Making sense of self harm

1
Making sense of self harm

• Dr Mike Smith
• mikesvoice_at_aol.com

2
Session structure

• Session 1
• The basics of self harm, definitions, separating
  suicide from self harm, risk safety assessment,
  a little of the research
• Session 2
• Working with self harm, a structured approach
  focussed towards recovery using a workbook, the
  role of therapy

3
Some publications referred to todaymail me
mikesvoice_at_aol.com

• Working with self harm
• Working with voices
• Assessing risk safety in self harm (SHARS)
• Psychiatric first aid
• DES
• MI(PWSH)
• Who's hurting whoHelen Spandler/42nd street
• karen_at_roncolemanvoices.co.uk

4
Some Tips we can explore

• First separate self harm from suicide, when they
  co exist treat them as co-morbid
• Self harm is not the problem so dont focus on it
  when working
• Self harm is a messenger that there is a problem,
  help the person listen to the message
• Dont aim for the self harm to stop, aim for the
  person to have more control or to make choices
  and oddly enough it often stops
• Recovery from the problem is natural and we know
  how long it takes even if we do nothing

5
Do we all harm ourselves? How have you self
harmed in the last 7 days?

• What about your clients, how do they self harm.
• When does it become a pathology/illness?
• When is it abnormal?
• Who says?

6
A continuum of self harm
Cutting
Piercing
7
So when, therefore is self harm a problem?
Intensity
functioning
culturally innapropriate
repetitiveness
disruption
distress
control
pervasiveness
severity of outcome
when a medic says!!
8
Define self harm
To do so, differentiate between self injury and
suicide and what about para-suicide?
9
Suicide is--

• Three factors
• A deliberate act
• With direct intent
• to end ones own life.
• Risk assessments should consider the 3 factors

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Self Injury is the Deliberate damaging of Body
Tissue without the conscious attempt to commit
suicide DSM IV TR
3 types
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Self harm

• Any harmful act to the self, or omission, in
  which the direct intent is not to die Smith 2003

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Para suicide

• Two different definitions in use
• A failed suicide attempt
• Harmful acts that appear to be without direct
  intent to die--or may not be repetitive
• Not very helpful?

13
What then are the intents in self harm if it is
not to die?

• To survive
• To communicate
• To cope
• To feel better
• To get help
• Transfer emotional pain to physical
• To show I am different

• To heal
• To see blood
• To check Im alive
• To feel something
• I deserve it/punish self
• To punish others
• To dissociate
• To control something
• Its complex!!

14
Self Injury in psychiatryThe three types
referred to are-

• Major self Mutilation
• Stereotypic self mutilation
• Superficial or moderate self mutilation Singular,
  Episodic, Repetitive

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So where are we now?
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Classifying self harm

• 1st separate the pathological from the
  culturally sanctioned

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Classifying self harm

• Culturally sanctioned
• Rituals Reflect community tradition, underscored
  by deep symbolism, link person to community, done
  to heal, express spiritual enlightenment, marks
  social order
• Practises
• Little underlying meaning, may be fad or fashion,
  ornament, link to cultural group, medical-hygiene
  reasons

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What forms of self harm are culturally acceptable?

• Neck stretching
• Tattooing
• Facial scarring
• Crucifixion
• Lip plates
• Piercing
• Flagellation
• Starvation (fasting)

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What forms of self harm then are acceptable as
fashions?

• Tattooing
• Piercing
• Heroin?
• Food
• Body modification
• Cosmetic surgery
• Tongue splitting

20
So how can we assess severity and when to
intervene?
21
Assessing risk and safety in self harm (SHARS)

• Risk and safety should be jointly considered
  based on the 5 domains of self harm

22
Self Harm Assessment of Risk Safety (SHARS)

• About Judgement
• Considering 5 domains
• Professional, client and carers opinion
• Agreeing the dialectical approach

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5 domains of self harm

• Directness
• Intent
• Potential lethality
• Repetitiveness/frequency
• Control/distress

