DELIBERATE SELF

DELIBERATE SELF-HARM - workshop notes

Why people self-harm
Definitions
Risk factors
Statistics
Psychological characteristics
Types of self-harm
Responding to Self-harm
Self-harm and suicide
Personal strategies for those who self-harm.
What self-harmers say about why they self-harm.
Helpful responses to self-harm
Myths and common sense
Summary of interventions

Some reasons why people self-harm include:

	Childhood trauma – witnessing or being subject to physical violence
	Divorce or separation of parents
	Sexual abuse
	Emotional / psychological abuse
	Conflict with parents / carers, friends, teachers, authority figures
	Bullying – being constantly undermined
	Being pushed too hard to achieve or succeed
	Poor self-image
	Being in a minority group
	Exam failure or fear of failure
	Feeling or having let someone down
	Unwanted pregnancy
	Drug / alcohol misuse in the family
	Feelings of extreme happiness

WHAT IS SELF-HARM?

DEFINITIONS

Moderate / superficial self-injury

"…the commission of deliberate harm to one’s own body. The injury is done to oneself, without the aid of another person, and the injury is severe enough for tissue damage, (such as scarring) to result. Acts that are committed with conscious suicidal intent or are associated with sexual arousal are excluded."

(Winchel and Stanley, 1991)

Self-mutilation, high risk for

"…a state in which an individual is at high risk to injure but not kill himself or herself, and that produces tissue damage and tension relief. "

Risk factors:

	membership of an ‘at risk’ group
	inability to cope with increased psychological / physiological tension in a healthy manner
	feelings of depression, rejection, self-hatred, guilt
	separation anxiety
	de-personalisation
	command hallucinations
	parental emotional deprivation
	dysfunctional family

‘At risk’ groups include:

	borderline personality disorder (especially females aged between 16 and 25)
	clients in a psychotic state (usually males in young adulthood)
	children with learning disabilities / autism
	clients with a history of self-injury
	clients with a history of physical, sexual or emotional abuse.

(Mosby’s Medical, Nursing and Allied Health Dictionary, 1994)

STATISTICS

	Like anorexia, it has a higher prevalence in teenagers and young people and is experienced more commonly by women than men.
	The best estimate is 1 in 130 people – 446, 000 or nearly half a million across the UK.
	The only recorded figures are from hospital admissions to A&E (142,000 resulting hospital admissions per year in England and Wales), but the numbers of people who self-harm who refer or are referred to A&E will be very small. This is because self-harm itself is not an attempt at fatal injury, but rather an attempt to inflict harm without the need for medical intervention.
	Is it a growing issue? Yes – the issue is becoming more widely recognised. But it’s difficult to say whether the numbers of people self-harming are themselves increasing. It is much more common than could be seen from the only available statistics, but it is very probable that there have been high numbers for a long time – it’s not something that’s suddenly started happening. What’s changing is the increasing willingness on the part of service users to talk about the issue and their dissatisfaction with services.

(Mental Health Foundation, February 2000)

WHO IS LIKELY TO SELF-HARM?

Psychological characteristics in self-injurers:

	strong dislike of themselves
	hypersensitive to rejection
	chronically angry, usually at themselves
	tend to suppress their anger
	have high levels of aggressive feelings, which they highly disapprove of, and often suppress or direct inwards
	are impulsive and lacking in impulse control
	tend to act in accordance with their mood of the moment
	tend not to plan for the future
	are depressed and suicidal / self-destructive
	suffer chronic anxiety
	tend toward irritability
	do not see themselves as skilled at coping
	do not have a flexible repertoire of coping skills
	do not think they have much control over how / whether they cope with life
	tend to be avoidant
	do not see themselves as empowered

(Sheri Wallace, 1999)

TYPES OF SELF-HARM

PATHOLOGICAL – suicidality, self-mutilation, unhealthful behaviour

CULTURALLY /SOCIALLY-SANCTIONED

rituals- reflect community tradition, represent a way for the individual to connect to the community
practices – usually fads done for ornamental purposes, identification with a cultural group (Favazza, 1996)

NB Body piercings, tattoos..etc. may fall into either class

3. COMPONENTS OF SELF-HARMING ACTS

Directness- how intentional the behaviour is. Direct- completed in brief period of time, done with full awareness of harmful effects. If not, indirect.

Lethality- the likelihood of death resulting from the act in the immediate or near future. If lethal, highly likely to result in death, usually the intent of the person doing it.

Repetition- whether the act is a one-off or is repeated frequently over a period of time.

Useful in assessing potential risk of self-harming behaviours to a young person.

RESPONDING TO SELF-HARM- WHAT CAN WE DO?

1. Notice when the person seems upset, withdrawn or irritable (mood change)

2.Encourage them to talk about what’s upsetting them. Show them that you’re listening to them. Offer sympathy and understanding.

