Self-harming behaviour can be characterized as complex in nature, with different functions for the patient. The perspectives of patients and healthcare providers differ, often leading to unsatisfactory therapeutic relationships and ultimately resulting in inappropriate care. The main aim of this thesis has been to study whether care for patients who self-harm can be improved through targeted improvement of the attitudes and self-efficacy of healthcare providers.
We concluded, based on scientific literature, that nurses have both positive and negative attitudes towards patients who self-harm, but that – unfortunately – negative attitudes prevail. Professional caregivers may experience feelings of irritation, frustration, anger and personal incompetence. Compared with other healthcare professionals, mental health nurses make relatively frequent mention of the need for supervision and support by management and colleagues. Three factors appear to increase the risk of a negative attitude towards patients who self-harm: a low educational level of nurses, working in large hospitals, and working in general healthcare.
We evaluated the effects of a training programme on the attitude and self-efficacy of healthcare providers who care for self-harm patients. The basic principle of the programme was that healthcare staff need to understand the relationship between intensive and unbearable emotions and self-harming behaviour, and the difficulty self-harm patients have in dealing with these emotions. The second basic principle of the training programme was that staff also need a good understanding of their own feelings and perceptions about self-harm and how these influence their reactions to the patient. Lay experts played an important role in the development and implementation of the programme. We found significant improvements in healthcare providers’ attitude towards self-harm patients, as well as improved self-efficacy in caring for patients who self-harm. We also found that healthcare providers developed closer relationships with their patients.
Next, we presented the characteristics and treatment outcomes of a specialist inpatient treatment programme for patients who are considered extremely difficult to treat because of the disruptive nature of their relationships with treatment staff. Self-harm is a common behaviour in these patients. The main treatment method consists of providing safety, structure and cooperation. The basic attitude of staff is non-vindictive, with adequate communication with the patient. Guidance and investment in staff are important ingredients of this treatment programme. To evaluate the treatment within this facility, we used Routine Outcome Measurement (ROM) data as well as data collected with a self-constructed instrument on 108 patients. Pre-test/post-test measurements showed statistically significant improvements between admission and discharge on all questionnaires. We concluded that these patients can be treated successfully and that their functioning can be improved by taking the staff-patient relationship as the primary focus of treatment.
A qualitative study revealed the process of recovery of twelve patients with severe self-harming behaviour who had successfully stopped harming themselves. Six phases could be identified in their recovery processes: (1) limit setting and connecting, (2) self-esteem, (3) learning to understand, (4) autonomy, (5) stopping self-harm and learning new strategies, and (6) maintenance. Connection was found as the key concept influencing the entire process of recovery: both the lack of and the presence of a close, intense connection provided a reason for self-harm. Learning how to cope with their inner selves and others was an important skill for reducing and stopping self-harm, which was made possible by their having a positive connection with their healthcare providers.