Working with individuals who selfharm The approach of the Crisis Recovery Unit

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Working with individuals
who self-harmThe approach of the Crisis
Recovery Unit
SCOTTISH Personality Disorder Network
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Outline

• Setting the scene
• The unit where we started
• Dilemmas
• How to work with the work
• The unit where we are now
• Repetition and reparation

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Self-harm - an act of religious devotion
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Self-harm a form of protest
Shias stage anti-US protest Protests against the
US presence in Iraq have been staged by Shias in
the city of Karbala at the climax of a pilgrimage
that has attracted one million people. Groups of
marchers chanted slogans against a US-imposed
government calling for unity among Shias. Many
hit their backs with flails or cut their heads
with swords in ritual self-flagellation.

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Self-harm a way of restoring health!

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Definitions

• . an individual intentionally damaging a
  part of his or her own body, apparently without a
  conscious intent to die
• Feldman, 1988

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Definitions

• intentional self-poisoning or injury,
  irrespective of the apparent purpose of the act
• NICE Guidelines, 2004

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Definitions

• a deliberate act to damage yourself,
  without intending to die. This varies according
  to the situation the individual carrying out the
  act is a means of getting away from intolerable
  thoughts or feelings HOTUSH

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The Unit Where We Started
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The sufferer who frustrates a keen therapist, by
failing to improve is always in danger of meeting
primitive human behaviour disguised as treatment
Main,T. 1957
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• Inclusive definition
• Self-harm as a symptom

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Self-harm suicide

• Not about wanting to die
• Self-harm and suicide lie on a continuum

Socially acceptable self-harm
Suicide
self-harm
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Underlying principles

• Retention of Responsibility
• Short Term Risk Taking

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Dilemmas

• Anxiety

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Dilemmas Anxiety

• Unless anxieties can be identified, addressed
  contained within the system it is likely that the
  system itself will produce defences that actively
  hinder rather than help therapeutic intervention
  Menzies Lyth, 1970

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Dilemmas

• Polarity of thinking and catastrophysing

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Dilemmas

• Specialness

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Dilemmas Specialness

• These patients have the capacity to gain a
  unique position in the lives of their treaters,
  characterised by an intense, although mutually
  ambivalent, attachment on the part of the treater
  the patient
• Gabbard, G.1986

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Dilemmas

• Seeking of ideal attachments

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Dilemmas

• Insatiability and inability to get things right

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Dilemmas Insatiability

• leading people on then letting them use us, we
  get people to dislike us by doing things to
  making them angry. Some of exhaust people with
  our intense relationships I dont think youll
  ever get it right it changes for me each time
  HOTUSH

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Dilemmas

• Abuser-abused

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Dilemmas Abused/abuser

• they experience a sense of power through being
  in control of the shapes forms their bodies
  assume, as a result of the physical injuries
  abuse they inflict upon themselves
• Welldon 1988

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Dilemmas Abused/abuser

• self-abusing mutilating attacks in such
  patients may serve the double purpose of
  producing further additive, perverse excitement
  also of a punishing attack on the bad internal
  organs which have become contaminated by the
  identification with the excited, intrusive organs
  of the abuser
• Milton 1994

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Dilemmas Abused/abuser

• the patient is at times in her current life the
  abuser, then at times the abused. In fact the
  two are inextricable, as masochism involves the
  accompanying projection of sadism, forcing the
  other to be the helpless witness of suffering in
  which they are supposed to be implicated Milton
  1994

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Dilemmas

• Difficulty in thinking feeling

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Dilemmas Behaviour

• Practitioners impelled towards action rather
  than towards contemplation
• Heimann, 1950

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Dilemmas

• Breaking of boundaries

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Dilemmas

• Projection/countertransference

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Dilemmas Countertransference

• The psychiatrist cannot avoid hating them
  fearing them, the better he knows this the less
  will hate and fear be the motives determining
  what he does to his patients
• Winnicott, 1947

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Dilemmas Countertransference

• Though it is acknowledged that at times
  countertransference hate may be justified, the
  more justifiable it seems, the more likely the
  therapist is to act it out in a non-therapeutic
  fashion
• Progers 1991

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Dilemmas

• Breaking of boundaries

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Dilemmas Boundaries

• The Professional Boundary
• Treatment Boundary
• Self Disclosure Boundary
• Safety Boundary
• Boundaries and Individuality

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Dilemmas Boundaries

• "The skin ego is the interface between psyche and
  body, self and others"
• Anzieu 1989

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How to work with the work

• Protocols
• Mutli-disciplinary working
• Staff support/supervision
• Relationship with the institution
• Risk Assessment
• Understanding who owns the problem
• Communication
• Boundaries

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The Service

• 3 components
• In-patient unit (Crisis Recovery Unit)
• Self-harm Outpatient Service (SHOP)
• A national training programme

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The Unit
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Referral criteria

• Over 18 years
• Non-psychotic
• Not dependent on alcohol or substances
• No significant learning difficulties
• Not homeless

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Why referred

• Exhausted local services
• Enmeshed teams
• Loss of professional boundaries
• High levels of anxiety
• Desperation