3. Encourage and reward healthy and appropriately assertive expression of negative feelings. Can you think of some examples?

NB This may be difficult for you, particularly if the anger is felt towards you.

4. Help the person to think about other ways of dealing with unpleasant mood changes. Include exciting, relaxing and pleasurable activities.

NB You may first need to help the young person to identify and recognise mood changes in themselves, triggers.etc. The commonest trigger is an argument with a parent / carer / close friend.

5. Self-harming behaviour may be being maintained by carers’ responses. (a self-harming incident produces a flurry of interaction and intense activity around the person.) Try to make time to be with the person when self-harm is not an immediate issue.

Provide some space to encourage the person to talk about their self-harm in a practical, problem-solving way.
Keep your responses to each episode of self-harm as low-key, matter of fact and unpunitive as possible.

* Anybody who is concerned about somebody who is self-harming should be aware that they cannot necessarily change their life or coping mechanisms. Instead, they should simply try to be caring, respectful and willing to listen (if that is what is wanted) while allowing the person to retain their dignity. They should not patronise, condemn, judge, attempt to explain, or control, or panic) however hard this may seem!)

SELF-HARM AND SUICIDE

Among young people who self-harm themselves, the factors that are most likely to be associated with a higher risk of later suicide include:

	male gender
	older age
	high suicidal intent
	psychosis
	depression
	hopelessness, and
	having an unclear reason for the act of self-harm

(Royal College of Psychiatrists, London, 1998)

IS SELF-HARM ATTEMPTED SUICIDE?

No, self-harm and suicide have an intimate relationship, but are different. Each individual has their own motivations and mix of self-harming and suicidal feelings.

	self-harm often represents the prevention of a suicidal period
	self-harm is one way of averting suicide
	self-harm may be a survival strategy
	self-harm is frequently the least possible amount of damage and represents extreme self-restraint

NB A diminishing sense of worth may culminate in suicide as its ultimate expression. People who self-harm are statistically at a greater risk of going on to commit suicide.

PERSONAL STRATEGIES FOR PEOPLE WHO SELF-HARM

People who self-harm find a variety of personal strategies useful to minimise or manage their approach including:

	Having a better understanding of why and when you self-harm – and identifying those people who are supportive and make you feel good about yourself – building up your support network
	Minimisation – making a small cut rather than a big one, using clean implements. This may mean cutting earlier rather than later when distress has built up.
	Distraction – trying to go and do something else rather than cut yourself.
	Avoidance – not keeping razor blades or other sharp objects in the house.
	Deterrent – having the item with which you self-harm in sight all the time as a reminder not to use it.
	Talking – talk to somebody who you see as ‘safe.

Why do people self-harm? What self-harmers say self-harm does for them.

	Escape from emptiness, depression and feelings of unreality
	To ease tension
	Relief: when intense feelings build, self-harmers feel overwhelmed and unable to cope. By causing pain, they reduce the level of emotional and physiological arousal to a bearable one.
	Expression of emotional pain
	Escaping numbness: many of those who self-harm say they do it in order to feel something, to know that they’re still alive
	Obtaining a feeling of euphoria
	Continuing abusive patterns: self-harmers tend to have been abused as children. Mutilation can sometimes be a way for punishing oneself for being ‘bad.’
	Relief of anger: many self-harmers have enormous amounts of rage within. Afraid to express it outwardly, they injure themselves as a way of venting these feelings.
	Biochemical relief: there is some thought that adults who were repeatedly traumatised as children have a hard time returning to a ‘normal’ baseline of arousal and are, in some sense, addicted to crisis behaviour.
	Obtaining or maintaining influence over the behaviour of others
	Exerting a sense of control over one’s body
	Grounding in reality, as a way of dealing with feelings of depersonalisation and dissociation
	Maintaining a sense of security or feeling of uniqueness
	Expressing or repressing sexuality
	Expressing or coping with feeling of alienation

Miller (1994) and Favazza (1986, 1996)

HELPFUL RESPONSES TO SELF-INJURY

	Show that you see and care about the person in pain behind the self-harm
	Show concern for the injuries themselves. Whatever ‘front’ they may put on, a person who has injured herself is usually deeply distressed, ashamed, frightened and vulnerable. It is cruel and counter-productive to ‘withhold attention.’ You have an opportunity to offer compassion and respect; to show them something different from the way they have been treated by most people in their lives.

Make it clear that self-harm is okay to talk about, and can be understood

Convey your respect for the person’s efforts to survive, even though this involves hurting herself

Help her make sense of her self-harm. For example, ask when the self-harm started, and what was happening then. Explore how self-harm has helped the person to survive (physically and emotionally), in the past and now. Ask how she feels before she hurts herself, and how she feels afterwards. Retrace with her the steps leading up to an act of self-harm – the events, thoughts and feelings which led to it.

