Vous êtes sur la page 1sur 9

bs_bs_banner

Clinical

Motives for self-harm: views of nurses in


a secure unit
P.T. Sandy

RMN, BSc (Hons), PGDipED, PGCertED, MSc, PhD

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.

2013 International Council of Nurses

world (Favazza 1996; Sandy & Shaw 2012). Acknowledging this,


self-harm is a behaviour that is not new to mankind. Although
self-harm is believed to be a preventable behaviour, it is perceived as an international public health problem, as its incidence and subsequent suicides are increasing (Cooper et al.
2005). While it is difficult to offer precise information on the
number of people hurting themselves worldwide because of the
secrecy associated with the behaviour (Sadler 2002), the World
Health Organization (2009), in its publication, suicide prevention, highlighted that globally more than 1 million people
commit suicide every year. It is reported in the same document
that the incidence of self-harming behaviours is 10100 times

358

Motives for self-harm

greater than the number of suicides. However, estimates of these


incidences tend to vary widely from state to state, with UK considered to have the highest rate in Europe (National Institute for
Health and Clinical Excellence (NICE) 2004). This variation in
rates is likely to be a function of the absence of a universal definition, reflected in the use of a plethora of terms, such as deliberate self-harm and parasuicide in describing self-harming
behaviours (Magnall & Yurkovich 2008). This use of different
terminologies not only causes confusion for users, but also for
clinicians and researchers alike. To minimize terminological
confusion, this study uses the term self-harm to refer to all selfharming acts in clinical practice. Added to this, the study adopts
the definition proffered by the NICE guideline on self-harm as
it encompasses a range of behaviours, including cutting commonly encountered in secure environments. It refers to selfharm as self-poisoning or self-injury, irrespective of the
apparent purpose of the act (NICE 2004, p. 16).
NICE is an independent organization in England and Wales,
established in the late 1990s for offering reliable guidance to clinicians and users in making appropriate decision about treatment and management of health conditions (Pitman & Tyrer
2008). In relation to self-harm, NICE clinical guidelines were
published in 2004 and these offer clinicians very specific guidance on the management of people who harm themselves
(Pitman & Tyrer 2008). The essence of this is to improve the
standards of care offered to this user group and to ensure that
care provision is consistent and user centred.
As mentioned in an earlier paper, self-harm is a complex phenomenon, a puzzle in which, despite its ubiquity and established academe of researchers exploring it, the reasons for its
occurrence are still not fully comprehended by nurses (Sandy &
Shaw 2012). This position is succinctly expressed by Favazza
(1996). As a psychiatrist with long-standing personal experiences with users who self-harm, he describes this behaviour as a
riddle. This is an indication of the complexity of this behaviour
and difficulty of understanding it. Users who self-harm in
secure settings often claim that their health needs are usually
not met by nurses (Pembroke 2006). This assertion could be
attributed to the differential perceptions between nurses and
users of the motives for self-harm. Generally, users perceive selfharm as a means of communicating distress, while nurses tend
to consider it as a desire to seek attention and manipulate others
(Dickinson et al. 2009). Such attitudes may inhibit usernurse
relationships as well as negatively impact on the quality of care
offered to the former, a view also acknowledged by James &
Warner (2005). Given that the majority of care providers in
secure mental health services are nurses, the quality of care this
user group receives will depend in part on how they are perceived by these professionals. Hence, an understanding of this

2013 International Council of Nurses

359

professional groups reasons for self-harm would be helpful in


the planning and delivering of care for users with this behaviour. Yet, very little empirical research, such as Dickinson &
Hurley (2011) and Sandy & Shaw (2012), has been conducted in
this area of practice. Hence, this study seeks to explore the views
of nurses working in a secure adolescent unit of the motives for
users self-harming behaviours.

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.