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At assessment

• Psychologically minded
• Contemplating change
• A degree of adult functioning

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Post assessment

• Provisos
• Reporting
• Outreach
• Voluntary admission

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Admission

• Timed admission
• Work not care
• Responsibility
• Relationships
• Tolerance of self-harm
• Work on internal damage not SH management

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Admission

• Community
• Repetition then change
• Conflict
• Group
• Individual
• Creative therapies
• Practice at home

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Admission

• Family therapy
• All part of day are work
• Finishing relationships
• Post discharge group
• Responsibility for handover to local workers

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The programme

• Community group
• Coping skills
• Projective art
• Creative writing
• Movement group
• CRU group
• Weekend planning

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The programme

• HOTUSH
• Negotiation
• Planned meetings
• Safety planning
• Evening activity
• Evaluation
• Occupational therapy

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Ground rules

• No use of alcohol or illicit drugs
• No violence towards others
• No assisting others in their SH
• Deliberate damage to property paid for
• Consideration for others
• Keep to provisos

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Boundaries for self-harm

• Report SH 2 hours (sooner if severe)
• Accept treatment
• Complete an incident form
• Consider handing in implements
• Dispose of sharps correctly
• Clean up blood spillages

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Boundaries for self-harm

• Immerse burns in cold water for 20/60
• Not to share implements
• Not to involve others in self-harm
• To continually assess severity/frequency of your
  SH with the team
• Report when feeling suicidal

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Aims

• To develop alternative, healthier ways of coping
• To improve interpersonal communication
• To have a sense of self
• To move away from eliciting help through
  behaviours only
• To move away from services

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Average number of self-harm incidents per month
in consecutive series of patients admitted to
CRU, 2001-2005 (n66)
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The breaking of boundaries

• When provisos are broken then the resident goes
  on reflective boundary leave

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Staff containment

• Selection psychologically minded
• why undertake this work?
• No secrets
• Work as a team
• Work with the anxiety
• Work within the countertransference
• Supervision
• Challenge each other
• Encounter then evaluate

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Staff containment

• Ongoing risk assessment
• Challenge perversity
• Discuss sadistic, maternal etc. feelings
• Training
• Similar model to residents
• Health attachments
• Role model emotions
• Challenge conflict
• Limit setting

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• CASE HISTORY

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History of cutting

• Aged 12 piercing picking with dress making
  pins
• Aged 13 superficial wrist cutting whilst
  boarder. Introduced to cutting by school peers.
  Unsuccessfully concealed
• Aged 14 Referred to psychiatrist
• Short period of abstinence
• Aged 15 Cutting returned

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Cutting behaviour on referral

• Forearms - from elbow to wrist
• Legs - from the inside of thigh to hip
• Areas covered by clothing.
• Clean razor blades/scalpels
• Important to cut in a ritualistic manner
• Cutting slow controlled, enabling
• regain control over emotions
• achieve a sense of calm

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Cutting behaviour on referral

• Fascination with cutting injuries
• Deliberate bleeding release of bad stuff
• Self-competitive cuts need to be deeper longer
  each time
• When to stop? severity of damage or duration of
  cutting episode

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After cutting

• Experiences a range of feelings including
• Euphoria
• Restoring herself to happy normal C
• Sense of relief feeling 'spaced out'
• Latter two feelings last about 1 - 2 hours
• (although decreasing over time)

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Wounds Suturing

• Wounds always require suturing
• Frequently sutures own wounds
• Scarring
• Wishes that she did not have them
• Upset they are becoming worse
• Conspicuous wounds get in way of life
• A strong motivation to stop

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Damage

• Severed 3 veins requiring surgical repair
• Damaged a tendon in her arm X 1 exposed
  tendons on two other occasions
• Has permanent loss of sensation

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Bloodletting

• Started aged 16 years
• Use of syringes tourniquets
• 2 x 50ml syringes of blood
• Daily x 2 for a period of a week, stops for a
  while starts again
• Up to 4 x per day, (i.e. 400mls per day)
• Helps her to feel in control
• Denied deliberate attempt to decrease Hb.

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Treatment for blood loss

• 3 blood transfusions since May 2006
• Lowest Hb. 4
• June 2006 treated with ferrous sulphate after
  Hb. dropped to 7

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Medication overdoses

• First overdose aged 16 years
• 20-30 overdoses in total
• Overdoses associated gtsuicidal intent
• Normally plans in advance
• Researched on Internet
• 2 types
• Small 30 - 40 Paracetamol or Aspirin
• Large 100 Pro-Plus tablets, 70-80 Paracetamol or
  Aspirin

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Treatment of overdoses

• Low mood ? wanting to O/D ? informs CPN
• More prone to seek help if she has consumed
  alcohol
• Often too afraid to ask for help
• Has tried to discharge herself against medical
  recommendation

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Swallowing sharp objects

• Swallowed crayons aged 10
• Swallowed dressmaking pin aged 18
• Pre CRU admission X 2 swallowing sharp objects,
  as an inpatient
• Swallowing a razor blade while alcohol
  intoxicated.
• Swallowed smashed glass

