Principles and strategies for teaching therapeutic responses to self-harm

MCALLISTER M. & ESTEFAN A. (2002)

Journal of Psychiatric and Mental Health Nursing

9,

573–583

Principles and strategies for teaching therapeutic responses to self-harm


, 2002,

9

, 573–583

©

2002 Blackwell Science Ltd

573

Blackwell Science, LtdOxford, UKJPMJournal of Psychiatric and Mental Health Nursing1351-0126Blackwell Science Ltd, 20029525Therapeutic responses to self-harmM. McAllister and A. Estefan10.1046/j.1351-0126.2002.525.doc.xOriginal ArticleBEES SGML

Principles and strategies for teaching therapeutic responses to self-harm

M . M C A L L I S T E R

1

r n

e

d

d

& A . E S T E F A N

2

r n

b n

1

Senior Lecturer, School of Nursing, Griffith University, Brisbane, and

2

Nurse Educator, Greenslopes Private Hospital, Greenslopes, Queensland, Australia

Correspondence:

Margaret McAllister

School of Nursing

Griffith University

Nathan, 4111

Queensland

Australia

This paper explains the educational principles and strategies underpinning a nursing

course offered at an Australian university. The course is entitled ‘Self-harm and thera-

peutic responses’ and explores contemporary theories and practices to improve under-

standing and responses to people who self-harm. The course aims to shape the practices

of nurses in developing healthier clinical and social environments for people who self-

harm.

Keywords

: education, self-harm, teaching

Introduction

Self-harm, defined as any intentional damage to one’s own

body without a conscious intent to die, is a major problem

in society. Deliberate self-harm can be thought of as an

extreme coping mechanism that occurs in response to feel-

ings or memories that are overwhelming. According to Wil-

helm

et al.

(2000), approximately 4% of the population

self-harms and it is one of the top five causes of acute med-

ical admission for adults.

Lack of sufficient health carer education and training

obviously undermines the client’s opportunity to access

high quality, effective healthcare. It also has damaging con-

sequences. Unskilled health carers might abandon clients,

leaving them alone and unsupported at a time when they

have a high need for nurturance and empathy. Health car-

ers might also compensate for their own feelings of loss

of control by providing excessive control over clients, for

example putting them on a suicide watch, detaining them

involuntarily, restraining or sedating them. Carers also

indirectly convey to clients that there is no health expertise

available to help them, and as a result clients leave the ser-

vice before consultation is complete and are frequently lost

to follow-up (Dennis

et al.

1990). One can see therefore

how the spiral of repeated self-harm unfolds.

Whilst nurses are not the only health carers who are

called to respond to people who self-harm, they are impor-

tant players. Consumers identify nurses as the key people

with whom they have contact (Horsfall & Stuhlmiller

2000). They are also the healthcare professional most likely

to be positioned to provide empathy, nurturance and refer-

ral information (Stein-Parbury 2000). Further, nurses are

the healthcare workers who are most consistently and

intensely involved in emergency department care. Emer-

gency nurses are called to provide triage to ensure accurate

referral and prompt response to and containment of the

problem, first aid and more advanced interventions, psy-

chosocial support, and coordinate discharge or referral

services. Mental health nurses are called to provide psycho-

social, risk and mental state assessment and to engage and

motivate the client to engage in longer-term therapeutic

work. Clearly there is much that nurses need to know in

order to efficiently and effectively respond to clients who

self-harm. Yet in a recently completed Queensland survey,

Accepted for publication

: 1 August 2001

M. McAllister and A. Estefan

574

©

2002 Blackwell Science Ltd,


9

, 573–583

McAllister

et al

. (2001) found that most nurses have

received no formal education in relation to self-harm.

The course

In 2000, the first author established a curriculum working

party comprised of community workers, nurses, consum-

ers, academics and students to oversee the development of

a new core course offered within a Graduate Certificate of

Mental Health, and as an elective within all programmes

offered by the School of Nursing, Griffith University in

Brisbane. This 10 credit point course involving 42 hours of

teaching over a semester, was written to appeal to under-

graduates and postgraduates of nursing and related health

disciplines. It contains two levels of assessment so that

undergraduates are challenged to describe and apply

learning and postgraduates are challenged to synthesize,

explain, apply and extend knowledge. An experienced cli-

nician/nurse educator and current postgraduate student

(the second author) was invited to co-convene the under-

graduate element of the course. This arrangement offered

mentorship and collegiality and assisted in the development

of creative teaching strategies and greater student support.

After gaining approval through university committees,

acquiring and developing learning material and promoting

the course to local health services, the first class was offered

in the first semester of 2001. A class size of 15 comprised

four males and 11 females, of which nine were undergrad-

uates and six postgraduates. Content and processes of

learning for the course were collaboratively decided draw-

ing upon the first author’s current research into self-harm

and teaching expertise, as well as the expertise of consum-

ers and community workers experienced with the issues of

deliberate self-harm. The course was organized to comprise

preparatory activities, intensive teaching and learning in

classroom contact delivered singly or in a teaching team by

the authors, and post-class extension activities. Students

were given a study guide containing the preparatory and

extension activities and purchased a book of readings. The

course was run in flexible mode, which meant that students

met in the first week of the semester to discuss the course

goals, teaching and assessment activities and to receive a

study guide and book of readings. The study guide con-

tained readings and activities designed to be completed

prior to, during and after the forthcoming week of work-

shops. Throughout the intensive week of contact, students

were given handouts such as brochures or interview check-

lists and encouraged to file them carefully so that they

could become an education and change resource for their

future practice.

