- Email: [email protected]
Building therapeutic staff: Client relationships with women who self-harm
Building Therapeutic Staff: Client Relationships With Women Who Self-harm Karen Rea, BA (Hans), DPSN Ashworth Centre Ashworth Hospital Liverpool John Moores School of Health Care Liverpool, England
University
Fran Aiken, RMN, MSc Clancy Borastero, RMN Ashworth Ashworth Liverpool,
Centre Hospital England
T
here is a growing recognition that the reasons for women selfharming are complex and, therefore, need to be addressed in a therapeutic milieu. Although self-harming behavior is not restricted to only those women who are involuntarily detained in various institutions, the incidence within such institutions is high. In England, a small number of women will end up detained within maximum security hospitals under the 1983 English Mental Health Act. It can be argued that the reasons for this incidence originate from gender discrimination practices and socially constructed beliefs about what is, or should be, “normal” women’s behavior. Within such environments, however, there is a growing recognition of the relationship between self-harming behavior and previous experiences of abuse and feelings of powerlessness, both in experiencing and dealing with their abuse and in their everyday lives. Much conventional response has been pejorative and punitive, reinforcing socially constructed beliefs about women. A multidisciplinary group of workers within a English special hospital devised a training package aimed at changing and informing staff attitudes toward selfharming behavior and encouraging therapeutic responses and interventions. This article explores the aims and objectives of this package, and the reasons for its implementation, with a group of nurses in the institution who work with women who self-harm. At the end of 1995, members of the Ashworth Centre, the nurse education department of the Ashworth Hospital, were contacted with a view to contributing to a training package to be devised for nursing staff working directly with women who self-harm and were detained in the hospital under the 1983 English Mental Health Act. The training package (copies of which are available from the authors) although initiated by members of the departments of psychology and of reha-
o
1997 by The Jacobs of Women’s Health Published by Elsevier
Institute Science
,049.3867,~7,s17,00 PI151049-3867(96)00112-O
REA
ET AL: WOMEN
WHO
Inc.
SELF-HARM
121
r bilitation at the hospital, was intended to be provided to nurses. The lecturer practitioners of the Ashworth Centre were therefore contacted for their nursing expertise and help. The need for a training package had been identified as a result of workshops run by the Psychology Department for a group of women who self-harm and were currently within the hospital.’
WHY
DO WOMEN
SELF-HARM?
There is a plethora of published information available on why women selfharm.2-7 Some work has focused solely on the reasons women self-harm while detained within the British Special Hospital system.8 The reasons for women self-harming, however, whether out in the community or within a closed environment, have a consistent similarity and, at times, a relationship. For example, women detained in Ashworth cited one of the reasons for self-harming as a fear of being out in the community with little or no resources to help them with their anxiety and anguish.’ The common themes running through the women’s reasons for selfharming were those of histories of abuse and the feelings of powerlessness that the women experienced and still felt. Enforced detention within the special hospital system only added to these feelings, and the inability of the staff to “treat” not only the self-harming behavior both in the women’s past and present but also the underlying causes of the behavior, inevitably led to the continuation of, and in some situations, an increase in, the likelihood of the self-harming activity. Several highlighted classifications of self-harming behaviors have been produced,” and it is not our intention to repeat them here. Indeed, part of the training package for nursing staff would be to identify the range of behaviors, both from personal experience of witnessing and dealing with the outcome of such behavior and also by being directed to the multitude of literature available. Much feminist thought has concerned itself with the effect of patriarchy and oppression on women’s lives.“-‘4 Women within the high-security mental health system and women who self-harm often appear to be the very antithesis of patriarchal beliefs about womanhood. They do not conform to patriarchal beliefs about the passivity of women nor, and often, to the biologically reductionist argument surrounding heterosexuality, motherhood, and the “natural” caring role of women. Listening to the women in Ashworth, one is provided with graphic examples of the effects of oppression and sexism on women’s lives. Common life-themes include abuse, being taken into care, and living in institutions and many “homes”, where they often are subjected to various forms of abuse. As adults, the abuse continues through the hierarchies and male-dominated institutions, such as the medical profession’5 and the courts and legal system.” It was apparent to the three lecturer practitioners that any training package designed for nurses working with women who self-harm needed to include feminist thought, theory, and discourse. The Bristol Crisis Service for Women was an invaluable source of information relating to women and the reasons for their self-harming behavior. In addition, it provided both theoretical and practical information on how to help women who are harming themselves. Although providing literature aimed at informal carers and friends, much of the philosophy and information the literature contained was relevant to nurses, perhaps especially so, in that it could be used to help promote a more person-centered attitude among staff. The nursing staff need to understand that the personal is the political, that the women who self-harm are responding to often horrendous life experiences, 122
WOMEN’S
HEALTH
ISSUES
VOL.
