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Self harm
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How to manage self harm

• PPT Sommerkurs, Storefjell 2007
• Per Johan Isdahl
• Ullevål University Hospital
• Finn Skårderud
• Lillehammer University College
• Ullevål University Hospital

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Definition A non-life threatening, non-suicidal
self-inflicted bodily harm that is not socially
accepted
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Functions of self harm

• Primary function is affect regulation relieve
  negative emotions (Suyemoto 1998, Gratz 2003)
• Contrary to conventional wisdom, research has
  failed to document that the primary intent of
  self harm behaviour is to elicit a caring
  response from the environment (Gratz 2003, Brown
  et al. 2002)
• Effects on relations often functioning as
  triggers for new episodes of self harm

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• The what
• Search for meaning in symptoms and behaviour
• The how
• The embodied expressions of inner say something
  important about function of mind

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The dilemma of therapeutic alliance

• Put simply, no one loves self-mutilators.
• Armando R. Favazza

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Psychotherapy
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• Psychodynamic traditions
• Mentalisation-based treatment (Bateman Fonagy,
  2004, 2006)
• Cognitive traditions
• Dialectical behaviour therapy (Linehan 1993)

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DBT and MBT

• Common
• Originally developed for borderline personality
  disorders
• Manuals
• Treatment context Combination of group and
  individual therapy
• Psychoeducation
• Scientific evidence

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Cognitive traditions
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Self harm truisms

• Challenging dysfunctional cognitions
• Self harm is acceptable
• Ones body and self are disgusting and deserving
  punishment
• Action is needed to reduce unpleasant feelings
  and bring relief
• Overt action is necessary to communicate feelings
  to others

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Dialectical behavioural therapy

• Dialectic?
• Balancing insistence on change and an acceptance
  of self harm behaviour as a legitimate effort to
  deal with life circumstances.
• Acceptance and validation as therapeutic stance
  (inspired by zen).
• Change refers to cognitive techniques and
  behavioural modification.

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Structure

• Four modes working with self harm
• Skills training group
• Individual therapy
• Telephone consultations
• Consultation team

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Skills training group

• Mindfulness
• Self-validation, acceptance, metareflection
• Relational skills
• Describe, observe, represent oneself, present
  wishes, negotiate etc.
• Affect regulation
• Reflexive relation to ones emotions and
  opposite actions
• Endure
• Tools to prevent acting out distract, use
  senses, change the present moment by fantasy,
  relaxation

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Use of therapeutic relationship

• Why shouldnt I kill myself?
• You and I have an agreement to work together. I
  know that things are intolerable at this moment,
  but I also know that things will improve. I care
  about you and Im asking you not to do this.
• (McCabe Marcus 2004)

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Agreements

• Treatment targets and procedures should
  explicitly be discussed and agreed upon prior to
  initiating treatment.
• Agreements are considered as a central tool in
  building the therapeutic relationship.
• 24-hour rule contact prior to self harm act,
  not immediately after

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Treatment hierarchy

• Self harm is given highest priority in individual
  therapy
• That is, no other symptoms, behaviours, or issues
  are addressed if self harm ideation or behaviour
  is present or has occurred since the last session.

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Behaviour chain analysis

• The first individual session following self harm
  is used to conduct a behaviour chain analysis of
  the environmental and intrapersonal circumstances
  preceding, during and following the self harm
  act.
• Actual vulnerability
• Immediate triggers
• Positive and negative, short-term and long-term
  consequences of behaviour
• Concludes with alternative coping strategies

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Mentalisation
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MentalisingA new word for an ancient concept

• Implicitly and explicitly interpreting the
  actions of oneself and other as meaningful on the
  basis of intentional mental states (e.g. desires,
  needs, feelings, beliefs, reasons)
• Fonagy et al.

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To see ourselves from the outside and others
from the inside To understand ones
misunderstandings
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Related concepts

• empathy
• insight
• psychological mindedness
• observing ego

• mind-mindedness
• mindfulness
• (self)reflection
• affect consciousness

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Examples from Reading the Mind in the Eyes
(Baron-Cohen et al., 2001)
surprised
Sure about something
joking
happy
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Examples from Reading the Mind in the Eyes
(Baron-Cohen et al., 2001)
friendly
sad
worried
surprised
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Embodied mind
Objective (world)
Intersubjective (mind of others)
Subjective (own mind)
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Embodied mind
Objective (world)
Intersubjective (mind of others)
Subjective (embodied mind)
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The concept of mentalising as a fulcrum for
contemporary theory and research
evolutionary biology
neurobiology
MENTALISING
attachment
theory of mind
Bateman Fonagy
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Reflective function
The Cassel hospital study (Fonagy et al., 1996)
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Modes of psychic reality
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Modes of psychic reality

