Should I Lock Up The Sharps?

"Should I Lock Up The Sharps?"

A few days ago, the mother of a 14-year-old girl (let’s call her Sarah) asked me a question. Sarah had been referred to us by the ER due to some suicidal statements after her boyfriend broke up with her. She also had done some cutting that resulted in a series of thin, superficial horizontal cuts on her arm.

Mom: “The crisis worker in the ER told us that we needed to keep a close eye on Sarah and ‘lock up the sharps’ at home. It’s been a week—should we keep doing that?”

For those who don’t know, “locking up the sharps” means denying or restricting Sarah’s access to items in the house—knives, razors, scissors, etc.—that could potentially be used to cut herself.

I realized at that point that, despite “locking up sharps” being a common recommendation made by clinicians to parents, it’s one I’ve never made during the course of my career.

Before I continue, I should say that there are a wide variety of opinions on the subject. What’s more, just because I’ve never recommended “locking up sharps” before doesn’t mean I won’t run into a situation in the future in which it makes sense to me. Restricting access to sharps can be an appropriate part of a safety plan depending on the individual adolescent and the level of risk. My concern is with treating “lock up the sharps” as an automatic response to self-injury rather than considering its potential benefits, limitations, and costs in the particular situation.

Also, a word about different types of cutting. The way I see it, there are at least two very different clinical situations to consider. The first is nonsuicidal self-injury, which is often superficial. It’s more common, and may represent a poor way of coping with stress, or a socially-driven habit, or an attempt to substitute physical pain for emotional pain, or an act of retribution against a boyfriend/girlfriend/parent or the world at large. The second is cutting in an attempt to seriously injure or kill oneself. Distinguishing nonsuicidal self-injury from suicidal behavior is critically important, although the distinction isn’t always obvious and nonsuicidal self-injury itself can be associated with increased suicide risk.

Given what we know about Sarah, it sounds like the cutting has been superficial, and she appears more likely to fall into the first category. That conclusion, however, requires an actual assessment of her suicide risk rather than simply looking at the cuts. Keep both categories in mind, as I’ll return to them later.

Let’s say mom decides to go with the “lock-up-the-sharps” approach. She takes all the knives from the silverware drawer, the scissors from the desk in the office, and the shaving razors out of the bathroom. She puts them into a cabinet and locks it up. She only gives them to Sarah when she can supervise their use, and then promptly locks them up afterward again. Let’s also assume, for the sake of argument, that Sarah isn’t a great lockpick. She can’t use those sharp objects to cut herself again.

Less access to sharps equals less chance of using those particular objects to cut again, so the thinking goes. Pretty simple and straightforward.

Now let’s look at some of the problems with the “lock-up-the-sharps” approach, which may not be so obvious.

Problem #1: It’s hard to lock up all of the sharp items at home.

Things that are sharp are everywhere. Not only knives and razors, but pencils, glass, broken cans, pins, you name it. It’s a nearly impossible task to keep them all out of Sarah’s hands.

That doesn’t mean reducing access is pointless. It means that restricting access has practical limits and should not be confused with eliminating the underlying risk.

Problem #2: It may set up (or worsen) a power struggle.

Many teenagers—and maybe Sarah is one of them—like to fight. It’s part of what teenagers do. One can easily imagine the following scenario: mom locks up sharps; Sarah brings home broken glass she found on the street; mom takes broken glass; Sarah brings in a razor blade from a pencil sharpener at school; mom takes razor blade; Sarah smuggles in scissors and hides them under her bed; mom starts conducting regular room searches; and so on.

The power struggle between Sarah and her mom isn’t just a pain in the butt. It’s going to get in the way of their relationship. It’s going to negatively impact the chance of any kind of cooperative effort to solve whatever the real problem is, because the two are getting distracted by a sharps war.

Of course, avoiding a power struggle is not more important than keeping a child safe. If the level of risk warrants restricting access, parents should do it even if their teenager objects. The question is whether the restriction is proportionate to the actual risk and how long it needs to continue.

Problem #3: It may inadvertently give the message to Sarah that she can’t stop herself or control her own actions.

If it becomes the primary or indefinite strategy, locking away sharps may inadvertently tell Sarah that she is incapable of managing her own behavior. Worse, it may suggest to her that keeping from cutting is her mother’s responsibility, not her own. Sarah may tell her therapist later on that her recent cuts are mom’s fault because mom didn’t do a good enough job keeping her away from sharps. (That’s actually one I’ve heard before.)