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Other forms of self-harm

• Burning
• burnt herself with a cigarette
• last incident in July 2006
• did not particularly enjoy as character of pain
  different hurts gt cutting
• Harm from others (inc. rapes)
• Running into traffic

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Disordered eating

• Aged 13restricting intake to 1,000 cals/day
  purging
• Aged 16 years 4 months restriction ? weight
  dropped to 8 stone. Amenorrhea
• At assessment BMI 21.Reported binge eating
  self-induced vomiting
• No formal treatment for her disordered eating

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Alcohol

• First started drinking aged 13, with peers at
  school
• Aged 14 15 getting drunk with friends at
  parties
• Aged 17 ?consumption socially on own
• ½ a bottle of vodka once weekly
• didnt see her drinking as problematic
• to relax in social situations
• Alcohol increases severity of self-harm

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Drug use

• Cannabis
• regular since age 15
• 2 joints per week
• Often took 'skunk' recreationally with friends
• Snorted heroin on three occasions
• Smoked crack cocaine twice

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Early development schooling

• Breach birth, no complications
• Normal development
• Frequent school moves fathers work
• 3 primary schools - bullied 6-11
• 3 secondary boarding schools
• Education severely disrupted between 16-18 due to
  SH
• No clear hx of conduct problems, had friends
• Gained 2 A-levels (grade A)

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Occupational history

• Worked as a waitress during secondary school
• Unemployed prior to admission to CRU
• Currently due to take up place at uni.to study
  History of Art

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Family

• Mother
• aged 51
• part time French teacher housewife
• described caring, kind religious
• the less dominant of parents, forgiving
• Father
• aged 61
• retired after 35 years Navy (Rear Admiral)
• now CEO for charity
• described strict, rigid, remote

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Sisters both older

• Eldest sister
• works for large commercial company
• treated for OCD
• described as fragile
• Younger sister
• junior doctor
• tendency to over-exercise
• described as successful and angelic

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Past psychiatric history

• Aged 14 - parents arranged psychiatric assessment
  
• Aged 15 - school organised psychiatric assessment
  
• Aged 16 - prescribed Fluoxetine, then Sertralline
• Admitted aged 16/17 after an overdose.
• 2 years of psychodynamic psychotherapy
• Several other short lived attempts at family
  therapy CBT

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Mental state examination

• Well kempt, cooperative, normal speech
• Wearing a pedometer. BMI 22.5
• Euthymic
• Ongoing resistible suicidal thoughts
• Over valued ideas of thinness range of angry
  cognitions towards self, parents professionals
• No evidence of other overvalued ideas, delusions
  or obsessions

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Summary

• 20 year old Caucasian female
• History of self-harm from 12 years
• History of food restriction, binging
  self-induced vomiting
• Alcohol substance misuse
• Raped X 2, reckless risk taking
• SCID II
• Obsessive Compulsive Disorder
• Borderline Personality Disorder

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Summary

• High risk to self
• Heavy use of services
• ward admissions including 1 year on s3
• burnt out care coordinators
• frequent attendance to AE
• Polypharmacy Antidepressant, Benzodiazepine,
  Antipsychotic

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Progress on unit

• Family therapy x 6 sessions
• First time she felt parents showed an emotional
  response to her problem
• Felt a greater understanding their way of coping
  with her problems
• Reduced and discontinued diazepam

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Self-harm on unit

• lt cutting gtbulimia
• Overdose of Stelazine Quetiapine
• Occulogyric crisis
• Swallowed razor blades X 2
• Serious overdose in December 2007
• 10 grams of Quetiapine (internet order)
• 2 seizures, intubated
• discharged after 48 hours
• residual memory loss

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After care

• No self-harm since December
• Discharged off all medication
• Currently working in shop prior to starting
  course in Sep.
• Follow up with care coordinator
• Team not good enough vs specialness of CRU
• Post discharge once weekly group for 3/12

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Repetition or reparation

• within relationships our experiences also lead
  us to self-harm. We have memories of being hurt,
  abandoned, rejected neglected by others. This
  has left us feeling lonely, empty, uncared for
  have problems in trusting
  HOTUSH

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Repetition or reparation

• Reparation is the wish to put right,
  reinstate or repair the object that has been
  damaged or destroyed
• Klein 1945

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Repetition or reparation

• Some of us need to be cared for, need to be
  ill cant allow ourselves to be happy. We
  dont know how to NOT to be hurt by ourselves or
  by others
• HOTUSH

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Repetition or reparation

• We repeat patterns, in our minds, our bodies
  in relationships
• HOTUSH

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Repetition or reparation

• The ego is first foremost a bodily ego
• Freud 1923
• as an attempt to master the trauma through
  recreating the original situation but hoping for
  some resolution of the conflict
• Motz 2001

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Repetition or reparation

• demolish any capacity for trust foster
  transference distortions such that supposedly
  strong helpful figures are seen as weak,
  malicious dangerous
• Stone 1987

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Repetition or reparation

• at those times when you feel most pressure to
  act, to do something which seems logical, urgent
  necessary. STOP, take space think. It is
  probably the case that you are caught up in some
  form of re-enactment

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