Guest Post: Hanna Pickard and Steve Pearce
Sullivan’s emphasis on the importance of supporting autonomy and independence among vulnerable people who self-injure is fundamental to good clinical practice. This is why some forms of harm minimization, such as encouraging reflection, responsibility, safe cutting and where appropriate self-aftercare, are uncontroversial and already widely practiced within community settings. The situation is different, however, with respect to both secure and non-secure inpatient settings. It is also different when we consider the other forms of harm minimization that Sullivan advocates, namely, the provision of self-harming instruments on wards alongside education about anatomy.
In secure (forensic) inpatient settings, it is neither practical nor ethical to provide implements that can be used as weapons to any patient, for any reason. This would be to severely compromise staff and patient safety.
In non-secure inpatient settings, patients are likely to be detained under the Mental Health Act. This raises the question of the grounds of detention. Typically, patients who self-injure are detained because they are judged to be currently at risk of life-endangering or life-changing injury. As Sullivan notes, it is not clinically or ethically appropriate to provide patients with the means to self-injure when they are in this state of mind. This means that the relevant inpatient population for which a harm minimization approach could even be considered is relatively small: those who have a standing pattern of self-injury and who are detained on non-secure units for reasons other than acute self-injury.