Acknowledge how frightening it may be to think of living without self-harm.

Encourage the person to use the urge to self-harm as signals of buried feelings, memories, needs. (These will be unfamiliar and frightening; go slowly and offer support.) Help her to learn to express these in other ways, e.g. talking, writing, drawing, hitting something. Encourage her to ask for support and to care for herself.

Help the person to break down isolation and shame and to build support networks. (e.g. groups)

Don’t see stopping self-injury as the most important goal. A person may make great progress in many ways and still need self-harm as a coping method for some time. Self-harm may also worsen for a while when previously buried issues or feelings are being explored, or when old patterns and ways of living are being changed. This can be frightening, but is understandable.

It takes a long time for a person to be ready to give up self-harm. Encourage her and yourself by acknowledging each small step as a major achievement. Examples of very valuable steps might be: taking fewer risks (e.g. avoiding drinking if she thinks she is likely to self-harm); taking better care of the injuries, putting off hurting herself for a day or an hour, reducing the severity or frequency of the injuries even a little. In all cases more choice is being exercised the ‘hold’ of the self-harm is being loosened.

SELF-HARM: MYTHS & COMMON SENSE

Stereotype	Experiences of self-harmers
‘It’s attention-seeking’	If attention was the motivation for self-harm, it’s not an efficient way of getting it. There are many easier, less painful and less degrading ways of attracting it.
‘It’s a Borderline Personality Disorder’	Self-injury is not a diagnosis. What is true for some person is not necessarily true for another. Commonly, self-harm is dialogue with yourself – an expression of inexpressible emotion or an absence of self-value.
‘They’re manipulative’	Self-harm is a private activity. Accident and emergency departments will see only a few of the injuries before healing; it’s not about its effect on others.
‘Self-harmers are usually hysterical women under 30 who grow out of it’	Recent research shows the difference in rate of self-harm between men and women is less marked. There is no evidence to show people ‘grow out’ of it. It is not a behaviour or development ‘disorder.’
‘It’s self-inflicted so it’s not serious’	How severe staff think the wound is won’t tell them how bad the person feels. You may not witness all the forms of harm. Individuals have many ways of expressing their distress, often substituting one for another. Your perception of the seriousness of the harm may not indicate the extreme distress that injury represents.
‘Either they enjoy pain or they can’t feel it’	Each person has a different threshold. Commonly the loss of sensation some people experience during harming returns soon after. By the time a person is receiving treatment, it is common for the sense of pain to be amplified.
‘Don’t waste your time with her, we’ve been treating her for years’	A long history of harm often results in being considered a ‘hopeless case.’ No attempt is made to offer support as it’s assumed you’re ‘incurable.’
‘It’s tension relieving’	Tension is rarely the sole pressure on an individual to harm; each person has their own pressure triggers to harm.

Summary of Interventions in Self-Destructive Behaviour

Principle	Rationale	Action
Protection from harm	Highest priority given to life-saving activities, including: supervision, promotion of self-control	Close observation. (level to be decided) Removal of harmful objects, safe environment. Provision for basic physical needs
Increase self-esteem	Behaviour reflects underlying level of mood, self-esteem and anger	Identify strengths of person. Engage in good hygiene and appearance
Reinforce healthy coping skills	Unhealthy coping skills must be replaced with healthy ones to manage stress and anxiety	Encourage healthy interpersonal relationships. Assist person to recognise unhealthy coping mechanisms. Reward healthy coping skills and behaviours
Goal: acceptance of help Social support	Social isolation leads to low self-esteem and depression, which perpetuates the behaviours	Assist others to communicate constructively with the person. Promote healthy family relationships. Identify community and social resources and assistance to engage the person.
Educate about health care needs	Understanding increases co-operation.	Involve person in the plans. Explain health care needs. Encourage decision-making.

PROBLEMS OF THOSE WHO SELF-HARM

Self concepts / schemas	Possible expression
Abandonment / loss	"I’ll be alone for ever. No one will be there for me."
Unlovability	"No one will ever love me or want to be close to me if they really got to know me."
Dependence	"I can’t cope on my own. I need someone to rely on."
Lack of ability to assert oneself	"I must please others or they will abandon or attack me."
Mistrust	"People will hurt me, attack me, take advantage of me. I must protect myself."
Inadequate self-discipline	"It is impossible for me to control myself or discipline myself."
Fear of losing emotional control	"I must control my emotions or something terrible will happen."
Guilt / punishment	"I’m a bad person. I deserve to be punished."
Emotional deprivation	"No one is ever there to meet my needs, be strong for me, to care for me."

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