24
Directness

• How directly is the persons harming/injury linked
  by them or you to their emotions, feelings and
  their history.
• Do people know why they harm themselves, the
  function it has in their life
• To what degree is your self-harm related to how
  you feel? Is your self-harm related to something
  that happened in your life? Do you know why you
  self harm?
• 0 good understanding
• 5 no understanding

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Intent

• How clearly is the persons intent not to die?
• Do you do what you do, to end all your feelings,
  or do you do it to feel better? Score how clear
  you are.
• 0 no desire to die
• 5 unclear or may be suicidal

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Control/Current distress

• To what degree do you have control over if, when
  and how you injure yourself?
• How often do you think about harming yourself,
  how often do you do it? Why are there
  differences between the two? How many different
  ways do you self harm. Consider the most recent
  time you harmed yourself, how able do you
  currently feel to limit it. Do you actually
  limit your self-harm, how far will you go, can
  you stop doing it?Does current distress affect
  this
• 0 great control
• 5 No control, great compulsion or impulsivity

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Potential lethality

• How likely is it that you could die as a result
  of it, through accident or mistake?
• Do you set limits to your harm and keep to them?
  Do you make efforts to keep yourself safe? Have
  you had any near misses? Do you make plans to
  keep yourself safe and to reduce risk? Do you do
  other things to hurt yourself less, such as
  harming in a less hurtful way some of the time or
  doing it when you know others will stop or detect
  you? People who have changed their method of
  self-harm recently should always have potential
  suicidality excluded.
• 0 great effort taken to keep safe
• 5 no efforts or reckless

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Repetitiveness

• How often do you now self harm?
• Are there predictable patterns in your self-harm?
  Is it increasing or is it changing? How often
  are you currently injuring yourself?
• 0 stable and predictable in how often they self
  harm, who are not increasing frequency or are
  decreasing
• 5showing patterns of escalation in intensity and
  severity

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Available frommikesvoice_at_aol.com
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Self harm is still not yet a diagnosis in itself
it is associated with-

• Post Traumatic Stress Disorder
• Dissociative Identity disorder
• Eating disorders
• Character or personality traits (BPD)
• Substance abuse
• Clinical depression
• Psychosis (coping bargaining)

1.1.2
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Repetitive Self Harm Syndrome as a diagnosisThe
BOGSAT method
Bunch Of Guys Sat About a Table The expert
consensus model
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Repetitive self harm syndrome as a diagnosis

• Preoccupation with harming oneself
• Repeated failure to resist impulses to destroy or
  alter oneself
• Increasing tension before and a sense of relief
  after the act of self harm
• No association between the act and suicidal
  intent
• Not a response to retardation, delusion,
  hallucination or transsexual fixed idea.

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Just because we can put a name to it, doesn't
mean that we understand it.
1.3.1
34
So what are the common life experiences of those
who self harm

• Childhood physical or sexual abuse
• Violence at home
• Stormy parental relationships or broken homes
• Loss of a parent through death or divorce
• Lack of emotional warmth from parents/neglect

2.1.1
35
So what are the common life experiences of those
who self harm

• Hypercritical fathers
• A history of medical procedures or illnesses
  resulting in significant hospitalisation in
  childhood
• Parental depression or substance abuse
• Confinement in residential establishments
• Work in the paramedical fields

2.1.2
36
And what personality factors are associated with
self harm by psychiatry

• Perfectionist tendencies
• Dislike of body shape
• Inability to tolerate intense feelings
• Inability to express emotional needs or
  experiences
• Prone to rapid mood swings

2,2.1
37
Other life events associated -

• Loss or abandonment
• Social isolation, confinement or helplessness
• Rejection
• Failure
• Anger
• Guilt

3,1.1
38
How many people self harm

• 1.4 lifetime incidence
• 1,400 per 100,000 population
• Prisoners with PD 24
• Institutionalised people 13.6

• FE students 12
• Bulimia 40.5
• Anorexia 35
• MPD/DID 43

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Anything else?