Student learning was assessed formatively through the

request for input on activities they had completed in the

study guide, quiz games, short answer reflections at the end

of a session and question-posing throughout interactive

sessions. Undergraduate students were required to com-

plete an exam and an essay discussing contemporary issues

in relation to self-harm and therapeutic responses. Post-

graduate students were required to complete the same

exam, and undertake a case study that required analysis of

practice and an essay that required the student to draw

comparisons of various treatment approaches.

Educational principles

Critical education

The teaching team set out to develop a curriculum that

would provide opportunities for healthcare professionals

to gain the knowledge, skills and attitudes to be effective

helpers and critical thinkers, whether they be generalists

or mental health nurses. Our shared view was that there

is much more to learning than that which is explicitly

taught. The hidden curriculum (Giroux 1981), or that

which is learned implicitly through role modelling, per-

sonal insight development and peer interaction, is also

important in learning requisite knowledge, attitudes, val-

ues and skills.

The authors share the view of critical educationalists,

who believe that authoritative educational structures are,

by their nature, oppressive (Freire 1972, Giroux 1981). As

Giroux (1981, p. 83) declared: ‘The content of classroom

instruction must be paralleled by a pedagogical style which

is consistent with a radical political vision’.

Critical education is that which sets out to enable and

empower. It is also explicitly idealistic. Thus, in this course

we consciously aimed to engage students in learning: the-

ory applied to life and work; how to live more democratic

lives and to work with clients in more democratic ways;

to develop a critical consciousness; and to become self-

reflective critical thinkers. The team determined to enact

what Freire (1972) termed conscientization. Conscientiza-

tion refers to the development of a critical consciousness

demonstrated in authentic, reflective actions, not just reac-

tive, automatic behaviours. It was used to assist students to

become critical of dominant ways of thinking rather than

passively accepting, and to make a conscious effort to use

knowledge to help people live more liberated lives.

In practical terms, the focus of teaching was to show

the ways theoretical issues (see Fig. 1) were lived out in

practice, to provide vivid, memorable examples of how

understanding, insight development and good treatment

mattered for clients and changed peoples’ lives. We wanted

to impress upon students, and to help them believe in, their

power to change practices.

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Therapeutic responses to self-harm

The team planned strategies to engage students in dis-

cussion of their own experiences, and to regularly draw

upon examples they themselves had raised. In this way we

valued their personal knowledge and helped them trans-

form it from being uncritical knowledge, to that which was

theorized, interpreted, and more deeply understood. The

importance of reflection was explicitly reinforced, role

modelled and actively encouraged. Through reflection on

practice, and articulating thoughts and feelings, we

believed students would have opportunity to clarify their

attitudes, knowledge and values. In this way students sur-

faced intuitive knowledge, thus opening them up to the

possibility of increased self-awareness and self-efficacy.

Another issue central to conscientization is dialogue

(Freire 1972). Dialogue enables the building of connection

between people. It further disseminates insights and can be

a motivator for solidarity, carrying the potential to unite

previously separated individuals, motivate collective action

and reinforce a commitment to change. Dialogue builds

connection between people. It makes public, private

thoughts and reflections, opening ideas up to scrutiny, chal-

lenge and revision. As dialogue was seen as crucial to a crit-

ical education, the teaching team made a concerted effort

to engage in dialogue at multiple levels: with community

workers and consumers in order to plan the curriculum;

with each other as teaching colleagues both within the

classroom and in discussions following; and with students

who were frequently involved in group activities and mean-

ingful dialogue related to learning. The students were also

engaged in fun activities such as film viewing, and memory

games that helped to build a sense of cohesion, connection

and shared commitment. Dialogue was also promoted as a

Figure 1

Educational aims

Contemporary

theories and

practices

Patterns and theories of self-harm: as a disorder of biology,

psychology, social and community function, bio-social theory

(Linehan 1993), psychodynamic theory (Freud 1935) and

cultural theory (Favazza 1996)

Assessment of: mental state, psychosocial and risk assessment

Contemporary

theories and

practices

Patterns and theories of self-harm: as a disorder of biology,

psychology, social and community function, bio-social theory

(Linehan 1993), psychodynamic theory (Freud 1935) and

cultural theory (Favazza 1996)

Assessment of: mental state, psychosocial and risk assessment

protocols; BASK model (Braun 1987); needs and strengths

(Rawlins et al. 1993)

Therapeutic framework: C.A.R.E. (McAllister, personal communication)

Therapeutic communication (Heron 1990)

Safety: conflict theory, responding to and preventing

aggression/acting out (Geen & Quanty 1997)

Awareness raising: reflexive and dialectic critique (Streubert &

Carpenter 1999)

Legal issues: duty of care, provision of safety, assessment of risk,

follow-up

Service innovations: clinical pathways for self-harm; emergency

contact card consultation liaison, clinical supervision

Attributes

Skills

Efficient, effective, empathic, caring, ethical, informed, assertive

culturally sensitive, empowering, enabling

Accurate assessment of first aid needs

Accurate assessment of risk

What to do in an emergency

What not to do

Containment and safety

Engagement: compassion, empathy, active listening

Resilience: building of strengths and social connections, refocus on

abilities, community development


576

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useful tool in conducting patient assessments. Teachers

used the metaphor of ‘interrogation’ to critique the style of

health assessment interviews, which privilege the clinician’s

knowledge and silence and depersonalize the patient’s.

