Making sense of self harm

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Making sense of self harm
Dr Mike Smith mikesvoice_at_aol.com
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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

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Suicide is--

• Three factors
• A deliberate act
• With direct intent
• to end ones own life.

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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 Injury in psychiatryThe three types
referred to are-

• Major self Mutilation
• Stereotypic self mutilation
• Superficial or moderate self mutilation

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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?

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So if its not suicide what is it??
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Self harmers in psychiatric services are seen as
attention seeking, are disliked by staff and are
seen as in control of manipulative behaviour.
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Institutional wisdom perceives these
performances as the maladaptive attention
seeking malignancy of untreatable psychopaths.
5,2.1
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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)
Dont over emphasize your importance in your cli
ents life, you arent that important that they
would hurt themselves, its not personal.
8,4.1
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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

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

• Escape emptiness
• Ease tension
• Reduce emotions to levels you can cope with
• Grounding in reality
• Maintain security
• Continuing abuse
• Prevent something worse

• Relieve intense feelings
• Escape numbness
• To feel euphoria
• Influence others
• Prevent suicide
• Addicted to crisis
• Its complex!!

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The reasons can be grouped into 3 broad groups

• Affect regulation -- Trying to bring the body
  back to equilibrium in the face of turbulent or
  unsettling feelings. This includes reconnection
  with the body after a dissociative episode,
  calming of the body in times of high emotional
  and physiological arousal, validating the inner
  pain with an outer expression, and avoiding
  suicide because of unbearable feelings. In many
  ways, self-harm is a "gift of survival." It can
  be the most integrative and self-preserving
  choice from a very limited field of options.

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The reasons can be grouped into 3 broad groups

• Communication -- Some people use self-harm as a
  way to express things they cannot speak. When the
  communication is directed at others, the SIB is
  often seen as manipulative. However, manipulation
  is usually an indirect attempt to get a need met
  if a person learns that direct requests will be
  listened to and addressed the need for indirect
  attempts to influence behavior decreases. Thus,
  understanding what an act of self-harm is trying
  to communicate can be crucial to dealing with it
  in an effective and constructive way.

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The reasons can be grouped into 3 broad groups

• Control/punishment -- This category includes
  trauma re enactment, bargaining and magical
  thinking (if I hurt myself, then the bad thing I
  am fearing will be prevented), protecting other
  people, and self-control. Self-control overlaps
  somewhat with affect regulation in fact, most of
  the reasons for self-harm listed above have an
  element of affect control in them.

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The assumption is that the alternative to
self-injury is "acting normally," but on the
contrary . . . the alternative to self-injury is
total loss of control and possibly suicide. It
becomes a forced choice from among limited
options.Solomon and Farrand (1996)
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So what are the reasons why people harm
themselves?

• What are people trying to communicate
• What are they coping with
• Why should they be punished
• What is their fault
• Why cant you feel
• Why do you dissociate
• Why do you feel dead

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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
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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
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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
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Other life events associated -

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

3,1.1
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Alexithymia

• Alexithymia is a fairly recent psychological
  construct describing the state of not being able
  to describe the emotions one is feeling. they
  frequently cannot pinpoint any particular feeling
  that was present. This is especially important in
  understanding the communicative function of
  self-injury "Rather than use words to express
  feelings, an alexithymic's communication is an
  act aimed at making others feel those same
  feelings" (Zlotnick et al., 1996).

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And also

• Belonging, do you feel wanted, do you feel as if
  you are noticed!
  
• A combination of Life events and the formation of
  self/ internalisation of those expereinces

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Why do more women appear to self harm?

• Women are not socialized to express violence
  externally and when confronted with the vast rage
  many self-injurers feel, women tend to vent on
  themselves. Miller (1994)
• Men are socialized in a way that makes repressing
  feelings the norm

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Why do more women appear to self harm?

• "Most women have not even been able to touch this
  anger except to drive it inward like a rusted
  nail."
  
• Adrienne Rich
• "Men act out. Women act out by acting in."

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Why do more women appear to self harm?

• Linehan's (1993) theory that self-harm results in
  part from chronic invalidation, from always being
  told that your feelings are bad or wrong or
  inappropriate. This experience is more
  applicable to Women than Men

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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
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assessing severity and when to intervene?
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Assessing risk and safety in self harm (SHARS)

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

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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

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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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Using a workbook and helping
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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

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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!

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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

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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

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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

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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

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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

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A systematic model for working toward 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
• Self help
• Alternative belief systems DES, survival
• Focus upon recovery not maintenance

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Famous people who self harm

• 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?