7, NO. 2 MARCH/APRIL
1997
and that their self-harming behavior is, as one writer has commented, “fundamentally a way of living. It is a means of getting through the day.“’ Understanding why women resort to self-harm is the first key step for nurses if they are to help women who harm themselves. Understanding why women behave in this way, accepting their reasons as valid, and not pathologizing their behavior are fundamental objectives of the training package. A further issue that this package hoped to enable staff to explore was that of the transference of the women’s violence onto the nursing staff themselves. The violent propensities that had led to the women being detained at Ashworth are often turned outward toward staff who may be representative of past problems that the women had experienced. The reasons for the women self-harming often include the dominance of older women (ie, parents/carers) as being causative factors,’ that is, the effects of violence on child development, adult women’s relating of the experience of the mother-parent ignoring the child abuse out of feelings of powerlessness or even fear of reprisal.17 It is, therefore, not difficult to understand that when women who have experienced abuse meet with women in positions of power (ie, nurses working in highsecurity hospitals), transference may occur.
THE
STAFF
TRAINING
PROGRAM
The training program provided carefully devised aims and objectives and was intended to be used within an adult learning approach. The intention was to use a seminar format, to be immediately followed by reflective practice sessions, thereby providing the nursing staff with the opportunity to explore how both theoretical constructs and women’s experiences could inform and influence the delivery of care. The aims of the package focused around enabling staff to understand why women self-harm and, through the creation of a positive approach, to support women who are self-harming. Greater knowledge of the reasons why women self-harm should encourage nursing staff to develop therapeutic skills further. The importance of this is reflected in the comments of one member of staff, that caring for women who self-harm involved seeing the self-harming behavior as a tree. Staff could develop competence in dealing with the branches of the tree (ie, the types of self-harm that the women inflicted on themselves) but they also needed to develop expertise and therapeutic skills in helping the women understand and deal with the causes (ie, the trunk and roots of the tree). The training program drew heavily upon community-produced and -focused support networks, incorporating the work of Burr0w.i’ The program consisted of six sessions, each lasting approximately 2 hours, 30 minutes. During the first part of each seminar session, nursing staff would explore the issues relating to self-harm. Seminar topics would include why women self-harm, types of women who self-harm, caring for women who self-harm, myths about women who self-harm, and communication issues. Following each session, there would be a reflective practice session, providing the nurses with the opportunity to discuss their feelings and experiences, based on a reflective cycle (Figure 1). During the introductory session, the nursing staff taking part were encouraged to voice their hopes, fears, and aspirations for undertaking this course. The nursing staff taking part in this program were also encouraged to evaluate their learning following each seminar session and to record their thoughts and feelings in a reflective log that they could share, if they so chose, either within the group environment or alone with one of the course facilitators. The inclusion of community-focused discourse on women’s self-harming behavior within the training program was deliberate and done in order to shatter a powerful myth that women’s self-harming behavior is directly attrib-
REA
ET AL: WOMEN
WHO
SELF-HARM
123
Description
What happened?
Action
Plan
Feelings
If if aroseagain what would you do?
What wereyou thinking andfeeling?
REFLECTIVE CYCLE
t
Evaluation
Conclusion
What wasgoodand bad abouttheexperience?