‘Dialogue’ became a useful alternative metaphor to imagine

the assessment interview and for therapeutic interactions

which follow (Tiberius 1986).

Another key point about critical education is that dom-

inant knowledge tends to be used to oppress the subordi-

nated (Cheek & Rudge 1994). Further, Freire (1972, p. 23)

offers the notion of the oppressed ‘housing’ the oppressor,

which means that oppressed people adopt the characteris-

tics of their oppressors in the belief that they will have

access to power. Similarly, oppressed nurses may seek to

become the oppressor as a means to experience some sense

of control over an often overwhelming or insoluble situa-

tion with a client who, for example, repeatedly self-harms.

The teaching team wanted students to become aware of

this paternalistic practice and so become sensitive to the

common complaint consumers have about their experience

with alienating, depersonalizing health service profession-

als (Arnold 1994). With increased awareness of how health

practices can be oppressive, the teaching team aimed to

prevent nurses from themselves becoming oppressors, and

to feel a sense of belonging with their nursing colleagues.

Making spaces for learning

In order to enhance this sense of belonging, to build self-

efficacy and belief in the valuable role of the nurse, the

team emphasized and developed learning processes. A

number of spaces in which learning and development could

potentially take place were considered to include: physical,

intellectual, emotional, social and spiritual spaces. In the

team’s view, these spaces needed to be widened and nur-

tured in order to enhance their potential to educate and

develop students.

Teaching the subject in an auditorium made physical

space. Rather than intimidating students and teachers, the

teaching team used it to our advantage. The large space

enabled students to group together, to interact and also to

seek time away from others if that were needed. Frequent

breaks were taken to provide the opportunity to both

reflect on content and also to put some distance between

themselves and the issue of self-harm, albeit for short

periods.

Intellectual spaces were created through a process of

scaffolded learning and validation (Spouse 1998). Scaf-

folded learning draws upon Vygotsky’s (1962) social con-

structivist theory in education, which suggests that a

learner has increased need for support structures when the

subject matter is new to them, and when they are at their

most dependent. Like building scaffolding, as the structure

(in this case the student) becomes more sturdy or confident

with learning, the support structures are gradually

removed. Scaffolding was seen as the provision of strong

supports such as encouragement, structure, guidance and

direction provided by teachers at the outset, and gradually

removed as students became more confident, active learn-

ers. Offering reassurance, praise and acknowledgement of

the merit of all contributions, suggestions and questions

provided validation. Early content and discussion elicited

the current resting knowledge of students and provided a

relaxed introduction to the subject matter. Crucial concepts

were explored simply at first and gradually expanded as the

teaching progressed. For example, students were briefly

introduced to the six-category assessment model, which

shows students how to communicate and respond strategi-

cally with clients. Students practised it with each other.

Later, dialectical behaviour therapy (DBT), an approach

that is explained later in this paper, was overlayed onto this

model, by explaining how dialectics can become part of

this strategic communication (Linehan 1993). This enabled

students to place those previously learned new interactive

skills into a dialectical framework, which can be helpful for

those with borderline personality disorder, many of whom

self-harm (Everett & Gallop 2000). These kinds of scaf-

folded and validating learning had the effect of creating

safe spaces for learning as well as creating intellectual

spaces, engaging students and inspiring them to look with

eagerness for greater complexity in content and skills

practice.

Emotional spaces were provided through frequent

reflection, validation and acknowledgement of the emo-

tional investment both nurses and clients possess in rela-

tion to self-harm. Furthermore, in order to increase the

sense of safety within discussions and lectures, students

were given prior notice of any topic material that might

cause distress.

Social spaces were developed using an informal teaching

style. The teaching team modelled conversation and reflec-

tion on dilemmas of practice. In this way, the team sought

to demonstrate that multiple perspectives on issues were to

be respected and invited. The teaching team recognized the

potentially confronting nature of group-work and intro-

duced it slowly. For example, the first group exercise

required students to clinically problem solve, which drew

upon familiar skills and required no self-disclosure. Later

exercises invited sharing of personal experiences. The team

noted that even the most reserved student contributed and

students were validating each other’s opinions.

Spiritual spaces were conceptualized as opportunities

to search for meaning and deeply interpret people’s moti-

vations for self-harm and individual paths to coping and

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recovery. Rather than conceptualize spirituality as rela-

tionship with God or the cosmos, the team used the broad

notion offered by Dyson

et al.

(1997) to encompass all

experiences where one has a sense of one’s place in the

world. Spirituality might therefore involve searching for

meaning and worth, finding value in past experiences,

searching for meaning in the future and accepting one’s

connection with others in the world. Spiritual spaces were

created for students throughout the week by using

excerpts from biographies, consumer stories and clinical

reflections on how individuals construct meaning in their

lives. This space began to be used by students when they

reflected on motivations of self-harm and the effect their

new learning was having on them as practitioners and

individuals.

