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Making sense of self harm


The basics of self harm, definitions, separating suicide from self harm, risk ... Angelina Jolie -cutting. Kelly Holmes -cutting. Brad Pitt --cutting and burning ... – PowerPoint PPT presentation

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Title: Making sense of self harm

Making sense of self harm
  • Dr Mike Smith

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

Some publications referred to todaymail me
  • 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

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

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?

A continuum of self harm
So when, therefore is self harm a problem?
culturally innapropriate
severity of outcome
when a medic says!!
Define self harm
To do so, differentiate between self injury and
suicide and what about para-suicide?
Suicide is--
  • Three factors
  • A deliberate act
  • With direct intent
  • to end ones own life.
  • Risk assessments should consider the 3 factors

Self Injury is the Deliberate damaging of Body
Tissue without the conscious attempt to commit
suicide DSM IV TR
3 types
Self harm
  • Any harmful act to the self, or omission, in
    which the direct intent is not to die Smith 2003

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?

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!!

Self Injury in psychiatryThe three types
referred to are-
  • Major self Mutilation
  • Stereotypic self mutilation
  • Superficial or moderate self mutilation Singular,
    Episodic, Repetitive

So where are we now?
Classifying self harm
  • 1st separate the pathological from the
    culturally sanctioned

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

What forms of self harm are culturally acceptable?
  • Neck stretching
  • Tattooing
  • Facial scarring
  • Crucifixion
  • Lip plates
  • Piercing
  • Flagellation
  • Starvation (fasting)

What forms of self harm then are acceptable as
  • Tattooing
  • Piercing
  • Heroin?
  • Food
  • Body modification
  • Cosmetic surgery
  • Tongue splitting

So how can we assess severity and when to
Assessing risk and safety in self harm (SHARS)
  • Risk and safety should be jointly considered
    based on the 5 domains of self harm

Self Harm Assessment of Risk Safety (SHARS)
  • About Judgement
  • Considering 5 domains
  • Professional, client and carers opinion
  • Agreeing the dialectical approach

5 domains of self harm
  • Directness
  • Intent
  • Potential lethality
  • Repetitiveness/frequency
  • Control/distress

  • 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

  • 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

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
  • 0 great control
  • 5 No control, great compulsion or impulsivity

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

  • 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
  • 5showing patterns of escalation in intensity and

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)

Repetitive Self Harm Syndrome as a diagnosisThe
BOGSAT method
Bunch Of Guys Sat About a Table The expert
consensus model
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
  • Not a response to retardation, delusion,
    hallucination or transsexual fixed idea.

Just because we can put a name to it, doesn't
mean that we understand it.
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

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
  • Parental depression or substance abuse
  • Confinement in residential establishments
  • Work in the paramedical fields

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
  • Prone to rapid mood swings

Other life events associated -
  • Loss or abandonment
  • Social isolation, confinement or helplessness
  • Rejection
  • Failure
  • Anger
  • Guilt

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

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

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
  • Self-harm may be the only way the young person
  • communicate their plight to other people
  • to try and get the attention, care and comfort
    they need

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.

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.

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

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.

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.

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

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
  • The medical/illness model
  • addiction, HPA axis, serotonin, beta endorphin
  • To control something, self or others
  • learning theories
  • Coping with Dysphoria, life, history

  • 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)

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

Chronic invalidation Linehan (1999) Pearlmann
  • "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

stress-reduction theory, and trauma Herman
  • 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

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

However there are other views and unfortunately
established wisdom!
Self harmers in psychiatric services are seen as
attention seeking, are disliked by staff and are
seen as in control of manipulative behaviour.
Institutional wisdom perceives these
performances as the maladaptive attention
seeking malignancy of untreatable psychopaths.
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
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)
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)
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.
  • 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
  • It forces your brain to go into survival mode

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?

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
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.

A systematic model for making sense of your
experiences and working toward your recovery
  • Turning points
  • Identifying
  • Exploring
  • Understanding
  • Resolving and moving on

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)

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

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?

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

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.

Activities to identify your experiences
  • Life history
  • write the three most important things in your
  • Interviewing
  • Guiding
  • Specific questions
  • When did it start
  • What was happening
  • Why

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

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.

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

Activities to explore your experiences
  • Others reactions
  • Triggers
  • Links to your feelings

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

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,
  • Be clear what you believe
  • Get support
  • Get direction (therapy)

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

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.

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

How can you help people to hurt themselves less
  • Write down all the things you can think of

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
  • 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.

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.

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.

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,
  • 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

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.

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.

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

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

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!

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

Wants of those who self harm
  • To have care providers who are not afraid of Self
  • 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

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

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

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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