360

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

Users reasons for self-harm are an aspect of care that is still


poorly comprehended by nurses in secure environments.
Therefore, there is a need to engage in further research to gain
more knowledge and understanding about the motives for this
behaviour. Phenomenological methodologies are better placed
to help develop such understanding, as they are considered
appropriate and effective for studying under researched and
poorly understood phenomena (Smith et al. 2009). Following a
comparative examination of the literature on the variants of
phenomenology, this study opted for interpretative phenomenological analysis (IPA) and utilized it both as a methodology
and as a tool of analysis for a number of reasons.
IPA enables researchers to understand peoples personal
experiences of specific issues by focusing on their personal perceptions of the same (Smith 2005). It recognizes that the meanings people attribute to experiences can be understood in
the socio-cultural contexts in which they are experienced
(Langdridge 2007). It stresses that the meanings that a phenomenon hold for people can be developed and understood through
participantresearcher interactions (Smith 2005). It is epistemologically assumed that access to these meanings can be possible if researchers adopt the hermeneutics of questioning
approach as well as take, in Conrads (1985) words, an insider
perspective. The stance of an insider requires researchers to use
their preconceptions to understand individuals personal worlds
and the meaning they attribute to them. In relation to the
hermeneutics of questioning, researchers are encouraged to
stand alongside participants and ask critical questions over
things they say. Adopting this double hermeneutic approach can
generate comprehensive insights into self-harm and associated
motives.

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

Ethical approval was gained from the National Research Ethics


Services and Research Ethics Committee. Consent was sought
and obtained from each participant before data collection. They
were reassured that the information they provided will be anonymized and treated with the strictest confidence. Participants
were also informed that they have the right to withdraw from
participation at any time should they wish to do so. Data were
collected using a semi-structured interview guide consistent
with IPA principles (Smith 2005). Individual interviews were
conducted and they lasted from 45 to 60 min. All interviews
were audiotaped and contemporaneous notes were taken during
the process.
Data analysis

All interviews were transcribed verbatim and transcripts were


analysed manually using Smiths (2005) IPA framework. Analysis using this framework took place in stages for each transcript
(see Fig. 1). Analysis proceeded in parallel with the interviews,
and was conducted iteratively throughout the interview period
until category saturation was achieved.

Stage 1: Reading and reading transcript to familiarize with participants account

Stage 2: Making notes of interesting issues about participants account

Stage 3: Development of emergent themes that capture meaning of participants account

Stage 4: Searching for connections across emergent themes

Sampling

The population of this study was the total number of nurses


working in an adolescent secure unit in England. This unit was
made of two 15-bedded clinical areas with 20 mental health
nurses each. A meeting was summoned for all nurses to discuss
the study. During this meeting, the researcher explained the aim
of the study, including its eligibility criteria and significance.

2013 International Council of Nurses

Stage 5: Development of a master table of themes containing superordinate themes,


sub-themes and quotes from transcript

Stage 6: Development of a single master table of themes from master table of themes
of individual transcripts.

Fig. 1 From transcript to master table of themes.

Motives for self-harm

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

This theme relates to the locations where the acts of self-harm


are carried out in clinical practice. Some participants coined the
term private self-harm, which relates to the secrecy associated
with the behaviour. They claimed that self-harm is a solitary
and secretive affair that is usually hidden from others.
This user does it several times. He hides, but I always catch
him. I am angry with his behaviour.
Concerns were frequently expressed by participants about the
secretiveness of self-harm, as they claimed that it could lead to
suicide if encouraged. Discussions also focused on concerns
about possible causes of the secretiveness of self-harm. Some
participants were of the view that it is the uncaring manner in
which they respond to users that sometimes makes the latter to
harm themselves in private. A minority of participants attributed this behaviour to the use of restrictive approaches, such as
contracts. Most participants reported that users sometimes
engage in public self-harm for attention. This means that they
sometimes hurt themselves in communal areas of their clinical
environments.
Some users hurt themselves openly in the day area. They do it
for attention.
While most participants believe that users self-harm to seek
attention and be listened to, a minority stressed that they do it
to express their feelings. Listening to users, some participants
asserted, would enable them to get relief from a terrible state of
mind.

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.