As students worked through these questions, the teach-

ers saw an interesting phenomenon occur. At the com-

mencement of the teaching week, students were asked to

review a case study and provide a character analysis of the

client. There was clearly some caution in the students

undertaking this exercise, and many responses were rather

‘textbook’ in nature. Many responses advocated actions

that emphasized control of the client. For example, state-

ments like ‘the client should be helped to’ and ‘They just

need to’ were used. However, by the end of the week, stu-

dents’ comments indicated they were more willing to allow

themselves to be guided by clients in negotiating treatment

options.

A wellness framework

There are many useful nursing models that provide a

framework for nursing responses (Orem 1985, Johnson

1993, Watson 1999). Within these models a person’s

strengths are one element to consider in helping a client

recover from an illness. Salutogenesis on the other hand, is

a theory that concerns itself less with illness and more with

health (Antonovsky 1987). The salutogenic perspective

‘propels the nurse to focus on strengths, capabilities,

achievements and personhood’ (Horsfall & Stuhlmiller

2000, p. 93) and is the key to maintaining wellness and

building resilience in a person recovering from trauma and

self-harm. This theory was used as the basis for all teaching

within the subject. Students were encouraged to uncover

and consider the client’s strengths in conjunction with

using strategies to address and remediate areas of need.

This approach, which highlights the complementarity of

the salutogenic and pathogenic models, assisted students to

identify a new focus for nursing care.

Discussion of this theory provided a sense of optimism

and hope for the nursing role in caring for clients who self-

harm, as many interventions congruent with the salutogenic

approach had not been considered by students. With knowl-

edge of salutogenesis students were able to consider new

ways of being with clients. In appreciating and helping to

build strengths, students were able to see how this approach

would assist them in being a more validating presence for the

client. In a pathogenic model, the nursing role may be seen

more as a function of ‘doing for’ the client. That is, under-

taking tasks associated with medical treatment and tradi-

tional notions of care. ‘Doing for’ the client is often

grounded outside of an interest for the well-being of the cli-

ent, and more closely associated with the needs of the nurse

or organization, such as in times of busyness, stress or pres-

sure (Arras & Dubler 1995). The salutogenic approach

therefore, offered students both new ways of being as a

nurse, as well as a way to experience a sense of efficacy in

caring for clients. In building strengths and resilience, stu-

dents needed to be able to first locate them. The following

strategies present deliberately selected and creative teaching

strategies that the teaching team found useful in facilitating

the acquisition of contemporary knowledge, skills and help-

ful attributes to respond to clients who self-harm.

Teaching strategies

Images

After welcoming the students to the class, explaining the

course objectives and requirements and briefly introducing

ourselves, the first structured interaction began. The class

was divided into groups of four and provided with a ran-

dom assortment of about 10 images taken from magazines,

the Internet, paintings, film or photography books. Exam-

ples of some of the images used included: Jack Nicholson’s

character from ‘The Shining’, Marilyn Monroe, a self-

portrait of Frida Kahlo (an artist who is assumed to have

been self-destructive and oppressed), and an image of a

child gazing at her reflection in a pool. Each group was

asked to complete one from a range of written tasks (see

Fig. 2).

The teaching team proceeded to engage students in crit-

ical thinking, discussion and decision making. Clearly there

are no simple right or wrong answers to this. Active dis-

cussion was encouraged by enthusiastically supporting all

suggestions. This role modelling of acceptance and support

of dialogue helped to create an atmosphere of acceptance

and aided in making frequent dialogue the norm. This sim-

ple exercise produced some important learning outcomes:

that self-harm is a subjective experience that cannot neces-

sarily be understood by its outward manifestations; despite

students’ protests that they knew nothing about self-harm

and had no strongly held values or beliefs about it the exer-


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cise revealed knowledge and values; and that students have

legitimate knowledge as well as a priori prejudices.

Five-dimensional assessment

The five-dimensional assessment model (physical, intellec-

tual, emotional, social and spiritual) was used to enable

students to consider multiple dimensions of the client, that

existed beyond the traditional biopsychosocial (Rawlins

et al

. 1993). The teaching team felt this was important

because some issues relevant to the client who self-harms

may not be evident in a traditional biopsychosocial view.

For example, understanding one’s experiences and finding

meaning in them relates specifically to the spiritual dimen-

sion and is an important aspect of working with a client

who self-harms (Vivekananda 2000). Also, having intellec-

tual as well as emotional dimensions, separates out feelings

about the act, from cognitions about the act, helping the

clinician and client to explore the level of conscious con-

trol, compulsiveness and emotional dysregulation that may

be operating in the person’s self-harm.

To ensure the model was integrated by students as a

component of their salutogenic and holistic repertoire, the

authors devised a case study. Prior to class, students were

asked to assess the case using the familiar biopsychosocial

assessment. Students reported on their findings of what

they felt was a holistic picture of the client. The assessments

were accurate, thorough and congruent with a pathogenic

approach to detecting problems. A lecture was next pro-

vided offering a new perspective on assessment, this time

focusing on assessing strengths as well as problems. After-

wards, students were asked to complete a five-dimensional

assessment of the same case study, focusing on areas of

need and strength. In this way, students were assisted to see

that the exploration of strengths at this early stage gives

nurse and client something to work towards as well as hope

for the future.

The results were impressive and validating for the stu-

dents, as well as hopeful for the nursing role in caring for

clients who self-harm. Many potential areas of strength

were located and possible interventions identified, which

would assist the client to capitalize on those strengths. Fur-

thermore, students were able to clearly identify the intel-

lectual and spiritual components of the client, something

they had been unable to elicit in the biopsychosocial

approach. By this time, students had become quite used to

being challenged with new ways of thinking and caring.

