Foreword

The notable aspect of this guidance, which has been developed in collaboration with members of the Mental Health and Learning Disability Nurse Directors Forum, Experts by Experience and the Care Quality Commission, place an emphasis on therapeutic engagement.

As a nurse myself, I know how easy it is to concentrate on the measurable aspects of a risk or difficulty. You can easily create a tick box form to say you have door handles that can't be used as ligature point; in this you feel as a healthcare worker you can demonstrate you have reduced the risk, which feels like a job well done.

However, as a person who has suffered from severe mental illness and used mental health services, I have learnt from my own lived experience that the interventions that are not so easily measurable, like therapeutic engagement, more often than not were the factors that reduced my risk of using a ligature.

To give an example, while I was sectioned under the Mental Health Act and was a patient in an acute mental health hospital for my own safety, I became emotionally distressed and started to try to harm myself. The response by the team caring for me was to put me in seclusion, a room with nothing in it apart from a plastic mattress. In this isolation, devoid of any human contact my suicidal thoughts increased and my mind increasingly focused on how I could physically end my life. In the limited resources I had in the seclusion room, I managed to create a ligature. I passed out and the next thing I knew were that people were surrounding me after the ligature had been cut from around my neck.

I share this distressing personal story to demonstrate that a ligature can be found, even in the most barren of places, particularly when a person becomes so desperate to stop the emotional distress. So what did help me in my distress?

Therapeutic engagement – human connection – someone sitting with me and acknowledging my suffering, so I didn't feel alone in my overwhelming emotional distress.

Therapeutic engagement is spoken about first in this guidance for a reason: from my experience it was a massive factor that not only in a moment stopped me from actively trying to take my own life, but it ultimately lead to me managing my distressing thoughts without self harming.

All parts of the guidance, including the recording template, are important but I would urge people using them not to fall in the trap that, as healthcare professionals, we can so easily fall into; that of only focusing on the measurable aspects of this comprehensive guidance, because the less measurable outcomes, like therapeutic engagement, can be the most powerful tool we have to reduce someone even thinking about creating a ligature.

Hannah Cadogan 
Lecturer in Nursing at Roehampton University, and Representative for Lived Experience at the Royal College of Nursing