• Gender 8020 FM !!! But contestable
• Age of onset mean 14 and falling
• Reasons why? 70 coping of some form
• Adult self harm onsets in adolescence 85
• Adults who self harm, attribute self harm to
  childhood trauma in over 95 of cases Romme,
  Ensink, Boevink, Woolthaus
• Links to adult suicide---contentious and unclear

40
Young peoples self harm

• Self-harm is a typically a very private act and
  young people rarely disclose their behaviour to
  an adult, or seek psychological help or medical
  attention.
• Self-harm may be the only way the young person
  can
• communicate their plight to other people
• to try and get the attention, care and comfort
  they need

41
Young peoples self harm

• Self-harm is most common in children over the age
  of 11 and increases in frequency with age. It is
  uncommon in very young children although there is
  evidence of children as young as five trying to
  harm themselves.

42
Young peoples self harm

• Self-harm is more common amongst girls and young
  women than amongst boys and young men. Studies
  indicate that, amongst young people over 13 years
  of age, approximately three times as many females
  as males harm themselves.

43
Young peoples self harm

• A study in Oxford found that approximately 300
  per 100,000 males aged between 15 and 24 years,
  and 700 per 100,000 females of the same age, were
  admitted to hospital following an episode of
  self-harm during the year 2000

44
Young peoples self harm

• A national survey of children and adolescents
  carried out in the community found that 5 per
  cent of boys and 8 per cent of girls aged 13-15
  said that they had, at some time, tried to harm,
  hurt or kill themselves.

45
Young peoples self harm

• In the same national survey, rates of self-harm
  reported by parents were much lower than the
  rates of self-harm reported by children. This
  suggests that many parents are unaware that their
  children are self-harming.

46
Young peoples self harm

• A study carried out in schools in 2002 found that
  11 per cent of girls and 3 per cent of boys aged
  15 and 16 said they had harmed themselves in the
  previous year.
• Average age of starting to injure self is 13
• Carries on into adulthood
• Self harm in adults starts in adolescence

47
The broad reasons why?

• What do you think are the reasons then why a
  person may self harm what are the theories
• Regulate moods and emotions
• To communicate something or be heard
  Alexithymia
• The medical/illness model
• addiction, HPA axis, serotonin, beta endorphin
• To control something, self or others
• learning theories
• Coping with Dysphoria, life, history

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Dysphoria

• People who self-injure tend to be dysphoric --
  experiencing a depressed mood with a high degree
  of irritability and sensitivity to rejection and
  some underlying tension -- even when not actively
  hurting themselves Herpertz (1995)

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Alexithymia Zlotnick, et al (1996)

• Alexithymia is a fairly recent psychological
  construct describing the state of not being able
  to describe the emotions one is feeling.
  Alexithymia was positively linked to
  self-injurious behaviour in a 1996 study
  (Zlotnick, et el.) and is congruent with how
  people who self-injure often describe the
  emotional state before an injury they frequently
  cannot pinpoint any particular feeling that was
  present. This is especially important in
  understanding the communicative function of
  self-injury

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Chronic invalidation Linehan (1999) Pearlmann
(2000)

• "when children experience shaming and punitive
  rhetoric or physical blows rather than responsive
  words" they cannot internalize others are loving
  and cannot develop the capacity to maintain a
  sense of connection to others.
• Linehan referred to this as chronic invalidation,
  which coupled with some personal factors
  (emotional dysregulation) can lead the personb to
  self injury as a way of dealing with the
  psychological and social consequences of the
  above. DBT

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stress-reduction theory, and trauma Herman
(1992),

• Most children who are abused discover that a
  serious jolt to the body, like that produced by
  self-injury, can make intolerable feelings go
  away temporarily. This may help explain how
  self-injury gets entrenched as a coping mechanism

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Physiological

• Cortisol
• Serotonin
• Beta endorphin
• Regulation of HPA axis
• Physiological consequences of trauma,
  invalidation and abuse.