What elsecouldyou havedone? Analysis
What sense canyou make of the situation?
J
Figure 1. Ref2ectivecycleupon
whichreflectivepracticesession following seminarwasbased. utable to involuntary detention within institutions. The training program intended to reinforce how abuse and oppression, which are everyday features of women’s lives, can lead to such severe and harmful behavior. The training package program emphasised the need to hear these women’s experiences and to encourage the nursing staff to listen to the women they are caring for.
CONCLUSION It is not the intention of this article to imply that nurses working within the British special hospital system have no skills to care for women who self-harm. Indeed, there is evidence to the contrary, not least from the women themselves who self-harm, through their anxiety and fear about how they will cope away from the protected and caring environment offered by the special hospital, and other mental health institutions.‘,” Clinical Nurse Specialist Alan Whittle, responsible for the women’s wards at Ashworth, is particularly interested in ensuring a therapeutic milieu for women who are living there. Intensive training and instigation of special observational procedures such as zonal observations have helped to reduce the severity of the incidence of self-harm. Whittle and his colleagues have adopted (insofar as it is possible with this group of women) the suggestions of Burdow’ relating to the frequency and severity of self-harm. They have also adopted the model of reducing severity as the priority for care, with the aim of reducing frequency once targets for severity have been met by the woman concerned. This enables the woman who self-harms to strive to meet realistic goals, and, at the same time, it provides a safe and accepting environment. The use of this training package is, therefore, to reinforce practice and to provide theoretical underpinnings for therapeutic care.
124
WOMEN’S
HEALTH
ISSUES
VOL.
7, ‘JO. 2 MARCH/APRIL
1997
REFERENCES 1. Liebling H, Chipchase H. Research with women who self-harm and training needs of staff who work with them. Special Hosp Res Bull, 1995. 2. Ennis J, Barnes RA, Kennedy S, Trachtenberg DD. Depression in self-harm patients. Br J Psychiatry 1989;154:41-7. 3. Brittlebank AD, Cole A, Hassanyeh F, Kernay M, Simpson D, Scott J. Hostility, hopelessness and deliberate self-harm: a prospective follow up study. Acta Psychiatr Stand 1990;81:280-283. 4. Adshead G. Damage: trauma and violence in a sample of women referred to a forensic service. Behav Sci Law 1994;12:23549. 5. Arnold L. Women and self-injury. Information booklet number 1: understanding self-injury. Bristol (UK): Bristol Crisis Service for Women, 1994. 6. Coppen-Hall K. Naming the effects of child sexual abuse. Health Visitor 1994;67(6). 7. Romans SE, Martin JL, Anderson JC, Herbison GP, Mullen PE. Sexual abuse in childhood and deliberate self-harm. Am J Psychiatry 1995;152:9. 8. Potier MA. Report of a workshop at Ashworth Hospital January 1993: developing a research agenda for women and special hospitals. Special Hosp Res Bull 1993;2: 2-7. 9. Burdow 8. Radical feminist therapy. Thousand Oaks (CA): Sage Publications, 1992. 10. Burrow S. Nursing management of self-mutilation. Br J Nurs 1994;3:382-6. 11. Spender D. Invisible women: the schooling scandal. Psychiatry 1982;161:451-64. 12. Oakley A. Becoming a mother. Oxford: Martin Robertson, 1979. 13. Graham H. Hardship and health in women’s Lives. London: Harvester Wheatsheaf, 1993. 14. Brownmiller S. Against our will: men, women and rape. Penguin Books, 1986. 15. Doyal L. What makes women sick. London: Macmillan Press, 1995. 16. Heidensohn F. Women and crime. London: Macmillan Education, 1985. 17. Bennett LL. Growing up with violence. Can Nurse 1993;89:336.
SUGGESTED Arnold L. Women and gling with self-injury. Arnold L. Women and guide for supporters Service for Women,
READING
self-injury. Information booklet no. 2: a guide for women strugBristol (UK): Bristol Crisis Service for Women, 1994. self-injury. Information booklet no. 3: for friends and family-a of women and girls who self-injure. Bristol (UK): Bristol Crisis 1994.