• Psychic equivalence
• Mind-world isomorphism mental reality outer
  reality
• Intolerance of alternative perspectives
• Self-related negative cognitions and emotions are
  too real
• The very hearth of severe eating disorders and
  self harm

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Modes of psychic reality

• Pretend mode
• Ideas form no bridge between inner and outer
  reality mental world decoupled from external
  reality affects that do not acompany thoughts
• Linked with emptiness, meaninglessness and
  dissociation in the wake of trauma
• In therapy endless inconsequential talk of
  thoughts and feelings
• Combined with the patients overcompensations in
  skills and social relations, this may confuse
  therapists

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Modes of psychic reality

• Teleological stance
• Expectations concerning the agency of the other
  are present but these are formulated in terms
  restricted to the physical world
• Patients cannot accept anything other than a
  modification in the realm of the physical as a
  true index of the intentions of the other.
• Again eating disorders and self harm precisely
  illustrates this

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Opaqueness of feelings

• Applied on eating disorders and self harm when
  psychic reality is poorly integrated, the body
  may take on an excessively central role for the
  continuity of the sense of self. Not being able
  to feel themselves from within, they are forced
  to experience the self from without

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• But he said to them Unless I see the nail marks
  in his hands and put my finger where the nails
  were, and put my hand into his side, I will not
  believe it.
• John 20 25

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Treatment implications
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The Bateman-Fonagy principle

• A therapeutic treatment will be effective to the
  extent that it is able to enhance the patients
  mentalising capacities without generating too
  many iatrogenic effects.
• Iatrogenic effects are reduced if intensity is
  carefully titrated to patient capacities and if
  treatment is coherent and flexible.

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On feelings

• Ones own thoughts are central to many therapies
  (e.g. CBT)
• In Mentalisation-based therapy this is extended
  to and emphasises
• The thoughts of others
• The feelings of others and oneself
• The process by which thoughts and feelings are
  communicated
• The role played by misunderstanding thoughts and
  feelings
• The role played by non-mentalising interactions
• In mentalising therapy, feelings are given top
  priority
• Central to change is recognising and empathising
  with the feelings of others breaks inhibitory
  cycle

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Interventions

• Key intervention
• To model the inquisitive stance mentalising
  stance
• Balance intensity of attachment relationship and
  complexity of mentalization

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Therapist Stance

• Not-Knowing
• Identify difference I can see how you get to
  that but when I think about it it occurs to me
  that he may have been pre-occupied with something
  rather than ignoring you.
• Acceptance of different perspectives
• Active questioning
• Monitor you own mistakes
• Model honesty and courage via acknowledgement of
  your own mistakes
• Current
• Future
• Suggest that mistakes offer opportunities to
  re-visit to learn more about contexts,
  experiences, and feelings

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Interventions

• Simple sound-bite
• Affect focused (love, desire, hurt, catastrophe,
  excitement)
• Focus on patients mind (not on behaviour)
• Relate to current event or activity
• De-emphasise unconscious concerns in favour of
  near-conscious or conscious content

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Mirroring sadness
Non-marked mirroring
Marked mirroring
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Clinical pathway for interventions
Identify the Affect not simply the behaviour
Explore the emotional context
Process not content
Define the current Interpersonal context outside
Examine the broad interpersonal theme in treatment
Explore the specific (transference) context
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How do I deal with self harm?

• Intervention
• Empathy and support
• You must not have known what to do?
• Oh dear! That must be disappointing after all
  this time.
• Define interpersonal context
• Detailed account of days or hours leading up to
  self-harm with emphasis on feeling states
• Moment to moment exploration of actual episode
• Explore communication problems
• Identify misunderstandings or over-sensitivity
• Identify affect
• Explore the affective changes since the previous
  individual session linking them with events
  within treatment
• Review any acts thoroughly in a number of
  contexts including individual and group therapy.

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How do I deal with self harm?

• Explore conscious motive
• How do you understand what happened?
• Who was there at the time or who were you
  thinking about?
• What did you make of what they said?
• Challenge the perspective that the patient
  presents
• DO NOT
• mentalise the transference in the immediacy of a
  suicide attempt or self-harm
• Interpret the patients actions in terms of their
  personal history, the putative unconscious
  motivations or their current possible
  manipulative intent in the heat of the moment.
  It will alienate the patient.