Qualitative Study Review: Triggers for Self Abuse

Title: executive summaries of specified papers

Triggers for self abuse; A qualitative study, Mary T Weber, Archives of psychiatric nursing, Volume 16, Issue 3, June 2002, Pages 118-124.

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This paper is essentially a qualitative study of a small cohort of 9 self abusing women. It was constructed using an analysis of a total of 42 semistructured interviews and attempting to draw out common themes.

It has to be observed that this is a very specific cohort and probably cannot be extrapolated to reflect the trends in the general population, as this particular group were all in a locked psychiatric ward in the USA. The paper is essentially divided into three sections. The first is a resume of the background to academic studies of self injury, the second is a justification and explanation of the methodology used in the study and the third is an analysis of the data which ends with a discussion of the findings.

An analytical overview would have to observe that the observational viewpoint in this paper is that of the social constructionist feminist. Although the paper sets out to be semi structured in its intervention, it appears clear that the interviewer is overtly active and sets out the parameters of the topics to be discussed and observes the fact that the “reality ….is jointly constructed.” (Parker and Lawton 2003)

The author clearly has an agenda in this paper and, to some extent this is presented in the discussion section. She believes that women who self harm are often considered to be manipulative and do not evoke sympathy from healthcare professionals. The author puts the point that it is by the examination of the aspect of “hope” in their lives that these women can be optimally helped.

This is clearly not a quantitative examination of the issues and might reasonably be considered more of an essay on the subject rather than an investigation into it. Although the outcomes presented are probably both laudable and admirable, the use of this paper as an evidence base for practice is effectively limited to consideration of this particular author’s opinion. (Henriksen et al 2003)

We could contrast this paper with the excellent monograph on the subject by Isacsson G and Rich CL (2001), two professors who offer their opinions (backed up with appropriate references to academia) on the management of the self harming patient. In essence their overview sums up their views that:

Patients who deliberately harm themselves should be assessed as comprehensively and thoroughly as possible, including the risk for suicide
A multidisciplinary team approach to assessment and management is optimal
A psychiatrist should be involved in the evaluation
Management should be individualised on the basis of the assessment; mostly treatment for associated psychiatric disorders and assistance with precipitating circumstances
Patients accepting offers for help should be followed up quickly.

We would suggest that this latter paper provides a much better evidence base for practice in the nursing profession.

Psychosocial and pharmacological treatments for deliberate self harm {Review} Hawton k, Townsend E, Arensman E, Gunnell D, Hazell P, House A, van Heeringen KThe Cochrane Database of Systemic Reviews 2005 Issue 4.

This paper is effectively a meta analysis of 23 studies in the area of self harm. It takes a wide database of papers published prior to 1999 from as far back as 1966. This paper is completely at the other end of the spectrum to the first one considered. It is both valid and relevant to everyday clinical practice.

The construction of the analysis is rigorous and methodical. It divides the various studies considered into 11 different subsets depending on the outcome variables declared. This reduces its ability to generalise, but equally increases its ability to be statistically valid. In terms of an evidence base. The first half of the paper is little more than an explanation of the search and inclusion strategy for the analysis

The overriding finding of the paper is that there is still insufficient research on the subject of self harm to allow the healthcare professional to feel confident of a secure evidence base (Mohammed, D et al 2003) and it calls for more large and well constructed trials to be done in the area.

It points to the fact that a great many of the trials published did not have a sufficiently large entry cohort to allow strong statistical analysis to be made. One of the benefits of a meta analysis is the fact that it can gain statistical validity from the assimilation of many smaller trials, but in this case, because the authors subdivided their considerations into 11 different subsets, this benefit is greatly reduced. (Grimes DA et al. 2002)

As for conclusions, the authors make a very self effacing statement that even their meta analysis does not provide a sufficient evidence base for effective forms of treatment of deliberate self harm. The implication of this statement is that, if this analysis cannot add to the evidence base, then the smaller, less statistically significant trials that it considered cannot do so either.

This view is echoed by another meta analysis paper (Healy D 2002) which we can present in support of this particular paper

Cognitive-behavioural intervention in deliberate self-harm, Anthony Joseph Raj M, V Kumaraiah, Ajit V Bhide, Acta Psychiatrica Scandinavica, Volume 104, Issue 5, Page 340, November 2001.

This paper is entirely different from the preceding two. It is a randomised controlled trial with a small entry cohort of 40 patients split into a treatment and a control group of 20 patients each. Clearly this is a very small sample and the site of the trial is in India so it may not have a great relevance to the UK culture. (Veitch RM 2002)

The first part of the paper gives an excellent overview of the evolution of various treatment strategies together with an indication of their relative efficacy. A noticeable strength of this trial was its robust measurement strategy with ten different measurement scales being employed to minimise observer bias. (Cochran and Cox. 1957)

A major shortcoming of this trial is that it attempted to contrast a number of different intervention strategies within the already small intervention cohort. The results therefore cannot really be seen as having any great generalisable significance. It may provide useful information, but as being suitable for inclusion in a firm evidence base, it could be considered sadly lacking. If we contrast this with the paper by Soomro, (Soomro GM 2004) which considers the efficacy of various aspects of cognitive behaviour therapy in the self harm group we can see that the latter’s entry cohort of nearly 500 has a much greater statistical significance and therefore a much greater relevance.