RE.A ET AL
WOMEN
WHO
SELF-HARM
125
University
Fran Aiken, RMN, MSc Clancy Borastero, RMN Ashworth Ashworth Liverpool,
Centre Hospital England
T
here is a growing recognition that the reasons for women selfharming are complex and, therefore, need to be addressed in a therapeutic milieu. Although self-harming behavior is not restricted to only those women who are involuntarily detained in various institutions, the incidence within such institutions is high. In England, a small number of women will end up detained within maximum security hospitals under the 1983 English Mental Health Act. It can be argued that the reasons for this incidence originate from gender discrimination practices and socially constructed beliefs about what is, or should be, “normal” women’s behavior. Within such environments, however, there is a growing recognition of the relationship between self-harming behavior and previous experiences of abuse and feelings of powerlessness, both in experiencing and dealing with their abuse and in their everyday lives. Much conventional response has been pejorative and punitive, reinforcing socially constructed beliefs about women. A multidisciplinary group of workers within a English special hospital devised a training package aimed at changing and informing staff attitudes toward selfharming behavior and encouraging therapeutic responses and interventions. This article explores the aims and objectives of this package, and the reasons for its implementation, with a group of nurses in the institution who work with women who self-harm. At the end of 1995, members of the Ashworth Centre, the nurse education department of the Ashworth Hospital, were contacted with a view to contributing to a training package to be devised for nursing staff working directly with women who self-harm and were detained in the hospital under the 1983 English Mental Health Act. The training package (copies of which are available from the authors) although initiated by members of the departments of psychology and of reha-
o
1997 by The Jacobs of Women’s Health Published by Elsevier
Institute Science
,049.3867,~7,s17,00 PI151049-3867(96)00112-O
REA
ET AL: WOMEN
WHO
Inc.
SELF-HARM
121
r bilitation at the hospital, was intended to be provided to nurses. The lecturer practitioners of the Ashworth Centre were therefore contacted for their nursing expertise and help. The need for a training package had been identified as a result of workshops run by the Psychology Department for a group of women who self-harm and were currently within the hospital.’
WHY
DO WOMEN
SELF-HARM?
There is a plethora of published information available on why women selfharm.2-7 Some work has focused solely on the reasons women self-harm while detained within the British Special Hospital system.8 The reasons for women self-harming, however, whether out in the community or within a closed environment, have a consistent similarity and, at times, a relationship. For example, women detained in Ashworth cited one of the reasons for self-harming as a fear of being out in the community with little or no resources to help them with their anxiety and anguish.’ The common themes running through the women’s reasons for selfharming were those of histories of abuse and the feelings of powerlessness that the women experienced and still felt. Enforced detention within the special hospital system only added to these feelings, and the inability of the staff to “treat” not only the self-harming behavior both in the women’s past and present but also the underlying causes of the behavior, inevitably led to the continuation of, and in some situations, an increase in, the likelihood of the self-harming activity. Several highlighted classifications of self-harming behaviors have been produced,” and it is not our intention to repeat them here. Indeed, part of the training package for nursing staff would be to identify the range of behaviors, both from personal experience of witnessing and dealing with the outcome of such behavior and also by being directed to the multitude of literature available. Much feminist thought has concerned itself with the effect of patriarchy and oppression on women’s lives.“-‘4 Women within the high-security mental health system and women who self-harm often appear to be the very antithesis of patriarchal beliefs about womanhood. They do not conform to patriarchal beliefs about the passivity of women nor, and often, to the biologically reductionist argument surrounding heterosexuality, motherhood, and the “natural” caring role of women. Listening to the women in Ashworth, one is provided with graphic examples of the effects of oppression and sexism on women’s lives. Common life-themes include abuse, being taken into care, and living in institutions and many “homes”, where they often are subjected to various forms of abuse. As adults, the abuse continues through the hierarchies and male-dominated institutions, such as the medical profession’5 and the courts and legal system.” It was apparent to the three lecturer practitioners that any training package designed for nurses working with women who self-harm needed to include feminist thought, theory, and discourse. The Bristol Crisis Service for Women was an invaluable source of information relating to women and the reasons for their self-harming behavior. In addition, it provided both theoretical and practical information on how to help women who are harming themselves. Although providing literature aimed at informal carers and friends, much of the philosophy and information the literature contained was relevant to nurses, perhaps especially so, in that it could be used to help promote a more person-centered attitude among staff. The nursing staff need to understand that the personal is the political, that the women who self-harm are responding to often horrendous life experiences, 122
WOMEN’S
HEALTH
ISSUES
VOL.