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However there are other views and unfortunately
established wisdom!
54
Self harmers in psychiatric services are seen as
attention seeking, are disliked by staff and are
seen as in control of manipulative behaviour.
55
Institutional wisdom perceives these
performances as the maladaptive attention
seeking malignancy of untreatable psychopaths.
5,2.1
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Recent studies have suggested some alarming links
between sexual abuse and the development of
mental distress in later life, many of these
links made by the self harmer themselves.
Romme Escher (1993) Boevink (1995) . In their
study Diclemente et al (1991) found that amongst
adolescents in a psychiatric service who reported
childhood sexual abuse, 83 cut themselves. This
mental distress is believed to be a common factor
which may manifest itself in many ways. The
commonest of these ways is in some form of self
harm.
7,4.1
57
Self injury is quite an obvious response to
abuse. The need to get rid of the filth is
often reported by survivors of abuse who cut
themselves to get rid of internalised feelings of
shame Dianne Harrison (1994)
7,4.2
58
If I wanted to attract attention to myself Id
take my clothes off in the streets, it would be a
lot less painful.L R Pembroke (1997)
8,4.1
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The psychoanalytical theories of suicide and self
harm prove, perhaps, only what was already
obvious that the process which leads a man to
take his own life or injure himself are at least
as complex and difficult as those by which he
continues to live. The theories help to
untangle the intricacy of motive and define the
deep ambiguity of the wish to die or need to
injure but say little about what it means to be
suicidal, to be a self harmer, and more
importantly how it feels. The theories tell a
lot yet say so little about what it feels like to
self harm.
10,1.1
60

• Karl Marx the only antidote to mental suffering
  is physical pain
• B ass CP wearing the scars of your suffering
• Reduce all your fears and anxieties to a single
  knifepoint
• It forces your brain to go into survival mode

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Eleanors story

• Abandoned at birth, in care to age 2yrs, in
  potential foster family2-5, they sent her back,
  in group fostering 5-10, adopted age 10, raped by
  adoptive father aged 12-14, disclosed abuse,
  taken back to care, father found guilty, Eleanor
  threatened mother with knife, jailed for 8yrs for
  attempted murder, served 17 yrs in secure
  hospital treated as a muppet and a murderer.
  Found biological family recently, 2 older, 2
  younger siblings.
• Why does she self harm?
• What can you do to help her?

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So what can we do?
For professionals the recovery approach implies a
fundamental shift from doing for to doing with,
similarly for the system or team, the fundamental
shift is from mental health solutions to
solutions which involve a broad array of
governmental and community resources
14,3.1
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Making sense of it all

• People generally do things for reasons that make
  sense to them. The reasons may not be apparent or
  may not fit into our frame of reference, but they
  exist and recognizing their existence is crucial
  to understanding self-harm
• With understanding of the reasons behind
  self-harm comes knowledge of the ways of moving
  on, making choices, hurting yourself less,
  learning other ways of coping with feelings or
  managing your own risks.

64
A systematic model for making sense of your
experiences and working toward your recovery

• Turning points
• Identifying
• Exploring
• Understanding
• Resolving and moving on

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Turning point

• A clear turning point which may be a result of an
  event or an individuals inspiration which results
  in you resolving to move on and determining to
  conquer barriers to you living your life. Topor
  et al (1998)

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Turning point activities

• Give information
• Inspire
• Offer opportunities
• Meet others
• Have hope
• Self help
• Alternative belief systems DES, survival
• Focus upon recovery not maintenance

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Famous people who have self harmed and moved on

• Princess Diana --Bulimia. Relationships, cutting
• Angelina Jolie -cutting
• Kelly Holmes -cutting
• Brad Pitt --cutting and burning
• Gail Porter cutting
• Courtney Love
• Christina Ricci
• And what about drugs and alcohol?

68
Values and perceptions

• Write down, brainstorm all the different ways you
  use to cope with life
• As a group decide which are positive or negative
  coping strategies

69
Negative
Positive
Neutral
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Identifying your experiences

• Identifying and forming a clear view in your own
  language about what your experiences actually
  have been, how they have changed, when they
  happened and what were the effects upon you.

71
Activities to identify your experiences

• Life history
• write the three most important things in your
  life!!
• Interviewing
• Guiding
• Specific questions
• When did it start
• What was happening
• Why

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Writing life histories

• Leave people alone where possible
• Review and revisit life history
• Our perception of history changes over time
• Write it in your own words
• How you interpret it (the client)
• Write it in 3rd person if too painful
• Write a novel

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Exploring your experiences

• Exploring in depth why and how you have become
  distressed including any things that trigger your
  current experiences, relating it beyond yourself
  to your social system such as the responses of
  mental health services. What has helped, what
  hinders, who helps.