2013 International Council of Nurses

361

Self-harm served as an emotional release for users as it


allowed them to feel calmer after the act. Some participants
claimed that the emotions specifically associated with selfharm are anger, frustration, fear and guilt. These emotions
form a cocktail that is distressing and unmanageable by users.
Some participants stressed that users who use self-harm to
cope with these emotions generally lack the ability to verbally
express themselves. They also believed that the injury takes
users attention away from their distress onto something that
feels more manageable. Although infrequent, punishing the
self is another motive for self-harm reported by participants.
They explained that users hurt themselves, as they sometimes
feel worthless or bad for a wrong they believed they have committed, for which they should be punished. It is almost as if
there is a punishing self who delivers the injury and a guilty
self who deserves it.
A user reported that she deserved to be blamed and punished
for letting it happen (rape). She cuts herself when she feels
this way.
Cutting was considered the most common form of self-harm
in secure settings. A physical consequence of cutting mentioned
by participants was bleeding, which was often associated the
concept of cleansing. Participants mentioned that most adolescents who self-harm have been sexually abused and usually
claim to feel guilty and dirty as a result of these events. Cutting
themselves and letting the blood flow, participants asserted, is
self-cleansing. Most participants believed that people with traumatic encounters usually experience a cocktail of unbearable
emotions that if not safely expressed could result in near fatal or
fatal outcomes. Users with these experiences use self-harm to
avert death.
A user said that she sometimes gets very tormented by the
thoughts of her rape ordeal. She claimed that each scar on her
body represents a period of time she escaped death.
Such affect regulatory and survival functions were believed to
act as reinforcers for self-harming behaviour. Participants
repeatedly claim that users sometimes hurt themselves to
assume ownership of or regain control of their bodies. In contrast to this way of coping, participants indicated that users
sometimes self-harm to prevent future abuse. Few participants
reiterated that the scars that subsequently develop when users
wound themselves make them look ugly. It is the ugliness that
drives abusers away and consequently makes them feel safe.
Other motives noted in the participants narratives were
related to interpersonal functions of self-harm. Participants
claimed that self-harm is an outcome of interactions between
users and others, including the environments they live in.

362

P. T. Sandy

Cry for help

Some participants reiterated that the behaviour of self-harm is a


re-enactment of traumatic experiences of abuse. Individuals
who have been subjected to such encounters are more likely to
feel bad and guilty. It is this cocktail of emotions that users
cannot control (loss of control) that participants claimed to
sometimes lead to self-injury.
A user told me that she was overpowered by her abuser when
it happened. She cut to alleviate the feelings of self-hatred she
developed.
There was agreement among some participants that feelings
of self-hatred, self-blame and guilt are not uncommon with
victims of sexual abuse. They acknowledged that individuals
with these experiences sometimes express feelings of anger and
hatred for their perpetrators. So, cutting is punishing their
abusers.
Users sometimes self-harm to get at those who abused them.
They cut themselves as though they are cutting the abuser.
The majority of participants communicated a shared opinion
about self-harm. They claimed that self-injury of any kind, particularly cutting, does have a significant influence on how others
may react to users. Participants stressed that users sometimes
hurt themselves to seek attention and manipulate their care
because of their inability to verbally request for help. While
most participants recognized that self-harm can be used as a
means for attracting care, others put forward a contrasting
reason. Although nurses in secure settings always feel obliged to
fulfil their professional responsibility of offering care, some participants highlighted that users sometimes harm to drive others
away from them.
One in particular told me that she sometimes cut deep to
push us away.

regaining control of their losses. Some participants thought of a


controlled environment as a setting that enables users to reminisce about abuses they suffered during childhood.
Users at risk of killing themselves are usually closely monitored. We even enter the bathrooms when they are taking care
of their needs. This reminds them of their past trauma of
abuse.
Participants claimed that being subjected to such forms of
monitoring would be distressing to anyone. They stressed that it
would be even more distressing for someone who has been
exposed to abusive encounters. However, some participants
highlighted that it is the confinement, lack of involvement in
decision making and rigid rules, not the monitoring that plays
a major role in generating distress. Participants frequently
repeated that being confined in a controlled environment and
not taking part in decision making could lead to depletion of
coping skills to deal with personal problems. Self-harming
behaviour was attributed to deficits in problem-solving skills.
Here users do what we tell them to do. Such approach makes
them lose their coping skills.
Adolescents can also hurt themselves if they feel stigmatized
(enact stigma). Added to this, they may be subjected to discriminatory practices if labelled or stigmatized by healthcare
workers (express stigma).
What sometimes make them to continue to harm is the
stigma of being in a psychiatric hospital and the stigma of
being given labels, such as attention seekers.
Participants claimed that such labels would generate feelings
of humiliation and loss of hope in users which, in turn, may
result in more self-harming acts. Simply, adolescents in secure
environments sometimes self-harm to cope with the impact of
labelling and stigmatization.