7, NO. 2 MARCH/APRIL
1997
and that their self-harming behavior is, as one writer has commented, “fundamentally a way of living. It is a means of getting through the day.“’ Understanding why women resort to self-harm is the first key step for nurses if they are to help women who harm themselves. Understanding why women behave in this way, accepting their reasons as valid, and not pathologizing their behavior are fundamental objectives of the training package. A further issue that this package hoped to enable staff to explore was that of the transference of the women’s violence onto the nursing staff themselves. The violent propensities that had led to the women being detained at Ashworth are often turned outward toward staff who may be representative of past problems that the women had experienced. The reasons for the women self-harming often include the dominance of older women (ie, parents/carers) as being causative factors,’ that is, the effects of violence on child development, adult women’s relating of the experience of the mother-parent ignoring the child abuse out of feelings of powerlessness or even fear of reprisal.17 It is, therefore, not difficult to understand that when women who have experienced abuse meet with women in positions of power (ie, nurses working in highsecurity hospitals), transference may occur.
THE
STAFF
TRAINING
PROGRAM
The training program provided carefully devised aims and objectives and was intended to be used within an adult learning approach. The intention was to use a seminar format, to be immediately followed by reflective practice sessions, thereby providing the nursing staff with the opportunity to explore how both theoretical constructs and women’s experiences could inform and influence the delivery of care. The aims of the package focused around enabling staff to understand why women self-harm and, through the creation of a positive approach, to support women who are self-harming. Greater knowledge of the reasons why women self-harm should encourage nursing staff to develop therapeutic skills further. The importance of this is reflected in the comments of one member of staff, that caring for women who self-harm involved seeing the self-harming behavior as a tree. Staff could develop competence in dealing with the branches of the tree (ie, the types of self-harm that the women inflicted on themselves) but they also needed to develop expertise and therapeutic skills in helping the women understand and deal with the causes (ie, the trunk and roots of the tree). The training program drew heavily upon community-produced and -focused support networks, incorporating the work of Burr0w.i’ The program consisted of six sessions, each lasting approximately 2 hours, 30 minutes. During the first part of each seminar session, nursing staff would explore the issues relating to self-harm. Seminar topics would include why women self-harm, types of women who self-harm, caring for women who self-harm, myths about women who self-harm, and communication issues. Following each session, there would be a reflective practice session, providing the nurses with the opportunity to discuss their feelings and experiences, based on a reflective cycle (Figure 1). During the introductory session, the nursing staff taking part were encouraged to voice their hopes, fears, and aspirations for undertaking this course. The nursing staff taking part in this program were also encouraged to evaluate their learning following each seminar session and to record their thoughts and feelings in a reflective log that they could share, if they so chose, either within the group environment or alone with one of the course facilitators. The inclusion of community-focused discourse on women’s self-harming behavior within the training program was deliberate and done in order to shatter a powerful myth that women’s self-harming behavior is directly attrib-
REA
ET AL: WOMEN
WHO
SELF-HARM
123
Description
What happened?
Action
Plan
Feelings
If if aroseagain what would you do?
What wereyou thinking andfeeling?
REFLECTIVE CYCLE
t
Evaluation
Conclusion
What wasgoodand bad abouttheexperience?
What elsecouldyou havedone? Analysis
What sense canyou make of the situation?