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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
  

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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.

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Activities to identify your experiences

• Life history
• write the three most important things in your
  life!!
  
• Interviewing MIPSH
• 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

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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)

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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.

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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
• Less harmful ways of coping

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Hurting yourself less

• Substitute, what do you get from self harm, can
  you get it another way?

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Hurting yourself less

• 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.

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Hurting yourself less

• 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.
• Rant at the thing I am cutting/tearing/hitting. I
  start out slowly, explaining why I am hurt and
  angry, but sometimes end up swearing and crying
  and yelling. It helps a lot to vent like that.

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Hurting yourself less

• 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.
• Have a fight

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Hurting yourself less

• sad, soft, melancholy, depressed, unhappy
• Do something slow and soothing, like taking a hot
  bath with bath oil or bubbles, curling up under a
  comforter with hot cocoa and a good book, babying
  yourself somehow. Do whatever makes you feel
  taken care of and comforted. Light sweet-smelling
  incense

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Hurting yourself less

• Listen to soothing music
• Smooth nice 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.

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Hurting yourself less

• 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, kind of like burning would.)
  Put a finger into a frozen food (like ice cream)
  for a minute.

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Hurting yourself less

• 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.

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Hurting yourself less

• 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.

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Hurting yourself less

• 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 games and distractions

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Hurting yourself less

• 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 paint.

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Hurting yourself less

• 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

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EVALUATE AND CHANGE YOUR LIFE CIRCUMSTANCES IF
NECESSARY.

• As long as you are in a physically or emotionally
  unsafe environment, it will be much harder (maybe
  impossible) for you to stop providing yourself
  with relief through self-injury. Ask yourself how
  you feel about where you are living....who you
  are living with....how you spend your days. Are
  you comfortable with these things? If not, start
  focusing on changing them. Support groups or
  therapists can be helpful for this.

79
DECIDE IF YOU WANT TO STOP SELF-INJURING NOW

• For some people, the rewards that they get from
  hurting themselves so far outweigh the negative
  consequences that they have little desire to stop
  this behaviour immediately and the idea of doing
  so is very threatening. If this is the case for
  you, you may want to focus on longer term
  suggestions for changing your life, rather than
  focusing on immediate control of your self-injury
  behaviour.

80
IF YOU WANT TO STOP NOW

• Think about the times that you've hurt yourself
  and see if you can identify certain kinds of
  events that provoke the feelings that make you
  want to hurt yourself, or thoughts that you start
  thinking before you self-harm. Write these down.
  Try to recognise these events, or thoughts in the
  future, when they start to occur, rather than
  waiting till the feelings are overwhelming.

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IF YOU FEEL LIKE YOU MIGHT HURT YOURSELF

• Can you wait another 15? Do it if you can.
• Ask what you're feeling. Are you angry? Why?
• Breathe. Sit comfortably with both feet on the
  floor. Feel the grounded-ness of your feet.
  Inhale through your nose for a count of six
  seconds

82
Keep yourself safe

• Stay in the company of others. People usually
  injure themselves privately. Spend as much time
  as possible in public places
  
• Try to delay the act in any way you can
• Try distracting yourself by calling a friend,
  going somewhere, writing in a journal, watching a
  movie, painting a picture, exercising
  
• Set limits
• Go for a run
• Have a hot bath

83
Keep yourself safe

• Even if you end up hurting yourself, recognize
  that you made progress by delaying the act and
  try to delay longer in the future. This is a HARD
  thing to do. As in substance addictions, some
  people find that the longer they go without
  harming themselves, the easier it becomes to
  resist.

84
Keep yourself safe

• Stay away from the materials that you know you
  might hurt yourself with, like razors, glass,
  pins, etc. Many people find it helpful in the
  short term to remove razor blades or other
  tempting items from their home.

85
Keep yourself safe

• Some people find that the impulse to injure
  themselves passes if a loved one holds them
  tightly when they feel overwhelmed by feelings or
  out of touch with their bodies. Since many people
  who self-harm have been abused in some way, this
  may not work for them, or the choice of who can
  hold them should be made very carefully.
  Sometimes having someone hold your hand, or
  stroke your arm is helpful.

86
Keep yourself safe

• Some people find it helpful to say "NO!" or
  "STOP!" out loud to themselves when they think of
  hurting themselves, and this seems to interrupt
  the immediacy of their usual self-injury response
  to stress. In essence, it helps them think before
  acting and take responsibility for their
  self-harm.

87
As one more example

• Try to substitute more socially accepted methods
  such as piercing your ears (again), or better yet
  get your hair cut or your hair color changed.