Detention and institutional factors

It was indicated at interviews that some users start to hurt


themselves when admitted to secure environments. This was
attributed to feelings of disempowerment, powerlessness, and
issues of neglect such as not being listened to and being confined in a controlled environment. In addition to these risks of
self-harm, other factors that may contribute to this behaviour in
controlled environments are illustrated in Fig. 2. Participants
referred to a control environment as a setting in which people
are being locked, closely observed, monitored and engaged in
treatment. Within such environments, most participants
believed that users do frequently experience feelings of loss or
lack of control of their lives and use self-harm as a strategy for

2013 International Council of Nurses

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-

Motives for self-harm

363

Examples of issues of
detention:
Rigid rules &
regulation
Coping skills
depletion
Controlled
environment
Stigmatization
(express stigma)

Detention and neglect

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

Examples of issues of neglect:


Not addressing
emotional needs
Negative attitudese.g. ignoring user
Stigmatization (enact
stigma)
Labelling

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

Fig. 2 Self-harm explanatory model.

tress. Secretly hurting themselves would help users avoid being


described as manipulators or attention seekers.
Secure environments are hotbeds for self-harming behaviours (Gough 2005). Participants reported that some users only
commence acts of harm when detained in these settings. This is
certainly not surprising as being detained and neglected, characteristics that are inherent in secure environments are significant
risk factors for self-harm (Tantam & Huband 2009). Acts of
neglect are manifested in these settings because of a social and

2013 International Council of Nurses

psychological gap that exists between users and nurses


(Goffman 1961). This means that the latter are providers of care
and instructions, while the former are expected to comply with
rules and care provided. Not having control in such encounters
could result in users to experience feelings of anger, frustration
and loss of control. Such a cocktail of emotions could lead to
the development of psychological tension that requires a safety
valve for safe expression. Self-harm is a behaviour that users
have total control of and is believed to be the safest channel for

364

P. T. Sandy

venting these emotions. This assertion is based on the view that


users may feel uncomfortable to externalize these emotions
against others for fear of repercussions.
The provision of care within an atmosphere of a social and
psychological apartheid could be disempowering for users. It is
reiterated by some participants that care provisions in secure
settings are generally not carried out in partnership with users.
This approach to care would, over a period of time, deplete
users of essential life skills including those of problem solving,
leaving self-harm as one of the few options for addressing life
difficulties. The apparent relationship among self-harm, control
and depletion of coping skills is illustrated diagrammatically in
Fig. 1. The direction of arrows in the figure shows the sequence
of events that relate to aspects of control that may lead to selfharming behaviours. Detention and its associated environmental controls, rigid rules and negative attitudes can generate in
users feelings of powerlessness, frustration and anger. This
cocktail of emotions may trigger self-harming behaviours. The
occurrence of these behaviours may in turn lead to higher levels
of control that may further increase users levels of frustration
and subsequent need for self-harm.
The desire to achieve emotional control is not the only
motive for self-harm. Individuals also tend to engage in it to
attain a state of emotional calmness when distressed. Coping
with unbearable feelings is one of the most common motives
for self-harming behaviours. Some participants claimed that
users in their clinical areas usually bottle-up angry emotions
that are generally generated by the overpowering and malevolent nature of secure environments (Favazza 1996). Customary
ways of coping, which include social interaction and activities,
are usually ineffective in restoring emotional calmness. Long &
Jenkins (2010) reiterate that self-harm is an effective means for
minimizing tension to bearable levels, an opinion also reflected
in this inquiry.
Participants of this study seem to believe that adolescents
who have been exposed to distressing events, on occasions, do
experience mounting internal tensions with overwhelming
thoughts of wanting to kill themselves. Self-harm is used in
these extreme cases to facilitate emotional release with the view
to relieving affected individuals from emotional distress. Simply,
it serves as an alternative to suicide in instances where adolescents feel unsafe and being out of control of their emotions. It is
therefore a coping strategy considered by participants to offer
users a sense of emotional control.
The researcher acknowledges that the study only focuses on
nurses perceptions of the motives for self-harm. The study was
carried out in a single trust and utilized a criterion purposive
sample of nurses to capture their views of self-harm. It is
important to acknowledge that no two secure environments are

2013 International Council of Nurses

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.

