Focus Assessment Criteria
The nurse must be able to differentiate between the diagnoses of Risk for Suicide and Risk for Self-Mutilation or Self-Abuse. Although initially they may appear (in action) or sound (in statements) the same, the distinction lies in the intent. Self-mutilation and self-abuse are pathologic attempts to relieve stress (temporary reprieve), whereas suicide is an attempt to die (to relieve stress permanently). The nurse will be able in the assessment to gather data that enable him or her to distinguish which diagnosis is appropriate for the client. It is prudent to remember that some clients may become so self-harmful that they eventually die, even though they are not intentionally suicidal.
Assess for Risk Factors
Have you experienced a severe stressor recently?
How are you feeling?
Do you want to hurt yourself?
Can you tell me the reason?
Do you want to die or just have the pain (thoughts/feelings) go away?
Assess for a suicide plan.
Method: Is there a specific plan (eg, pills, wrist-slashing, shooting)? Plans for rescue?
Availability: Is the method accessible? Is access easy or difficult?
Specificity: How specific is the plan?
Lethality: How lethal is the method?
Assess if person is suffering from withdrawal or is under the influence. Chemical use lowers cognition ability and raises the level of impulsivity.
History of psychiatric problems
Previous history of self-harm
Outpatient follow-up support system
Acute or chronic illness—how is it affecting life?
Sources of stress in past environment
Failure in work/school
Threat of financial loss
Death of significant other
Alcohol/drug use in family
Dysfunctional family dynamics
Physical, psychological, sexual abuse
Of child by parent
Of parent by child
Sources of stress in current environment
Any of the above (past environment)
Threat of criminal prosecution
Alcohol/drug use by person
Any threat to self-concept (real or perceived)
Assessment of person’s awareness of self-harm activities
Acknowledgment or denial—does the person admit self-harm or claim to have “accidents”?
What are the payoffs or reasons for self-harm?
Is nonverbal communication—gains someone’s attention and coerces others for their needs
Makes others believe—physical evidence of pain
Demonstrates the feeling of hopelessness
Demonstrates outside what person feels like inside (ugly, scarred, garbage)
Feels he or she deserves it—bad, ugly, evil, crazy
Releases pain and anger—use of self-harm is a safety valve to prevent suicide
(Re)establishes control over one’s body
Verifies there is still life—physical evidence of life in flow of blood
Is sadomasochistic pleasure
Is an addiction to near death
Can the person identify specifics in the process?
Motivation to cease self-harm
Wants to stop and is willing to work toward that end
Wants emotional pain to stop, sees self-harm as part of that pain and is considering change
Unwilling to give up self-harm behavior
Who is relied on during periods of stress?
Personal and financial resources
Assess for Risk Factors
Behavior during interview
Evidence of self-harm
Be highly suspicious if
There have been repeated accidents
Person wears long sleeves in hot weather
Person is reluctant to uncover parts of body
Reddened, irritated areas
Areas that do not heal as expected
Clumps/patches of missing hair
Body parts often affected
Wrists, arms, legs, feet
Head, face, eyes, neck
Behaviors of self-mutilation
Hitting (eg, fists against walls)
Burning (cigarettes, lighters, matches, stove, clothes iron, curling iron)
Use of corrosives (eg, drain cleaner)
Behaviors of self-abuse
Nonlethal use of drugs/poison
Swallowing foreign objects (glass, needles, safety pins, straight pins, various hardware [eg, nails, screws])
Noncompliance with treatment for serious physical or medical conditions (eg, diabetes)
Establish a Trusting Nurse–Client Relationship
Demonstrate acceptance of client as a worthwhile person through nonjudgmental statements and behavior.
Ask questions in a caring, concerned manner.
Encourage expression of thoughts and feelings.
Actively listen or provide support by just being there if the person is silent.
Be aware of the client’s supersensitivity.
Label the behavior, not the person.
Be honest in your interactions.
Assist client to recognize hope and alternatives.
Provide reasons for necessary procedures or interventions.
Maintain client’s dignity throughout your therapeutic relationship.
Schizophrenia or Drug-Induced Psychosis
Tell the person “you are safe.”
Use quiet, calming voice.
Use “talk downs” when client has taken a hallucinogenic drug. If agitation increases, stop immediately.
Orient client as required. Point out sensory/environmental misperceptions without belittling his or her fears or indicating disapproval of verbal expressions.
Reassure client that this will pass.
Watch for signs of increased delusional thinking and/or frightening hallucinations (increased anxiety, agitation, irritability, pacing, hypervigilance).