Six-category intervention analysis

Many students were able to consider issues privately, but

some experienced difficulty in articulating their impres-

sions verbally. This difficulty translated into practice, as

students expressed concern with knowing what to say to

and how to therapeutically be with clients who self-harm.

Heron’s (1990) model of six-category intervention analysis

was chosen as a means for students to begin to experiment

with and extend their therapeutic presence. This approach

was felt by us to be appropriate as both verbal and non-

verbal communication may be considered to be interven-

tions. Students were provided with information regarding

the six categories of intervention: prescriptive, informative,

confronting, catalytic, cathartic and supportive. Prescrip-

tive interventions are those that guide a client’s actions.

Informative interventions are the provision of education

and information to increase health-seeking behaviours.

Confronting interventions are those that therapeutically

challenge the client. Catalytic interventions seek to clarify,

probe and elicit further information. Cathartic interven-

tions enable clients to access and release emotion. Support-

ive interventions validate and promote the client’s sense of

worth.

Role-plays were used to assist students in practising the

skills and identifying which categories they were using. A

positive result of this exercise was that students were able

to identify themselves as being therapeutic agents. That is,

Figure 2

Tasks when analysing images

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students valued their role as nurses. Clearly this has impor-

tant implications for our professional self-efficacy. Once

students had begun to understand this model and were

becoming comfortable with the verbal and non-verbal

skills, additional concepts and therapeutic strategies were

overlayed, to further strengthen students’ skills repertoire.

The dialectical tug of war

Linehan’s concept of dialectics is a key concept learned and

reiterated throughout the course. According to Linehan

(1993), a dialectical world-view is one that acknowledges

reality as a set of opposing forces that exist simultaneously

and that create tension and ambivalence for individuals.

For example, a primary tension of interest to the therapist

using dialectical behaviour therapy (DBT) is the tension

between trying to accept the client, whilst simultaneously

trying to change the client (Swales

et al.

2000). Another

belief is that people who self-harm tend to be non-

dialectical thinkers, unable to cope with the reality of

two opposing forces existing at the same time, and self-

invalidating their complex layers (Swales

et al

. 2000). Such

novel notions can seem complicated and inaccessible to

beginning practitioners or even experienced clinicians new

to DBT. A carefully planned combination of lectures,

games, reflection and skill development transformed what

could have been knowledge beyond students, to knowledge

that was remembered, used and applied.

First, students learned about the origins and compo-

nents of DBT. Then, students were engaged in an innova-

tive kinaesthetic learning game. Students were grouped in

pairs, and each student in the pair was handed a written

label describing one side of a tension. Each student was

encouraged to become that label, to feel it, to act it out.

Deliberate attempts were made to avoid common oppo-

sites. Instead teachers chose concepts that exist in tension.

Teachers began with simple tensions and moved to the

more abstract. For example: pleasure and pain; numb and

intense; acceptance and change; active and passive; feeling

in crisis and yet inhibiting grief; proud and ashamed; capa-

ble and incompetent; worthy and helpless, different and

diffuse; hurt and surviving; loving and hateful; strong and

fragile.

The paired students and the audience thought about

each role for a minute. The paired students were next given

one end of a piece of rope and encouraged to pull on the

rope in a game of tug of war. During the tug of war, each

student was reminded to remember what it feels like to be

pleasure, for example, but existing in tension with pain.

Questions such as this were posed: What did it feel like to

be pulled towards pain, when you were trying to be plea-

sure. The bodily experience of being in tension, of ‘being’

an emotion or a value and being pulled towards its polar

opposite was profoundly meaningful. Students thus came

to a deeper understanding about the reality of competing

internal tensions, to appreciate that it is possible to be both

strong and weak, surviving and not coping, being in unre-

lenting crisis yet at the same time not resolving pent-up

grief.

The exercise generated much discussion, and in the days

that followed students would often volunteer other dialec-

tics that became apparent within therapeutic situations and

upon reflection on theoretical concepts about self-harm.

Students came to understand that many individuals who

self-harm tend to oscillate between extremes, finding no

middle ground and no moderate way of being in the world.

Students learned that the challenge in the therapeutic

encounter is to assist the client to gain awareness of a dia-

lectical world-view, to learn to accept the self and to be

committed to change.

The activity powerfully communicated the concept of

the subjective self. Further, it foregrounds the tension in

being both an objective and a subjective self, a complex and

salient issue for many people who self-harm (Crowe 1996).

People who have survived abuse have been grossly objec-

tified and may feel nothing, have very low self-worth and

question their very self-ness. Crowe (1996) argues that the

body is that place where the public self exists with the pri-

vate self. On the body, the objective and subjective are

brought together and may be in conflict, but there may be

no words to express this tension and thus the person acts it

out. Thus, self-harm can at times be a desperate way of

asserting one’s subjectivity.

There was evidence also to show that students have

gone on to apply this teaching strategy in their therapeutic

encounters with clients. The following reflection reveals

how nurses can help clients to appreciate that ambiguous

internal emotional states can be troubling and difficult to

understand. Further, when the nurse conveyed this insight,

the client felt less alone, more understood – clearly a ther-

apeutic encounter, and one that has the potential to facili-

tate healing. The student wrote: ‘I explained to Skye how

she demonstrates on one hand how competent she was in

some areas while at the same time, actively denying she has

any skills. She was able to process this information. This

has generated further discussions on tensions experienced

by her and she is relieved that these are acknowledged by

others.’