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Activities to explore your experiences

• Explore in depth
• Look at dissociation
• Look at how you feel before and after
• How has it changed from 1st experience why
• What has helped you, what hasnt
• What are the real problems, is it self harm or
  other things or other people?
• Most recent experience

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Activities to explore your experiences

• Others reactions
• Triggers
• Links to your feelings

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Understanding your experiences

• Links, are your voices/beliefs/harm related to
  anything in your life. Can you do anything about
  this, do you want to. What are your beliefs or
  frame of reference for your experience

77
Activities to understand your experiences

• Create an ego document
• Get advice from others and alternate explanations
  
• Medical, trauma, dissociation, addiction,
• AHP axis, impulse control, learning,coping,
  survivor
• Be clear what you believe
• Get support
• Get direction (therapy)

78
Life histories versus ego documents

• Write down the three most important life events
  that have formed you as a person?
• Why are they important!!
• Why have they made you the person you are
• How do they effect you, how has it shaped your
  personalitywho you are

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Resolving moving on with your experiences

• What will help you, what coping mechanisms can
  you learn, can you resolve or accept any past
  issues in your life that are significant, where
  can you get the things that can help. What can
  mental health services do to help you, how can
  you develop alliances.

80
Activities to move on

• Where do you want to go
• PCP
• Deal with problems
• Find yourself not guilty
• Path
• Essential lifestyle plans
• Getting unstuck
• Recovery planning (Coleman et al)
• WRAP
• Harm reduction
• Finding for yourself less harmful ways of coping

81
How can you help people to hurt themselves less

• Write down all the things you can think of

82
Coping angry, frustrated, restless

• Try something physical and violent, something not
  directed at a living thingSlash an empty
  plastic soda bottle or a piece of heavy cardboard
  or an old shirt or sock. Make a soft cloth doll
  to represent the things you are angry at. Cut and
  tear it instead of yourself. Flatten aluminum
  cans for recycling, seeing how fast you can go.
  Hit a punching bag. Use a pillow to hit a wall,
  pillow-fight style. Rip up an old newspaper or
  phone book. On a sketch or photo of yourself,
  mark in red ink what you want to do. Cut and tear
  the picture. Make Play-Doh or other clay models
  and cut or smash them. Throw ice into the
  bathtub or against a brick wall hard enough to
  shatter it. Break sticks. These things work
  even better if you rant at the thing ur
  cutting/tearing/hitting.
• Start out slowly, explaining why I you are hurt
  and angry, sometimes end up swearing and crying
  and yelling. It helps a lot to vent like
  that.Crank up the music and dance. Clean your
  room (or your whole house). Go for a
  walk/jog/run. Stomp around in heavy shoes. Play
  handball or tennis.

83
Coping sad, soft, melancholy, depressed, unhappy

• Do something slow and soothing, like taking a hot
  bath with bath oil or bubbles, curling up under a
  quilt with hot cocoa and a good book, looking
  after yourself somehow. Do whatever makes you
  feel taken care of and comforted. Light
  sweet-smelling incense. Listen to soothing music.
  Smooth body lotion into the parts or yourself you
  want to hurt. Call a friend and just talk about
  things that you like. Make a tray of special
  treats and tuck yourself into bed with it and
  watch TV or read. Visit a friend.

84
craving sensation, feeling depersonalised,
dissociating, feeling unreal

• Do something that creates a sharp physical
  sensation Squeeze ice hard (this really hurts).
  (Note putting ice on a spot you want to burn
  gives you a strong painful sensation and leaves a
  red mark afterward, like burning would.) Put a
  finger into a frozen food (like ice cream) for a
  minute. Bite into a hot pepper or chew a piece
  of ginger root. Rub liniment under your nose.
  Slap a tabletop hard. Snap your wrist with a
  rubber band. Take a cold bath. Stomp your feet
  on the ground. Focus on how it feels to breathe.
  Notice the way your chest and stomach move with
  each breath. NOTE Some people report that
  being online while dissociating increases their
  sense of unreality be cautious about logging on
  in a dissociative state until you know how it
  affects you.