Methodological issues in nursing research, Nurses attitudes towards clients who self-harm, McAllister A, Creedy D, Moyle W, Farrugia C, Journal of advanced nursing Volume 40, Issue 5, Page 578, December 2002.

In many respects, this paper is a combination of many of the elements that we have discussed in the preceding three papers. It is designed to explore the attitude that receiving nurses have in the A&E dept, when they deal with patients who have self harmed.

Paper 1 (Weber M 2002) made the unsupported statement that nurses are less than empathetic when dealing with the self harm patient. This paper presents the evidence base behind this assumption. There is a section which reviews previous work in the area and comments on the rather counter intuitive fact that mental health professionals (who might be expected to me more empathetic and understanding) tend to be less tolerant and supportive as they typically see this type of patient as being primarily manipulative. (Anderson M 1997)

The professed aim of this study was to allow the development of a suitable tool in the form of a questionnaire. It was structured with three distinct elements. Firstly was the literature review (which we have already alluded to). Secondly they canvassed the opinions of a group of 10 post graduate nurses to set the baseline of nursing attitudes. This was used as the basis for the third element which was the construction and evaluation of a questionnaire.

This was drafted in the form of the ADSHQ questionnaire.

We should note that only 35% of the questionnaires were returned which is a major source of bias, since one might assume that the few respondents were those that felt strongly enough to respond and therefore their views, by definition, may not be typical. A strong point in this survey’s favour was the fact that those who did respond had an average of 17 years of nursing experience.

The results of the paper were rather disappointing with no significant correlation being found between attitudes and the many variables investigated. The only statistically significant finding was that staff in larger units tended to be less empathetic than those in smaller ones.

It should be noted that a negative finding, although superficially disappointing, can be just as significant as a positive one as the implication here is that there was no discernible predictive factor in a nurses’ attitude towards self harming patients.

This paper can be contrasted with findings in similar studies

House A (et al. 2000) supports the findings of negative attitudes of staff but is more of a discussion document than a study of enquiry.

Wilhelm K et al 2000) is primarily a paper which explores the efficacy of the interventions for self harming patients but makes considerable academic comment on the relevance of the nurses’ attitude to the efficacy of the treatment. We should also note that, like the original paper, it also originates from Australia.

Mckinlay A (et al 2001) takes the issue and looks deeper into the reasoning and rationale behind the negative attitude and makes a number of positive suggestions relating to the mechanisms of corrective action to remedy the situation.


Anderson M 1997, Nurses’ attitudes to suicidal behaviour, Journal of advanced Nursing 25, 1283-1291

Cochran and Cox. 1957, Experimental designs. New York: Wiley, 1957.

Grimes DA, Schulz KF.2002, Cohort studies: marching towards outcomes. Lancet 2002;359: 341-5

Healy D 2002, SSRIs and deliberate self-harm, The British Journal of Psychiatry (2002) 180: 547-548

Henriksen and Kaplan 2003 Hindsight bias, outcome knowledge and adaptive learning Qual. Saf. Health Care, Dec 2003; 12: 46 – 50.

House A, Owens D, Patchett L, Deliberate Self harm, Qual. Health care 2000. 8: 137-143

Isacsson G, Rich CL 2001, Management of patients who deliberately harm themselves, BMJ. 2001 January 27; 322(7280): 213–215.

Mohammed, D Braunholtz, and T P Hofer 2003 The measurement of active errors: methodological issues Qual. Saf. Health Care, Dec 2003; 12: 8 – 12.

Mckinlay A Coulston M, Cowan S 2001, Nurses’ behavioural intentions towards self-poisoning patients: a theory of reasoned action, comparison of attitudes and subjective norms as predictive variables, Journal of Advanced Nursing Volume 34 Page 107 – April 2001

Parker and Lawton 2003 Psychological contribution to the understanding of adverse events in health care Qual. Saf. Health Care, Dec 2003; 12: 453 – 457.

Soomro GM 2004, Deliberate self harm (and attempted suicide): Manual assisted cognitive behavioural therapy, Psychol Med 2004;33:969–976.

Veitch RM 2002, Cross-cultural perspectives in medical ethics, Jones & Bartlett 2002 ISBN: 0763713325

Wilhelm K, Schneiden V, Kotze B 2000, Selecting your options: A pilot study of short interventions with patients who deliberately self harm, Australasian Psychiatry. Volume 8 Page 349 – December 2000


13.2.06 PDG Word count 1,989

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