Consumer stories

Consumer involvement in this course was highly valued

and sensitively managed. Consumers, community workers,

nurses and academics participated in a curriculum working


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party making decisions about content and processes of

teaching and learning. Consumers agreed that students

needed to experience and learn from first-hand testimonials

because, they argued, a major distress at the point of health

service contact is the objectification and lack of under-

standing displayed by clinicians. Thus, if students learned

more about the subjective experience, they could be

assisted to appreciate that individuals who self-harm are

motivated, achieving, complex real people, and thus be

able to convey more empathy. At the same time consumers,

some of them health professionals in training, were con-

cerned to protect their privacy and did not want the session

to be reduced to voyeurism or tokenism. With these issues

in mind, the session was carefully planned.

Next, a selection of students were each handed a ques-

tion that they could have asked of the consumer, had the

story teller been present on the day. Remaining students

were asked to imagine themselves as that story-teller, that

consumer and to attempt to respond to the questions asked.

By pre-setting some of the questions, the teachers aimed to

provide guidance on how to respectfully engage in dialogue

with consumers. It also had the effect of giving students

confidence with question-posing, and set the stage for ques-

tions and answers, and soon legitimate discussion emerged.

Finally, a positive story was told (see Fig. 3). Upon crit-

ical reflection, students were able to identify specific ther-

apeutic and empowering strategies that characterized the

nurse–client interaction. Students could see that: the nurse

acknowledged the client as an individual who had needs

that the nurse may not have skills to respond to but the

nurse conveyed a wish to remain available; the nurse gave

the client choices on how the interaction could proceed; the

nurse was aware of both verbal and non-verbal signals and

adapted her manner accordingly; the client was assured

that the nurse was not going to attempt to ‘fix all problems’

as many health workers tend to do but intended to do only

what the client wanted her to do; and the whole interaction

was concerned with safety, consideration of individuality

and respect, and as one student stated: ‘I learned that you

don’t have to have all the answers all the time. You can say

to the client “I’ll take my lead from you” ’.

By engaging students in this shared critical reflection,

the notion of transactional learning was realized (Hooks

1994). With teacher facilitation and encouragement to

share ideas students extended and applied their own

knowledge about empowerment and thus teachers were

not required to engage in any transmission of ideas. This

was an example of active learning and critical thinking.

In order to reinforce for students the power of stories to

convey insights and teach skills, a copy of the story was

made for all. The class was reminded of the privilege they

gained in hearing this account from a consumer, and each

Figure 3

The voice of the consumer

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was encouraged to share the story’s insights with family,

friends, and colleagues. In this way, the consumer’s story

was transformed from being something simply heard by

one class, to becoming a resource for future education and

practice change.

Over the next few days, when students were engaged in

guided therapeutic interview practice, the teachers were

delighted to hear dialogue from the story frequently echoed

by the interviewer. Students were saying gently and in dif-

ferent ways ‘I may not have all the skills to help you, but I

want to try. I’ll take my lead from you’. The teaching team

think this is substantial evidence that students had shifted

from a position of uncertainty in therapeutic encounters, to

a position of respect, resourcefulness and empathy.

Affirmations and validations

It is our experience that using consumer testimonials in

class can be a risky practice because sometimes consumers

reveal highly personal information which in the telling can

be re-traumatizing. Teachers stressed the privilege students

have in being able to hear first-person experiences and to

respect how courageous and empassioned the consumer

must be to want to share it, and in this class the teaching

team went one step further. Students gain so much in lis-

tening: ability to understand the personal experience, abil-

ity to empathize, to learn from the misfortune and mistakes

of others so that their practice need not be one of repeating

similar errors. Students also have the opportunity to put

into practice a key theoretical principal learned in class:

validation.

According to Linehan (1993), one of the major pres-

sures placed upon the individual who self-harms is social

invalidation. Social invalidation occurs in response to the

self-damaging act being a cultural taboo, which elicits

strong, pejorative judgements in many. Every time a con-

sumer is looked upon with fear, neglect, horror, confusion

or anger, then they and their coping behaviours are being

invalidated. Further, sometimes the consumer themselves

can tend to self-invalidate (Swales

et al

. 2000). When the

individual who has self-harmed becomes self-loathing,

guilty, angry or suicidal because they see themselves as

being bad or hopeless, they are invalidating.

Alternatively, validation, the communication that one is

worthwhile, understood, respected and valued, is poten-

tially a very powerful and affirming therapeutic strategy.

So, once students had heard the consumer stories, they

were reminded about the power of, and the responsibility

for, health professionals to provide validation. Each was

handed a blank card and asked to reflect on the person who

shared their story, and on the ways the student has bene-

fited from hearing it. When they felt ready, the students

were invited to write reflections on the cards, which were

collected and delivered to the consumer. In this way, stu-

dents and teachers were honouring the consumer’s involve-

ment, as well as providing potential for validation for what

was a wonderful contribution to student learning. Letters

were subsequently received from the consumers who

expressed gratitude and pride that their stories had been

useful in teaching students. According to Linehan (1993)

this kind of validation is high level. It goes beyond respect-

ful listening, to actively and strategically communicating

to the individual that his/her current behaviour and self is

highly valued, functional and helpful to others.

