What I mean about not on an area that “has pull” means not on an area that pulls the wound apart. A sort of example would be a cut on the knee perpendicular to the floor. Every time you bend your knee, you pull apart…this widens a scar. You don’t want to cut in a direction or area where there is “pull” on the skin.

I don’t know about burning because I’ve never seen that. Honestly, I never would have thought of this advice about the cuts if I hadn’t seen it either. Not sure how it could be done badly or well.

Harm reduction is a public health concept that people will do what they do no matter what, so you try to make the damage from it as minimal as possible. The classic example is needle exchange programs.

And yes, although self-harm is flashy, it is a symptom, not a problem.

Tony You sound very knowledgable and understanding about the topic.

I write and teach about self harm from time to time and I found your comments on harm reduction interesting. Although I did not understand them all.

I do understand your comment about not having the cuts too close so that they cannot be closed asthetically. I also understand your comment about keeping the cuts superficial.

The grain of the skin I assume means where the lines in the skin naturally are already there. Right?

What did you mean by those areas where the skin during natural movement is pulled?

Also any ideas on harm minimization for burning the skin with cigarettes of some kind of hot metal .

Interesting post and statement on your relationship with this person. I worked for a number of years in a prison where my main job was the management and assessment of self harming and suicidal inmates – all 750 of them!

Over time I evolved a way of relating to the self harming inmates in what sounds like a similar way to which you did with this woman. I understand why they did what they did and so it was a bit business like really at least in relation to their cutting. I felt for them and understood the angst they felt from time to time. But the actual self harm sort of almost became irrelevant over time. They were going to do what they were going to do and so I focused more on how we related.

Tony

That’s not surprising, nice to hear it as a statistic…does that include smoking related stuff and weight and so on?

It is obvious that the ED, and even hospitalization to some degree, is highly dependent on behavior and socioeconomic factors. Diseases that just don’t need to end up in the ED if the patient has normal health care…do. Hospitalization is often for outpatient-treatable illness in patients who don’t take care of themselves.

It was obvious that she was in treatment by her medication list – although it seemed to me excessive for a kid…one of those “throw everything at it” type lists, antidepressant, antipsychotics (old AND new), some benzo or other…

I thought you had a public health background (for about 10 years now I’ve been waiting for the time for it to be right to do an MPH, never is). I think it was the thing you said about sentinel problem and root cause.

I also wondered at the time if it really was a “nurse” who did that. It’s a small community, I wondered if it wasn’t really some neighbor with some kind of clinic training or something, an ambulance volunteer, or something like that. Or maybe a psych nurse – here they are usually not very well trained in anything.

Harm reduction – in her case, I don’t think it would be possible to do more damage than she did or cut more than she did. If it was going to be that extreme, well then at least so that it will be with reparable wounds and later, less scars. The scars she will have are probably going to limit movement someday.

And my point was that as a “cutter” or wound, she has the same right NOT to talk as anyone else. I treated her with basic respect that is often denied in that kind of situation. Somehow most people think that they have to or should interrogate psych patients, or they are just curious. Does a morbidly obese person have to explain WHY he is that way, or a smoker WHY he doesn’t quit? I’ve found that too often, there is an element of judgment in asking about psych patients’ behavior. (Same for obesity but to a lesser degree.) She has the right to have her injuries treated with no further comment. She has the RIGHT to be just an “arm.”