence of between 1 in 12 and 1 in 15 for self-harming
behaviours, such as cutting and poisoning, among adolescents,
respectively (Haw et al. 2007). This is an indication of the significance of this behaviour in the lives of this group of people.
Yet, adolescents who present with self-harming behaviours in
care services, like secure mental health environments, are generally referred to as attention seekers and manipulators by
nurses (Sandy & Shaw 2012). While these descriptors indicate
nurses limited understanding of the motives for self-harm,
users find them derogatory and invalidating, and they serve
only to enhance their feelings of worthlessness and treatment
fearfulness (Shepperd & McAllister 2003). Additionally, these
negative experiences may increase users risks for further selfharm and avoidance of health services. Thus, identifying and
understanding the motives for self-harm could lead to
improved therapeutic relationships and care provision for this
user group, which in turn could prevent or at least reduce the
need to hurt themselves (Patterson et al. 2007). Despite this
assertion, there is limited literature relating to healthcare professionals, including nurses reasons for self-harm in secure
mental health environments.
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P. T. Sandy
Method
Aim
The aim of this study is to identify and understand nurses perceptions of adolescents motives for self-harm in a secure
mental health unit.
Design
Each nurse was given an information leaflet and a letter of invitation to partake in the study. They were also reminded to
contact the researcher to express their interest for participation
if they met the studys eligibility criteria. All nurses made
contact with the researcher and expressed their willingness to
participate. A total sample size of 25 nurses was recruited to
take part in the study, as they had training in the subject area
and over 2 years of experience working with this user group in
secure settings.
Data collection
Sampling
Stage 6: Development of a single master table of themes from master table of themes
of individual transcripts.
Finding
Four superordinate themes emerged from the data analysed:
visibility of self-harm, a cry of pain, a cry for help, and detention and institutional factors. Each of these themes contains a
number of sub-thematic categories indicated in bold italics.
Extracts from participants narratives are used to support the
discussions of identified themes.
Visibility of self-harm
Cry of pain
Participants claimed that the motives for self-harm were sometimes generated from within users, and the most commonly
cited among these was regulation of distress. All participants
frequently reported that that users self-harm to communicate
intolerable feelings of distress and to feel calm and safe.
Users do it when they are extremely stressed because of the
way they are treated. They feel calmer after harming
themselves.
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P. T. Sandy
Discussion
Users in secure settings usually like nurses to spend uninterrupted time listening to them (Dickinson et al. 2009). This
means nurses attention is very important for users in these
environments. So, users would adopt a range of strategies to
gain the attention of nurses. One effective means for achieving
this is self-harm; as it is behaviour that is very hard to ignore in
secure environments. Using self-harm this way is what is sometimes considered manipulative or attention seeking by nurses.
Given that self-harm in secure settings is a private and secretive
affair (Sadler 2002), some participants claimed that the behaviour is not for seeking attention, but for communicating dis-
363
Examples of issues of
detention:
Rigid rules &
regulation
Coping skills
depletion
Controlled
environment
Stigmatization
(express stigma)
Self-harming behaviour
(private or public)
Regain emotional control
Regulate distress
Avert death.
Punish self & others
Seek attention and
manipulate care
Drive others away &
prevent future abuse
Self-cleansing
Regain ownership or /
control of physical body
Frustration
Lack of control of their
lives
Depletion
of coping
skills
Mixture of emotions
Frustration, anger & anxiety
Distress, fear, feelings of
lack or loss of control
Anger:
Lack and / loss of control of
their lives
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P. T. Sandy
the same, and this is also true for the nurses working within
them. Hence, the findings of this study may not be generalizable
to nurses of other secure units in England and other countries
in the world. However, they are transferable to these environments as they provide knowledge for understanding nurses
explanations of users motives for self-harm.
Conclusion
It is claimed in this study that self-harm is used by users for a
number of reasons. Examples of these include affect regulation,
communication of distress, regaining control, punishing self,
manipulating others and seeking attention. There was some
disagreement between participants in relation to whether users
self-harm to seek attention. Some believed that this is not the
case as the behaviour is mainly carried out in private. Others
were supportive of the attention-seeking motive. They stressed
that users in secure environments always like nurses to spend
time listening to them. So, they frequently self-harm to secure
the attention of this professional group. However, harming
themselves usually results in the implementation of higher
levels of control measures (such as observations) that may perpetuate the need for further self-harm. Such use of control
measures is a function of nurses lack of or limited understanding of self-harm and its motives. Thus, understanding the
motives for self-harm is important to provide the most appropriate care. More research is therefore needed in this area of
practice.
Acknowledgements
The author gratefully acknowledges the mental health nurses of
the study site who offered their experiences of working with
people who self-harm. The author is also grateful to the managers of the study site for the support they offered throughout the
study period.
Author contributions
PS: Conception of design, data analysis, interpretation, drafting
and revising the article, critical revision for intellectual content.
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