Nursing Diagnosis: Application to Clinical Practice
11th Edition

Violence, whether directed toward oneself or others, can elicit strong reactions from people. Nurses, whose profession encompasses caregiving, health promotion, and nurturance, must examine their own attitudes, responses, and behavior toward violence.

Because much of the practice of self-harm is a “shame-based” problem, the condition is more likely to be underreported rather than overreported. Identification is difficult, because so many who engage in self-harm become extremely adept at hiding the causes of their injuries.

Self-harm is found in people from all economic and educational backgrounds, and in both men and women. It usually appears in the early teenage years, although it may commence before adolescence. It frequently is associated with long-term effects of physical, psychological, and sexual abuse during childhood.

Many people who harm themselves are given a psychiatric diagnosis of personality disorder or, more specifically, borderline personality disorder, although other psychiatric diagnoses may be associated with self-harm (see pathophysiologic section). An important consideration is that not all people with these diagnoses harm themselves, and not all self-injurers qualify for these diagnoses. Treatment will differ depending on the diagnosis (Carscadden, 1997).

The person who has delusions or hallucinations (either schizophrenic or drug-induced) presents a different rationale for self-harm. Delusions and hallucinations must be brought under control. Meanwhile, the person’s safety is essential. Self-harm also may be prevalent with mentally challenged people, and management in this particular population will differ again, owing to the cognition level of the self-injurer.

Often repetitive and chronic in nature, self-harm frequently distorts or disrupts the client–therapist relationship and increases the need for and length of hospitalizations. These hospitalizations often further exacerbate the problem. Hospitalization usually increases the client’s dependency and decreases his or her accountability.

The following presents the basics of dysfunctional family dynamics:

There are various levels or stages in impending self-harm. The transition from one level to another may be rapid or slowly progressive. The person may or may not be aware of the stages and the transition. Awareness of each stage and its characteristics facilitates intervention. The earlier the stage, the clearer the thinking, the less intense are the feelings, and the more control the person has. A person can easily identify stages once he or she learns the defining characteristics (Carscadden, 1993a).

Although self-harm may create a sense of urgency, imminent disaster, and a strong and immediate sense of responsibility in the listener or observer, one must be careful not to be caught up in this and feel compelled to do something. (This excludes the psychotic and mentally challenged population.) The very act of trying to intervene or prevent the behaviors may increase the likelihood of more serious harm, including completed suicide. The risk increases because: (a) the more often intervention takes place, the more likely death by mistake will occur (wrong pills, too many, the expected rescue being thwarted); (b) there may be a need to use increasingly dangerous methods to get the same result; or (c) before long, countertransference hate sets in. In an empathic, yet matter-of-fact manner, the nurse must convey that the person’s actions are in his or her hands alone and that no one can be his or her guardian or savior. This is the hardest thing for anyone to say; however, for the self-injurer to survive and mature, he or she must become responsible for his or her own actions. If someone else takes control, the self-injurer will not progress (Carscadden, 1998).

In settings mandated to prevent, contain, or reduce self-harm, common practices are to use seclusion or a system of physical restraint, often a four-point restraint in which the person is tied to a mattress or bed with each arm and leg restrained separately. Statistics indicate that early sexual abuse appears to be a common experience for many self-injurers. The use of restraints, being held down or tied up, spreading the legs, or otherwise being at the complete mercy of another can represent the reenactment of sexual abuse or rape. Questions should be raised regarding the ethical use of this type of containment as well its effectiveness when records show that restraints or seclusion are used regularly (Carscadden, 1998).

Families are often the forgotten sufferers in the self-harm syndrome. They are caught in the same shame-based system as the self-injurer, and this often precludes their reaching out for help with the bewilderment, frustration, and helplessness experienced in day-to-day living with the self-injurer. They need assistance in demystifying self-harm, identifying how it has affected them, and examining some coping methods for supporting themselves and the self-injurer on the road to recovery. Educational and support groups as well as family counseling are good ways to begin this process (Carscadden, 1997).

Self-harm ranges from injurious acts to reduce stress to direct acts of suicide. Self-abuse or mutilation behavior has the potential to be harmful and to result in death. Self-injurers are very aware
that their actions have a potential of resulting in death if they miscalculate (eg, how many pills, how much cutting or burning; availability of help; their own degree of control to stop once started; Carscadden, 1993a). With direct self-destructive behavior, usually referred to as suicidal, the intent is death, and the person is aware of that.

Suicidal behavior is an attempt to escape from intolerable life stressors that have accumulated over time. It is accompanied by intense feelings of hopelessness, little social support, and insufficient coping skills to manage extreme stressors that are present (Boyd, 2004).

Lack of healthy coping skills and use of avoidant behaviors such as alcohol and drugs frequently are correlated with suicidal behavior.

A suicidal crisis happens both to the person and to his or her support system. Suicide may be seen as a viable alternative both by the individual and by significant others.

Depression, low self-esteem, helplessness, and hopelessness are positively related to suicide. The greater the degree of hopelessness, the greater is the risk for suicide. Loss clearly increases the risk of suicide. Cumulative losses increase the risk dramatically.

People exhibiting poor reality testing, delusions, and poor impulse control are at high risk. Alcohol and drugs tend to lower impulse control.

Changes in behavior (eg, giving away possessions) may signal an increase in risk. A person may appear to be better just before an attempt. This may result from feelings of relief after making a decision.

Demographic factors can help identify people at high risk for suicide:

The more resources that are available, the more likely it is that the crisis can be managed effectively. Resources include personal support systems, employment, physical and mental abilities, finances, and housing.

Some people use suicide attempts as a way to cope with stress. The more frequent the attempts and the more lethal, the higher the current risk. Suicidal ideation moves from the general to the specific, with more detailed plans representing a higher risk. An event may precipitate an attempt. The difference between a negative life event and one that may lead to a suicide attempt is that with the latter, the person already has engaged in significant suicidal ideation.

Long-term suicide risk exists for some people. This can be assessed best by evaluating:

Lethality describes “the probability that a person will successfully complete suicide.” It is determined by the “seriousness of the intent and the likelihood that the planned method of death will succeed” (Boyd, 2005, p. 860).

Nurses should use verbal and nonverbal clues to assess risk, because seriously suicidal people may deny suicidal thoughts.

Prediction of suicide risk is not an exact science. Some errors that can be made result from:

Levels of risk can be assessed as low or high. Not all of the following parameters are necessarily present in any one person (Varcarolis, 1998).

In an HIV-positive person, the risk for suicide is greatest “shortly after learning of one’s infection and at the late stages of AIDS” (Siegel & Meyer, 1999, p. 53).

The AIDS-related multiple losses that HIV-negative gay men may experience can result in repetitive overwhelming emotions, physical exhaustion, and spiritual demoralization. If coupled with shunning and isolation, despair is increased and chronic (Mallinson, 1999).