85
wanting focus

• Do a task (a computer game like tetris or
  minesweeper, writing a computer program,
  needlework, etc) that is exacting and requires
  focus and concentration.
• Eat a raisin mindfully. Pick it up, noticing how
  it feels in your hand. Look at it carefully see
  the asymmetries and think about the changes the
  grape went through. Roll the raisin in your
  fingers and notice the texture try to describe
  it. Bring the raisin up to your mouth, paying
  attention to how it feels to move your hand that
  way. Smell the raisin what does it remind you
  of? How does a raisin smell? Notice that you're
  beginning to salivate, and see how that feels.
  Open your mouth and put the raisin in, taking
  time to think about how the raisin feels to your
  tongue. Chew slowly, noticing how the texture and
  even the taste of the raisin change as you chew
  it. Are there little seeds or stems? How is the
  inside different from the outside? Finally,
  swallow.
• Choose an object in the room. Examine it
  carefully and then write as detailed a
  description of it as you can. Include everything
  size, weight, texture, shape, colour, possible
  uses, feel, etc.
• Choose a random object, like a paper clip, and
  try to list 30 different uses for it.
• Pick a subject and research it on the web. Try
  some of the games and distractions on the net

86
wanting to see blood

• Draw on yourself with a red felt-tip pen. Take a
  small bottle of liquid red food colouring and
  warm it slightly by dropping it into a cup of hot
  water for a few minutes. Uncap the bottle and
  press its tip against the place you want to cut.
  Draw the bottle in a cutting motion while
  squeezing it slightly to let the food colour
  trickle out. Draw on the areas you want to cut
  using ice that you've made by dropping six or
  seven drops of red food colour into each of the
  ice-cube tray wells. Paint yourself with red
  tempera paint.

87
wanting to see scars or pick scabs

• Get a henna tattoo kit. You put the henna on as a
  paste and leave it overnight the next day you
  can pick it off as you would a scab and it leaves
  an orange-red mark behind.
• Another thing that helps sometimes is the
  fifteen-minute game. Tell yourself that if you
  still want to harm yourself in 15 minutes, you
  can. When the time is up, see if you can go
  another 15. I've been able to get through a whole
  night that way before.

88
Wanting to feel pain

• Tattooing
• Piercing
• Slap self
• Try to get what you want without causing lasting
  physical damage

89
Helpful responses to self harm

• Show that you see and care about the person
• Show concern for the injuries themselves, the
  person may be ashamed, frightened and vulnerable
  at this time.
• Make it clear that its okay to talk about the
  self injury
• Convey respect for the persons efforts to survive

90
Helpful responses to self harm

• Help them to make sense of their self injury
• Acknowledge how frightening it is to think of
  life without self injury.
• Encourage them to see the injury as a metaphor
  rather than as a problem in itself
• Help them to build up supportive networks
• Dont see stopping the injury as the goal
• It takes time!

91
Wants of those who self harm

• To caring humane treatment
• To participate in decisions about their care
• To body privacy
• To have the feelings behind SI validated
• To disclose to whom they choose
• To choose their own ways of coping

92
Wants of those who self harm

• To have care providers who are not afraid of Self
  harm
• To have Self harm viewed as a way of surviving
• To not automatically be considered dangerous
• To have Self harm seen as a way of communicating
  rather than manipulating

93
What do people who self harm think that a service
should do?

• Not confuse it with suicide?
• Help us look at life
• Accept our view
• Look at our relationships
• Help us make decisions/choices
• Relieve distress

• Accept us
• Help us see future
• Explore our feelings
• listen
• Help find solutions
• Keep us safe

94
What type of support

• Information about alternatives
• Publicity explaining Self Harm
• Specialised services
• Opportunity for anonymity
• Someone to talk to

• Something different
• Value us as people
• Non judgmental
• Choices
• Talking treatments
• Self help

95
What type of support

• Staff to realise they cant make it better
• Staff to be human
• Help us in recovery
• Person centered
• Be honest about barriers
• Do with not for

• Cares about its staff
• Offers supervision to staff
• Professions to be aware
• No labeling