The message mom may inadvertently give Sarah is that Sarah is too depressed, too anxious, too angry, too defiant, or otherwise incapable of managing her own behavior. Thus, mom needs to do it for her. This is a very common message that I see parents giving kids these days, and it is a big problem. You’ll see me refer to it in other posts.

Ultimately, Sarah needs to develop the ability to manage urges to hurt herself even when potentially harmful objects exist in her environment. Temporary environmental restrictions may help protect her while she develops that ability, but they cannot replace it.

In a way, if locking up sharps becomes the long-term solution, Sarah’s mom is taking a shortcut. Whatever mom gains in terms of short-term reassurance, she may lose in terms of hindering Sarah’s long-term development, learning to do things for herself, individuation from her mother, and pursuit of independence. In other words, growing up.

And though a single act such as locking up sharps may not be that big of a deal for Sarah’s development by itself, it’s usually part of a larger pattern of “interventionist parenting.” It’s the pattern that can be so problematic—and even damaging—to Sarah’s development.

As Sarah becomes safer and demonstrates increasing ability to manage herself, restrictions can be reconsidered in conjunction with her treatment team.

Problem #4: Locking up sharps at home may give a false sense of security.

Let’s say Sarah isn’t in the superficial cutting category, but is actually trying to seriously injure or kill herself. Keeping her home and “locking up the sharps” is a particularly bad idea if mom concludes from that alone that Sarah is now safe. Mom might feel reassured because the knives and scissors are hidden away. But restricting access to one means of self-harm does not establish that a suicidal adolescent is safe.

If Sarah’s mom thinks that Sarah is at imminent risk of seriously injuring or killing herself, this is no longer primarily a question about locking up the sharps. Sarah needs an urgent safety evaluation and a level of supervision and care appropriate to that risk. Depending on the circumstances, that may mean contacting her treatment team or crisis service, calling 911, or going to an Emergency Department.

Restricting access to dangerous objects may still be an important part of the safety response. It just isn’t a substitute for addressing the underlying acute risk.

Securing medication in the homes of struggling teens is a different story, and I take it particularly seriously when there is a risk of intentional or impulsive overdose. Parents may need to control and supervise access to medication based on the child’s level of risk. An impulsive overdose can cause serious medical harm very quickly.

And, I would hope I wouldn’t have to say this, but firearms should be securely stored so that children and adolescents cannot access them. When an adolescent is suicidal, removing firearms from the home while that risk is present should be strongly considered.

Problem #5: We may be focusing on the wrong means.

If the purpose of locking things away is to prevent suicide, we should also think about the relative lethality of different means. Cutting is an obvious target because we can see the cuts and knives and razors are easy to identify. But cutting is generally a much less lethal method of suicide attempt than firearms or suffocation. Among young people who die by suicide, firearms and suffocation—including hanging—account for the great majority of deaths.

This creates a strange problem. A parent may carefully lock away every kitchen knife while the house still contains medications, firearms, belts, ropes, electrical cords, car keys, and any number of other potentially dangerous things. Some of those are considerably more capable of causing death than the scissors in the desk drawer.

I’m not suggesting that parents should respond by putting every belt, extension cord, and set of car keys into a safe. In fact, that illustrates part of the problem: it is impossible to remove every potentially dangerous object from an ordinary adolescent’s environment. If a child is at sufficiently high risk that we believe they may use readily available objects to kill themselves, simply expanding the list of things we lock away may not be an adequate response. We need to reconsider the child’s overall level of safety, supervision, and care.

On the other hand, means restriction should be individualized. If an adolescent has contemplated a particular method, has access to an especially lethal means, or is highly impulsive during a suicidal crisis, restricting that access can be extremely important.

So will locking up the sharps protect Sarah from cutting herself again? It may reduce her access to some of the objects she could use, and in some situations it may be an important part of keeping her safe. But it isn’t a one-size-fits-all solution.

The better question is what level of intervention fits Sarah’s actual level of risk. How serious is the self-injury? Is it escalating? Is she suicidal? How impulsive is she? How confident are we that she can remain safe?

Parents should take reasonable steps to protect their children when safety is at stake. At the same time, our longer-term goal is to help adolescents develop the ability to manage their own behavior and eventually assume responsibility for their own safety. Good parenting requires doing both.

This article discusses general principles and is not a substitute for an individualized assessment of self-harm or suicide risk. If a child may be in immediate danger, seek emergency assistance.