Film analysis

Towards the end of the teaching, students were shown the

film ‘Good Will Hunting’ (Van Sant & Moore 1997). Film

viewing added variety and a challenge for students to apply

critical thinking skills. Questions were asked to prompt dis-

cussion on the range of self-harm behaviours in the main

characters, their differing motivations, their relationships,

as well as the range of therapeutic interpretations of Will’s

problem. Students were asked to decide how this was a

story of personal growth and to examine the meaning of

the title. For some students, ‘Good Will Hunting’ was

thought to mean that Will was searching for his goodness.

For others it meant that Will was looking for people who

could show goodwill towards him. The film analysis thus

inspired creative thinking and uncovered layers of meaning

insightful for both students and teachers.

Perhaps the most profound impact from this film was

that students were able to recognize the character of Will as

a person who self-harms. Rather than be distant from him

and unable to understand, students identified with many of

his struggles and saw him as a sympathetic character. Dis-

cussion further reinforced the point that different manifes-

tations of self-harm do not reveal much about what

compels the individual to act in this way. In Will’s case it is

not apparent until very late in the story that his self-

destruction is likely to be related to his long-standing self-

loathing, developed from the experience of early childhood

abandonment and neglect. The students also, despite many

indications to the contrary, saw Will as a healthy young

man and were able to provide many examples of ways in

which he possessed great strengths and how those contrib-

uted to their sense of hope for his future at the end of the

film. On the final day, students were asked to stretch their

creative mind even further, in one last exercise, designed to

encapsulate and extend the experience of caring for a client

who self-harms.


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Metaphors

Students were asked to generate a metaphor for the expe-

rience of caring for the client who self-harms. Metaphor is

a powerful form of creative thinking that offers new ways

of perceiving and understanding the old and the new (Pugh

1989). Metaphors contribute to communication by making

imagery more vivid, revitalizing overused and common

terms, and compacting the complex into simple, but

descriptive images (Ortony 1979). Metaphors can extend

knowledge because they use the meaning of one phenom-

ena to promote understanding of something else, providing

a way of thinking about the unknown in terms of the

known (Billings 1991, Pesut 1991). Used deliberately in the

therapeutic relationship, metaphorical thinking may offer

new solutions to recalcitrant problems and suggest new

possibilities for nursing practice. Incorporating metaphor

into the language of nurses may assist neophytes and

experts to think abstractly, to take risks and diverge from

conventional ways of thinking and behaving (McAllister

2000). Used as an heuristic device, metaphor has potential

to broaden and deepen understanding of the meanings of

self-harm and compassionate care and contribute to new

conceptions of nursing, thereby widening horizons and

possibilities for development (Heinrich 1992). Thus, this

exercise allowed students to be creative, extend under-

standings of self-harm and articulate the nursing experi-

ence in novel and unconventional ways.

Students constructed a farming metaphor to explain car-

ing. Students discussed the often hard and exhausting work

of preparing the land (establishing a relationship). The

farmer (nurse) must plough and aerate the soil in order to

plant (build trust and test boundaries) before finally sowing

the seeds (early intervention work) and watching seeds

grow (maintaining an ongoing relationship with reduced

contact). Just as crops need to be fertilized, weeded and

new growth pinched to encourage rigorous growth, so too

nurses must expect clients to return for re-direction and re-

motivation if they are to flourish. Students also discussed

that nurses who sow are not always around for the harvest

celebration, that time when client and therapist see the

rewards of their labour. Students identified that nurse and

client must find other opportunities to reap rewards. Thus

it is important to regularly reflect on areas of change and

acknowledge little signs of new growth, so that both people

can appreciate the value in their working relationship. The

activity helped students to see how the salutogenic model

offers opportunity to find aspects about the client that can

be nurtured and developed and not just contained and

treated. The approach was seen to extend nursing work, to

reclaim its value, and to reduce the tendency towards feel-

ing directionless or helpless.

Conclusion

The critical paradigm used to plan this subject enabled

teachers sometimes to step out of the role of lecturers and

become supportive co-learners with students. This facili-

tated dialogue and created a sense of safety, which encour-

aged experimentation and risk taking. In our judgement,

students seemed to be fully engaged, curious, challenged

and inspired throughout and beyond this educational expe-

rience. Evaluations of the course were overwhelmingly pos-

itive and many students have recommended the course to

their peers.

For the teachers, developing and teaching this subject

has been an energizing and refreshing experience. It has

taught us that it is important never to underestimate the

capacity of students to embrace new concepts and ideas

and to take them bravely into the clinical area, aware of the

challenges that lie ahead of them. In designing the subject,

the teaching team were reminded of the value of the voice

of the consumer in planning education for tomorrow’s

health carers, for without many of their ideas, this course

would have lacked richness and texture.

References

Antonovsky A. (1987)

Unraveling the Mystery of Health: HowPeople Manage Stress and Stay Well

. Jossey-Bass, San

Francisco.

Arnold L. (1994)

Understanding Self-Injury

. Bristol Crisis Service

for Women, Bristol.