J
Figure 1. Ref2ectivecycleupon
whichreflectivepracticesession following seminarwasbased. utable to involuntary detention within institutions. The training program intended to reinforce how abuse and oppression, which are everyday features of women’s lives, can lead to such severe and harmful behavior. The training package program emphasised the need to hear these women’s experiences and to encourage the nursing staff to listen to the women they are caring for.
CONCLUSION It is not the intention of this article to imply that nurses working within the British special hospital system have no skills to care for women who self-harm. Indeed, there is evidence to the contrary, not least from the women themselves who self-harm, through their anxiety and fear about how they will cope away from the protected and caring environment offered by the special hospital, and other mental health institutions.‘,” Clinical Nurse Specialist Alan Whittle, responsible for the women’s wards at Ashworth, is particularly interested in ensuring a therapeutic milieu for women who are living there. Intensive training and instigation of special observational procedures such as zonal observations have helped to reduce the severity of the incidence of self-harm. Whittle and his colleagues have adopted (insofar as it is possible with this group of women) the suggestions of Burdow’ relating to the frequency and severity of self-harm. They have also adopted the model of reducing severity as the priority for care, with the aim of reducing frequency once targets for severity have been met by the woman concerned. This enables the woman who self-harms to strive to meet realistic goals, and, at the same time, it provides a safe and accepting environment. The use of this training package is, therefore, to reinforce practice and to provide theoretical underpinnings for therapeutic care.
124
WOMEN’S
HEALTH
ISSUES
VOL.
7, ‘JO. 2 MARCH/APRIL
1997
REFERENCES 1. Liebling H, Chipchase H. Research with women who self-harm and training needs of staff who work with them. Special Hosp Res Bull, 1995. 2. Ennis J, Barnes RA, Kennedy S, Trachtenberg DD. Depression in self-harm patients. Br J Psychiatry 1989;154:41-7. 3. Brittlebank AD, Cole A, Hassanyeh F, Kernay M, Simpson D, Scott J. Hostility, hopelessness and deliberate self-harm: a prospective follow up study. Acta Psychiatr Stand 1990;81:280-283. 4. Adshead G. Damage: trauma and violence in a sample of women referred to a forensic service. Behav Sci Law 1994;12:23549. 5. Arnold L. Women and self-injury. Information booklet number 1: understanding self-injury. Bristol (UK): Bristol Crisis Service for Women, 1994. 6. Coppen-Hall K. Naming the effects of child sexual abuse. Health Visitor 1994;67(6). 7. Romans SE, Martin JL, Anderson JC, Herbison GP, Mullen PE. Sexual abuse in childhood and deliberate self-harm. Am J Psychiatry 1995;152:9. 8. Potier MA. Report of a workshop at Ashworth Hospital January 1993: developing a research agenda for women and special hospitals. Special Hosp Res Bull 1993;2: 2-7. 9. Burdow 8. Radical feminist therapy. Thousand Oaks (CA): Sage Publications, 1992. 10. Burrow S. Nursing management of self-mutilation. Br J Nurs 1994;3:382-6. 11. Spender D. Invisible women: the schooling scandal. Psychiatry 1982;161:451-64. 12. Oakley A. Becoming a mother. Oxford: Martin Robertson, 1979. 13. Graham H. Hardship and health in women’s Lives. London: Harvester Wheatsheaf, 1993. 14. Brownmiller S. Against our will: men, women and rape. Penguin Books, 1986. 15. Doyal L. What makes women sick. London: Macmillan Press, 1995. 16. Heidensohn F. Women and crime. London: Macmillan Education, 1985. 17. Bennett LL. Growing up with violence. Can Nurse 1993;89:336.
SUGGESTED Arnold L. Women and gling with self-injury. Arnold L. Women and guide for supporters Service for Women,
READING
self-injury. Information booklet no. 2: a guide for women strugBristol (UK): Bristol Crisis Service for Women, 1994. self-injury. Information booklet no. 3: for friends and family-a of women and girls who self-injure. Bristol (UK): Bristol Crisis 1994.
RE.A ET AL
WOMEN
WHO
SELF-HARM
125