Managing Self Harm
Definition
Self harm can be defined as the intentional or direct injuring to one’s body without suicidal intent. Practitioners may also note it being called self-mutilation, deliberate self harm, self wounding or para suicide.
Who self harms and how
The most common form of self harm is cutting but other forms include overdoses, burning, scratching, head banging or interfering with healing wounds.
Self harm appears to be most commonly associated with borderline personality disorder (see Borderline PD Top Tips), but it is also linked to other personality disorders and substance misuse. However, just to complicate matters, people who are suffering from anxiety, depression or PTSD do sometimes self harm.
This is why it is important to make sure that the service user is reviewed by mental health services, particularly if the diagnosis is unclear.
Why self harm
Self harm can be thought as a behaviour which has a meaning and a function which is hidden – sometimes hidden from the service user as well as the practitioner. Service users who experience intense emotions which they have few skills to manage, may find it incredibly difficult to talk about their distress without ‘acting out’ first.
You can try and work out the meaning and function from the list below:
- Communicating distress to others
- Trying to make other people help or notice you
- Trying to regain control of intense emotions or difficult interpersonal situations
- Soothing intense feelings or distracting from them
- Seeking a ‘buzz’ (including releasing a biological ‘natural high’ from a surge of endorphins in the brain)
- Striving to feel ‘real’, and in touch with the world
- Looking for a temporary escape from problems (rather than the permanent escape of suicide)
- Punishing oneself in response to feelings of guilt or shame, however irrational
So, a service user who self harms habitually can be like a drug addict – sometimes seeking a high, sometimes wanting to avoid a low.
What is the link between self harm and suicide?
Unfortunately, proportion of those who self harm go on to commit suicide. This is worrying for the practitioner who may become used to (and perhaps exasperated with) a service user self harming and subsequently recovering, and therefore suicide will come as a terrible shock.
We think that suicide may occur for the following reasons:
- The service user never intended to die, but because of the personality disorder traits of impulsiveness and recklessness, they misjudge the situation and are not saved in time.
If you think a service user is engaging in very reckless self harming behaviour which is potentially lethal, don’t be afraid to talk to them about your concerns.
- The service user becomes seriously depressed, but these symptoms are hidden and missed by services because of a lifetime of dysfunctional ways of coping and relating to others.
Mental health services are not always helpful when someone has a personality disorder and repeatedly self harms; however, if you think something has changed in the service user, and you are increasingly worried, do not hesitate to ask for advice from the local GP or mental health team.
Impact on the practitioner
Service users who self harm – particularly those who do it fairly regularly – have an impact on the practitioner. You might feel:
Disgust – the behaviour and the wounds are really repulsive
Anxiety – you just can’t tell whether the service user is going to kill him/herself, and you just can’t shake off that worried feeling, even when out with friends or when going to sleep
Anger – you spent ages trying to sort out access to services, offering support above and beyond the call of duty, only to find that when you follow up with a phone call, the service user is out drinking with friends
Guilt – you’re exhausted and simply can’t gather the energy to try and resolve the situation yet again; you’re secretly furious with the service user but feel really bad about.
The two R’s – rescue and reject
The above feelings draw you into tricky behaviours. The impulse to rescue the service user (with extra time and extra help, breaking a few small rules to sort things out) is often followed by a strong desire to reject the service user, not least because s/he caused problems for you by going to others behind your back and dismissed your efforts.
There is more information about these dynamics in the Top Tips section for Borderline PD.
The practitioner’s stance – do’s and don’ts
| DO | DON’T |
|---|---|
| Make sure the service user receives the necessary medical help | Fuss over the injury or the service user |
| Take an interest in the reasons for self harming | Let any sense of judgement or disapproval enter into your enquiries |
| Focus on the service user’s emotional distress, and empathise | Comment on whether self harm was the right or wrong response to distress |
| Aim to reduce the frequency and seriousness of self harm | Set yourself (and the service user) up for failure by aiming for abstinence |
| Explore a range of explanations for the behaviour | Dismiss the service user’s stated wish to die |
| Stick with it despite setbacks | Give up at the first disappointing hurdle |
| Be confident that talking about self harm is helpful to the service user | Worry that talking about self harm will prompt a service user to hurt him/herself |
Managing self harm
There are three steps to managing self harm, set out in the Figure below.
Identify the service user’s history of self harm, including the types and the reasons.
Analyse, in collaboration with the service user, the patterns of self harm in order to work out what are the triggering events. Triggers to self harm can be
- thoughts (I am useless, what’s the point, if he doesn’t care, why should I?)
- feelings (sadness, fear, anger)
- behaviour (drunk or high in some way)
- relationships (a row or rejection)
In order to help the service user think about triggers, you might want to develop a time line of relevant triggers. Some might occur just before the act of self harm, but others might have happened earlier in the day or a few days beforehand. The time line below provides an opportunity to add in the consequences as well as the triggers to self harm. The service user might find it difficult to talk about consequences as it could suggest something ‘positive’ about a situation which is experienced as very distressing.
Timeline
Intervene
Now you have a clearer idea of the problem, and the likely triggers, you need to work with the service user to develop a plan. This could be a crisis plan or cue card. It needs to be agreed to and owned by the service user – there’s no point insisting on something that won’t be used. Please see example crisis plan / cue card for more information.
Suggested techniques:
Distraction: listening to music, watching a movie, playing football, going for a walk (make sure s/he doesn’t ruminate while walking)
Replacement: using a stress busting toy, going to the gym, replacing pills with smarties in the bathroom, shouting into a pillow
Processing: write down thoughts and feelings, ring a trusted friend, call the Samaritans
In a crisis: ring…., pop down to ….., attend A & E out of hours