Post-Trauma or Dysfunctional
Tell the person “you are not bad, crazy, hopeless.”
Say you believe him or her when he or she tells you personal history; many grew up in denial or minimization.
Let the person know he or she is not the only one.
Help Reframe Old Thinking/Feeling Patterns (Carscadden, 1993a)
Encourage the belief that change is possible.
Assist client to identify thought–feeling–behavior concept.
Help client assess payoffs and drawbacks to self-harm.
Rename words that have a negative connotation (eg, “setback,” not “failure”).
Encourage identification of personal triggers.
Assist client to explore viable alternatives.
Help client to examine feelings of ambivalence about recovery.
Encourage client to become comfortable with and to use feelings.
Facilitate the Development of New Behavior
Validate good coping skills already in existence.
Serve as a role model in your own behavior and interactions.
Encourage the use of positive affirmations, meditation and relaxation techniques, and other esteem-building exercises.
Promote the concept of being helpful instead of helpless.
Encourage journaling, keeping a diary of triggers, thoughts, feelings, and alternatives that work or do not work.
Assist client to develop body awareness as a method of ascertaining triggers and determining levels of impending self-harm.
Assist with role playing to work on situations/relationships.
Promote development of healthy self-boundaries for the person.
Endorse an Environment that Demotes Self-Harm
How much control or influence a professional exerts in this area will depend on the diagnosis, the environmental setting, and the policies of that setting (eg, a person’s home, residential setting, treatment facility, or institution). If mandated by the setting’s policies to intervene in self-harm attempts, then the following interventions should take place.
Structure the Client’s Time and Activities
Provide a scheduled day that meets the person’s need for activity and rest.
Encourage assistance to and activities with others without competitiveness.
Relieve pent-up tension and purposeless hyperactivity with physical activity (eg, brisk walk, dance therapy, aerobics).
Reduce Excessive Stimuli
Provide a quiet, serene atmosphere.
Establish firm, consistent limits while giving person as much control/choice as possible within those boundaries.
Intervene at earliest stages to assist person to regain control, prevent escalation, and allow treatment in the least restrictive manner.
Keep communication simple. Agitated people cannot process complicated communication.
Provide an area where the person can retreat to decrease stimuli (eg, time-out room, quiet room; person on hallucinogens needs a darkened, quiet room with a nonintrusive observer).
Remove potentially dangerous objects from environment (if in crisis stage).
Reduce Triggers as Much as Possible
Assess problem areas and assist in problem solving with the client.
Promote the Use of Alternatives
Stress that there are always alternatives.
Stress that self-harm is a choice, not something uncontrollable.
Allow opportunities for verbal expression of thoughts and feelings.
Provide acceptable physical outlets (eg, yelling, pounding pillow, tearing up newspapers, using clay or Play-Doh, taking a brisk walk).
Provide for less physical alternatives (eg, relaxation tapes, soft music, warm bath, diversional activities).
Determine Present Level of Impending Self-Harm if Indicated
Beginning Stage (Thought Stage)
Provide soothing touch if permitted by person (predetermined).
Remind person that this is an “old tape” and to replace with new thinking and belief patterns.
Provide nonintrusive, calming alternatives.
Climbing Stage (Feeling Stage)
Remind person to consider alternatives.
Give as much control to the person as possible to support his or her accountability.
Provide more intense interventions at this stage.
Encourage person to turn over any potential items of self-harm.
Crisis Stage (Behavior Stage)
Give positive feedback if person chooses an alternative and does not harm himself or herself.
Ask person to put down any object of harm if he or she possesses one.
Continue to emphasize there are always alternatives.
Restrain only if person becomes out of control.
Release from restraints as soon as possible to give responsibility back to person. “Are you in control now?” “Are you feeling safe?”
Remain calm and caring throughout the crisis period.
Attend to practical issues in a nonpunitive, nonjudgmental manner.
Give positive reinforcements if person did not harm himself or herself.
Assist client to problem-solve on how to divert self before crisis stage.
Assess degree of injury/harm if person did not choose alternative.
Provide assistance or medical care, as necessary.
Pay as little attention as possible to the act of self-harm and focus on prior stages (eg, “Can you remember what triggered you?” “What kinds of things were going through your mind?” “What do you think you might have done instead?”).
Return person to normal activities/routine as soon as possible.
Initiate Support Systems to Community, When/Where Indicated
Constructive expression of feelings
How to recognize levels of impending self-harm
How to assist with appropriate interventions
How to deal with self-harm behavior/results
Supply Phone Number of 24-h Emergency Hotlines
Provide referral to: