Self Harm

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Self Harm

• Self-Injurious Violence
• (Self-Mutilation)
• Dr. Patricia E. Robertson
• Ms. Susan Elaine

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What is Self-Harm?aka self-injurious behavior
self-mutilation

• The Syndrome
• The diagnostic criteria for Repetitive Self-Harm
  Syndrome include
• Preoccupation with physically harming oneself
• Repeated failure to resist impulses to destroy or
  alter ones body tissue
• Increasing tension right before, and a sense of
  relief after the act
• There is no association between suicidal intent
  and the act of self-harm
• Behavior is not a response to mental retardation,
  delusion, hallucination

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What is Self-Injurious Behavior?

• Definitions
• Simon et al. (1992) the deliberate harm to
  ones body resulting in tissue damage without an
  unconscious intent to die
• Stone and Sias (2003) the deliberate
  destruction or alternation of body tissue without
  conscious suicidal intent
• Froeschle and Moyer (2004) those who seek out
  pain and blood in order to relieve emotional pain

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What Self Harm Is Not

• Self harm (SH) differs from other behaviors that
  can or may have injurious effects, such as
  professional tattooing or piercing, drug use,
  ritualistic mutilations and plastic surgery.

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Self-harm Distinctions

• The distinguishing factors between self-harm and
  these other behaviors
• generally relate to both purpose and means
• self-harm behaviors can be viewed as methods of
  coping, generally having the goal of immediate
  tension relief
• SH makes one feel better in the short term
  decreases anxiety, stress and negative feelings.

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Characteristics of SH

• Done to oneself
• Performed by oneself
• Physically violent
• Not suicidal
• Intentional and purposeful

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Types of Self-Harm

• Cutting oneself
• Burning oneself
• Interfering with the healing of wounds by
  reopening them
• Biting fingernails excessively
• Pulling out or plucking hair to an excessive
  degree (trichotillomania)
• Hitting or bruising oneself
• Intentionally breaking ones own bones

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Information about Self-Harm

• Most copying mechanisms, such as crying,
  sleeping, exercising, shopping and even SH lose
  their effectiveness over time.
• The occurrence of self-injurious behavior
  decreases with age.
• Most individuals stop engaging in SH by the time
  they reach their thirties.
• This decrease in SH seems to occur independently
  of any intervention of psychotherapy, medication,
  or related techniques.

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History of Abuse

• The majority of people who hurt themselves were
  hurt by others when they were children, suffering
  physical, sexual or emotional abuse.

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Abused Children

• Abused and neglected children can begin to
  exhibit self-injurious behavior at a disturbingly
  early age
• In a study of children aged 2.5 5 years, who
  were abused or neglected, both self-harm and
  suicidal behavior were described.
• In another study of somewhat older physically or
  sexually abused children, 41 exhibited self-harm
  such as head banging or self-biting.

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Abused Children (cont)

• Within the self-harming group
• The incidence of major disruptions in parental
  care was 89.
• The incidence of childhood trauma such as
  physical abuse, sexual abuse or witnessing
  domestic violence was 79.
• Sexual abuse most strongly predicted self-injury.

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Abused Children (cont)

• Interviews with self-harming individuals who
  experienced childhood incest and adult rape
  report
• That depersonalization occurs when tension
  associated with posttraumatic stress from sexual
  abuse becomes intolerable
• Self-mutilation reportedly alleviates these
  negative states.

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Shame Self-Harm

• Shame appears to be a critically important
  emotion in self-harm.
• Individuals who chronically self-harm often view
  themselves as evil and deserving of punishment.
• Several studies have suggested a link between
  shame and self-harm.

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Quote from Survivor

• A nineteen-year-old college sophomore relates,
  I hurt myself so that I can feel the pain of
  now, of today. Id rather feel pain from now,
  that Im creating, than the pain from my pastI
  was abused pretty bad as a kid.

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Why Do People Engage in Self-Harm

• Relief from feelings
• Attempt to preserve life
• A method of coping
• Stopping, inducing or preventing dissociation
• Euphoric feelings
• Physically expressing pain
• Communication
• Self-nurturing
• Make your internal wounds external and to nurture
  and heal these wounds

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Why Do People Engage in SH (cont)

• Self-punishment
• Reenacting previous abuse
• Establishing control

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The Nature of Self-Harm

• Shame and self-inflicted violence
• Isolation and alienation
• Vulnerability and loss of control
• Ritual and self-inflicted violence

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Rituals of Self-Harm

• Generally, SH follows some sort of ritualistic
  procedure
• Some types of SIV are less likely to follow a
  ritualized procedure, including hair pulling,
  nail biting and hitting oneself. These forms of
  self-injury are possible without the aid of
  objects (knives, matches, etc.) and can occur
  without much planning or forethought.)

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Ritual of Self-Harm (cont)

• Environment
• Many people choose to engage in self-harm
  activities only in a specific location, mostly at
  home since it offers the desired seclusion and
  privacy.
• Instruments
• Many people use one particular type of object or
  even one specific instrument when they injure
  themselves.

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The Cycle of Self-Harm

• SIV generally follows a fairly predictable cycle
• Thoughts Before SH
• Think of yourself and your world in a
  pessimistic, despairing way
• Thoughts During SH
• Many people enter a dissociative state
  immediately before injuring themselves.
• I need to hurt myself
• This is the only way I can feel better
• Just a few more (cuts, burns, bruises) and Ill
  be ok.

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The Cycle of SH (cont)

• Thoughts following SH
• Thoughts during this time tend to focus on three
  major themes
• Shame
• Guilt
• Relief

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Identifying Types of Self-Harm

• Stereotypic Most often seen in mentally retarded
  institutionalized individuals
• Major Most often seen in psychotic patients or
  in individuals who destroy a large portion of the
  body
• Moderate The most common type, is non
  life-threatening, occurs in many forms and is
  intermittent

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Why Should We Focus On This Behavior?

• Approximately 960,000 to1.8 billion individuals
  engage in these behaviors (probably more.)
• Lloyd (1997) sampled 143 high school students and
  found that 39 had participated in self-harm
  within a years time.
• Mental health professionals are seeing an
  increased number of individuals who self-harm in
  their schools, clinics, practices, etc.
• Several mental health professionals have referred
  to self-harm as the new anorexia.

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Who Is Cutting?

• 97 of cutters are female
• Middle, upper class
• Intelligent
• High-achievers
• History of physical and/or sexual abuse
• Observed family violence

• Eating disorders
• Alcoholic homes
• Have friends or family members who self-harm
• High levels of depression/anxiety
• Experienced a traumatic event
• Experienced loss

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Understanding Self-Injurious Behavior

• Is a suicide attempt and self-injury the same?
• Are piercings and tattoos typical of self-injury?
• Is the cutter who hides his/her wounds a phony?
• Are individuals who self-harm dangerous to
  others?
• Are the majority of self-harmers diagnosed with
  Borderline Personality Disorder?

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Why Self-Harm?

• Using physical pain to ward off emotional pain
• Inability to express feelings verbally
• Lack of effective copying mechanisms
• Real or perceived lack of support
• Inability to express feelings of anger toward
  another person
• Unconscious desire to inflict pain on a
  particular person
• Fusion of pain with attachment
• Punish self

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Two Types of Cutting

• Dissociative Cutters They are not aware that
  they have harmed themselves until they notice the
  blood running from the wound. (If your client is
  a dissociative cutter ask her/him if she/he is
  feeling numbness in other areas of her/his life.)
• NOTE It takes intense feelings to ignore pain!!
• Nondissociative Cutters Numbness is not the goal
  feeling pain is.

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What To Do If You Observe These Behaviors

• Take the client seriously!
• Assess lethality of the wound.
• Follow suicide protocol.
• Consult colleagues about ethical and legal
  obligations.
• Utilize a chain of helpers (i.e. keep
  communication lines open between school and
  community counselor.)

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Treatment Interventions

• Make a list of people she/he can use as a
  support.
• Make statements that demonstrate your
  understanding of the self-harmers feelings.
• Build a developmental history with your client.
• Attempt to understand why the client is partaking
  in these behaviors (be aware of the family
  system.)

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Treatment Interventions (cont)

• Involve the family in counseling, if possible.
• Find alternatives/additional coping behaviors the
  client can utilize in place of her/his
  self-harming behaviors.
• Help the client to find words to express her/his
  painIf your wounds could speak, what would they
  say about you?
• At each meeting, ask the client whether or not
  there are any new injuries.

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Treatment Interventions (cont)

• Ask her/him to reveal wound.
• Push the client to clarify the reason behind
  every self-harming act until the act itself
  becomes unnecessary.
• With each new cut, ask her/him to verbalize
  her/his feelings before, during and after the
  act.
• DO NOT treat as suicide attempt.

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Helpful Activities

• Journaling/writing poetry
• Using music to express feelings
• Drawing/painting
• Letter writing
• List making (i.e. create a feeling vocabulary)

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What NOT To Do!!

• DONT scold the client for cutting.
• DONT make the person stop their behaviors.
• DONT let your own feelings about the clients
  behavior get in the way.
• DONT miss/cancel/show up late for appointments.

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QUESTIONS???

• Information Taken From
• Alderman, Tracy PhD (1997). The Scarred Soul
  Understanding and Ending Self-Inflicted Violence.
  Oakland, CA New Harbinger Publications, Inc.
• Levenkron, Steven (1998). Understanding and
  Overcoming Self-Mutilation. New York, NY W.W.
  Norton and Company
• Hawton, K., et al (1998). Deliberate self-harm a
  systematic review of the efficacy of psychosocial
  and pharmacological treatments in preventing
  repetition. British Medical Journal, 317, 441-7
• Favazza, A.R. Rosenthal, R.J. (1993).
  Diagnostic issues in self-mutilation. Hospital
  and Community Psychiatry, 44, 134-140.