Implications for Measuring Outcomes & Service User Satisfaction

The purpose of delivering any intervention is to effect change for the better and to demonstrate this it is crucial to identify agreed outcome and satisfaction measures. Attempts to do this in relation to caring for people who self-harm have used frequency and/or severity of the act as a measure of success or otherwise and are reported in the literature. To illustrate this, Bateman and Fonagy’s (2001) study can be drawn upon which uses hospitalisation, incidents of self-harm and attempts at suicide as outcome measures. Yet Turp’s (2003) urge to consider the underlying state of mind behind acts of self-harm would be neglected in this way. Particularly as it is important to be mindful that for children and young people self-harm can serve a positive and worthwhile function and therefore is not always a product of distress (Bywater and Rolfe 2005; Smith,2002).

Further comment regarding the use of self-harm as an outcome measure may be found in Allen (2007) where it is argued that someone who has sought therapy may experience an increased frequency and/or severity of self-harm due to the exploration of difficult material,

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but this does not mean that undergoing therapy is not a positive step in the long term. It is also pertinent to reflect on personal experience of working with people who use services and which illustrate how self-harm may manifest in other ways, for instance limiting nutritional intake rather than cutting (Allen, 2007).

To further progress this point, where self-harm is prevented, for instance when experiencing in-patient care, it may be possible to conclude that this has been an effective strategy if focus is placed on the incidence of self-harm. However, if a loss of control and disempowerment are the by-products of this it can be argued that the intervention has clear limitations.

This is not the only issue to bear in mind here, evidence given to the national Inquiry into Self-harm by young people indicated that social isolation, feelings of shame and guilt and a reduction in choice and control were particular difficulties that were more likely to lead to young people attempting to end their life (MHF:CF, 2006). Additionally, the inquiry found direct evidence that if the focus of care is on self-harm, rather than underlying causes it can leave young people with no choice but to self-harm again (MHF: CF, 2006).

As such, interventions which are overly controlling and fail to engage with the complexity of self-harm risk doing more harm than good and focusing on the self-harm risks the dehumanising objectification of an individual whose identity is defined by far more than their relationship with self-harm. (Mental Health Foundation & Camelot Foundation, MHF:CF 2006).

Given this it is important to acknowledge the part that self-harm has played in the young person’s life but to refrain from using it as an outcome measure unless this is something that the individual sees as useful (Allen, 2007). To achieve this ways to gauge progress using the goals and measures formulated by the young person themselves are important and likely to lead to a more meaningful interpretation of progress (Allen, 2007).

This is particularly important when considering the experiences reported by people who use or have used services;

“Psychiatric hospitalisation only compounded my need to harm myself, and the response from staff was frequently angry and hostile...One doctor would stitch wounds which extended to the bone of my arm with just a skin suture, not bothering to repair the underlying layers.

As the verbal humiliation and hostility increased with each visit to A&E, I became

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increasingly reluctant to attend for fear of the response I would get.” (Pembroke, 2007 p163).

Warm et al (2002) evaluated levels of service satisfaction received by people who self-harm and found that medical personnel were rated most poorly, whilst self-harm specialists were deemed to be the most satisfactory. That said it may not be unreasonable to suggest that it is the response of the worker that is crucial as opposed to the nature of the service. This was argued by Skegg, (2005) who stated that the quality of the relationship with the helper is the most pivotal contributor to outcome.

With this in mind, Allen (2007) urges an individualised approach which was also stressed by Webb (2002) and Crowley et. Al (2003) who contend that self-harm and suicidality in children and young people is often/mostly a psychosocial issue, often requiring a non psychiatric, pragmatic resolution of the precipitants and triggers. It is therefore not unreasonable to suggest that by embracing such an approach, a positive outcome and satisfaction may be experienced and benefit the young person.

Such thoughtful reactions are important when it is borne in mind that adult responses to disclosures of self-harm can compound feelings of shame (MHF:CF,2006). This may impact on accessing services as described by Rissanen et al (2009) who found that shame and guilt actively inhibits children and young people from seeking help for their self-harm and associated problems.

Containing the young person’s worries and concerns is only possible if the worker is also contained. As such, any focus on outcome and satisfaction that neglects the worker in this process would be remiss. With this in mind, outcome and satisfaction measures should also be applied to those who have worked directly with young people who self-harm. Rayner, et al (2005) make the case for workers to have a place to air their concern and success and where the issues stirred up as countertransference may be explored and relived thereby enabling the worker to remain resourceful. As such, the need to remain engaged and thoughtful is only possible if the worker is supported and in nurturing a positive outcome and satisfaction for the benefit of the young person, should also include the workers evaluation as one component in the overall delivery of a quality service.

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10. Training and Education Issues for Primary Care Staff and the Interface between