References
Conrad, P. (1985) The experience of illness: recent and new directions.
Research in the Sociology of Health Care, 6, 131.
Cooper, J., et al. (2005) Suicide after deliberate self-harm: a four year
cohort study. The American Journal of Psychiatry, 162 (2), 297302.
Dickinson, T. & Hurley, M. (2011) Exploring the antipathy of nursing staff
who work within secure healthcare facilities across the United Kingdom
of young people who self-harm. Journal of Advanced Nursing, 68 (1),
147158.

Motives for self-harm

Dickinson, T., Wright, K.M. & Harrison, J. (2009) The attitudes of nursing
staff in secure environments to young people who self-harm. Journal of
Psychiatric and Mental Health Nursing, 16, 947951.
Favazza, A. (1996) Self-Mutilation and Body Modification in Culture and
Psychiatry, 2nd edn. John Hopkins University Press, Baltimore, MA.
Goffman, E. (1961) Asylums: Assays on the Social Situations of Mental
Patients and Other Inmates. Pilican, Middlesex, UK.
Gough, K. (2005) Guidelines for managing self-harm in a forensic setting.
British Journal of Forensic Practice, 7 (2), 1014.
Haw, C., Bergen, H., Case, D. & Hawton, K. (2007) Repetition of deliberate
self-harm: a study of the characteristics and subsequent deaths in
patients presenting to a general hospital according to extent of repetition. Suicide and Life-Threatening Behavior, 37 (4), 379396.
James, M. & Warner, S. (2005) Coping with their lives-women, learning
disabilities, self-harm and secure unit: a Q methodological study. British
Journal of Learning Disabilities, 33, 120127.
Langdridge, D. (2007) Phenomenological Psychology: Theory, Research and
Method. Pearson, Essex, England.
Long, M. & Jenkins, M. (2010) Counsellors perspectives on self-harm and
the role of the therapeutic relationship for working with clients who
self-harm. Counselling and Psychotherapy Research, 10 (3), 192200.
Magnall, J. & Yurkovich, E. (2008) A literature review of deliberate selfharm. Perspectives in Psychiatric Care, 44 (3), 173184.
Mental Health Foundation (2006) Truth Hurt: Report of the National
Inquiry into Self-Harm among Young People. Mental Health Foundation,
London.
National Institute for Health and Clinical Excellence (NICE) (2004) The
short term physical and psychological management and prevention of

2013 International Council of Nurses

365

self-harm in primary and secondary care: National clinical guidelines 16.


NICE, London.
Patterson, P., Whittington, R. & Bogg, J. (2007) Measuring nurses attitudes
towards deliberate self-harm: the self-harm antipathy scale. Journal of
Psychiatric and Mental Health Nursing, 14, 100115.
Pembroke, L. (2006) Limiting self-harm. Emergency Nurse, 14 (5), 810.
Pitman, A. & Tyrer, P. (2008) Implementing clinical guidelines for selfharm: highlighting key issues arising from the NICE guideline for selfharm. Psychology and Psychotherapy: Theory, Research and Practice, 81,
377397.
Sadler, C. (2002) Self-harm: look behind the scars. Nursing standard (Royal
College of Nursing (Great Britain): 1987), 17 (12), 1618.
Sandy, P.T. & Shaw, D. (2012) Attitudes of mental health nurses to selfharm in secure forensic settings: a multi-method phenomenological
investigation. Journal of Medicine and Medical Science Research, 1 (4),
6375.
Shepperd, C. & McAllister, M. (2003) A framework for responding therapeutically to the client who self-harms. Journal of Psychiatric and Mental
Health Nursing, 10 (4), 442447.
Smith, J.A. (2005) Semi-structured interviewing and qualitative analysis. In
Rethinking Methods in Psychology (Smith, J.A., Harre, R. & Van Langenhove, L., eds). Sage, London, pp. 927.
Smith, J.A., Flowers, P. & Larkin, M. (2009) Interpretive Phenomenological
Analysis: Theory, Method and Research. Sage, London.
Tantam, D. & Huband, H. (2009) Understanding Repeated Self-Injury: A
Multidisciplinary Approach. Palgrave Macmillan, Basingstoke, England.
World Health Organization (2009) Suicide Prevention Strategy. WHO,
Geneva.

Copyright of International Nursing Review is the property of Wiley-Blackwell and its content
may not be copied or emailed to multiple sites or posted to a listserv without the copyright
holder's express written permission. However, users may print, download, or email articles for
individual use.

Vous aimerez peut-être aussi