Arras J. & Dubler N. (1995) Ethical and social implications of

high-tech home care. In:

Bringing the Hospital Home: Ethicaland Social Implications of High-Tech Home Care

(ed. Arras,

J.), pp. 1–31. John Hopkins University, Baltimore.

Billings C. (1991) Therapeutic use of metaphors.

Issues in MentalHealth Nursing

12

, 1–8.

Braun B. (1987)

Treatment of Multiple Personality Disorder

.

American Psychiatric Press, Washington.

Cheek J. & Rudge T. (1994) Been there, done that? Consciousness

raising, critical theory and nurses.

Contemporary Nurse

3

, 58–

63.

Crowe M. (1996) Cutting up: signifying the unspeakable.

Austra-lian and New Zealand Journal of Mental Health Nursing

5

,

103–111.

Dennis M., Owens D. & Jones S. (1990) Epidemiology of delib-

erate self-poisoning: trends in hospital attendances.

HealthTrends

22

(3), 125–126.

Dyson J., Cobb M. & Forman D. (1997) The meaning of spiri-

tuality: a literature review.

Journal of Advanced Nursing

26

,

1183–1188.

Everett B. & Gallop R. (2000)

The Link Between ChildhoodTrauma and Mental Illness: Effective Interventions for MentalHealth Professionals

. Sage, Newbury Park, California.

Favazza A. (1996)

Bodies Under Siege: Self-Mutilation and BodyModification in Culture and Psychiatry

, 2nd edn. The John

Hopkins University Press, Baltimore.

©



9

, 573–583

583


Freire P. (1972)

Pedagogy of the Oppressed

. Penguin, Harmond-

sworth.

Freud S. (1935)

A General Introduction to Psychoanalysis

.

Washington Square Press, New York.

Geen R. & Quanty M. (1977) The catharsis of aggression: an

evaluation of a hypothesis. In:

Advances in Experimental SocialPsychology, Volume 10

(ed. Berkowitz, L.), p. 446. Academic

Press, New York.

Giroux H (1981)

Ideology. Culture and the Process of Schooling.

Falmer, London.

Heinrich K. (1992) Create a tradition: teach nurses to share

stories.

Journal of Nursing Education

31

(3), 141–143.

Heron J. (1990)

Helping the Client: a Creative Practical Guide

.

Sage, London.

Hooks B. (1994)

Teaching to Transgress. Education as the Prac-tice of Freedom

. Routledge, New York.

Horsfall J. & Stuhlmiller C. (2000)

Interpersonal Nursing forMental Health.

Maclennan and Petty, Sydney.

Johnson B. (1993)

Psychiatric-Mental Health Nursing: Adapta-tion and Growth

. Lippincott, Philadelphia.

Linehan M. (1993)

Cognitive-Behavioral Treatment of BorderlinePersonality Disorder

. The Guilford Press, New York.

McAllister M. (2000) Conquistadors and ruins: Metaphors for a

post-positivist world.

Australian Electronic Journal of NursingEducation

5

(2), 1–5. http://www.scu.edu.au/schools/nhcp/

aejne/vol5_2/mcallistermvol5_2.html

McAllister M., Higson D., Moyle W. & Creedy D. (2001)

Nurs-ing Responses to Patients who Self-Injure

. Griffith University,

Brisbane.

Orem D. (1985)

Nursing: Concepts of Practice.

McGraw-Hill,

New York.

Ortony A. (1979)

Metaphor and Thought

. Cambridge University

Press, Cambridge, Massachusetts.

Pesut D. (1991) The art, science and techniques of reframing in

psychiatric mental health nursing.

Issues in Mental HealthNursing 12 (1), 9–18.

Pugh (1989) Metaphor and Learning. Reading, Research andInstruction 28, 92–96.

Rawlins R., Williams S. & Beck C. (1993) Mental Health – Psy-chiatric Nursing: a Holistic Life Cycle Approach. Mosby, St

Louis.

Spouse J. (1998) Scaffolding student learning in clinical practice.

Nurse Education Today 18, 259–266.

Stein-Parbury J. (2000) Patient and Person. Harcourt, Sydney.

Streubert H. & Carpenter D. (1999) Action research in practice,

education and administration. In: Qualitative Research inNursing: Advancing the Humanistic Imperative, 2nd edn, pp.

251–280. Lippincott, Philadelphia.

Swales M., Heard H. & Williams J. (2000) Linehan’s dialectical

behaviour therapy (DBT) for borderline personality disorder:

overview and adaptation. Journal of Mental Health 9 (1), 7–23.

Tiberius R. (1986) Metaphors underlying the improvement of

teaching and learning. British Journal of Educational Technol-ogy 17 (2), 144–156.

Van Sant G. (Director) & Moore C. (Producer) (1997) Good WillHunting. Miramax Films, Hollywood.

Vivekananda K. (2000) Integrating models for understanding

self-injury. Psychotherapy in Australia 7 (1), 18–25.

Vygotsky L. (1962) Thought and Language. MIT Press, Cam-

bridge, Massachusetts.

Watson J. (1999) Postmodern Nursing and Beyond. Churchill

Livingstone, Edinburgh.

Wilhelm K., Schneiden B. & Kotze B. (2000) Selecting your

options: a pilot study of short interventions with patients

who deliberately self harm. Australasian Psychiatry 8 (4), 349–

354.

http://www.scu.edu.au/schools/nhcp/

Documents

Principles and strategies for teaching therapeutic responses to self-harm