Working with individuals who self-harm

1. Working with individuals who self-harm SCOTTISH Personality Disorder Network

2. Outline • Working with self-harming clients; what are we working with? • Encountering dilemmas • Supporting staff • Managing ourselves and others • Reflection and returning to work

3. Self-harm “ …. an individual intentionally damaging a part of his or her own body, apparently without a conscious intent to die” Feldman, 1988

4. Self-harm “…intentional self-poisoning or injury, irrespective of the apparent purpose of the act” • NICE Guidelines, 2004

5. Self-harm “…a deliberate act to damage yourself, without intending to die. This varies according to the situation, the individual carrying out the act and is a means of getting away from intolerable thoughts or feelings” HOTUSH

6. Self-harm • Cutting, bleeding, overdosing, head-banging, ingestion of objects, burning, use of ligatures • Substance misuse and consequential risks • Getting harm from others (acting provocatively) • Provoking negative responses/treatment in therapy • Engaging in high risk activities

7. Self-harm No definitive description: • Harming behaviours are both conscious and enacted in the subconscious • Includes both damage to the body and to the ‘self’ • Can be positive acts or an omission of care or attention

8. Self-harm • Rates increased over the past decade and are amongst the highest in Europe NICE, 2004 • Estimated that 1:130 people or nearly 500,000 engage in self-harm annually Mental Health Foundation, 2004

9. Self-harm and suicide 50% of the 4000 people who commit suicide each year will have self-harmed at some time in the past. NICE, 2004

10. Self-harm and suicide Good creatures do you love your lives And have you ears for sense? Here is a knife like other knives, That cost me eighteen pence. I need but stick it in my heart And down will come the sky, And earth’s foundations will depart And all you folk will die. Housman, cited by Hale 2008

11. Attack and Containment Self-harm can be understood as; • An act to avoid/rid self of something that is perceived as being unbearable • A communication of a sense of damage or of a need for help Both require a ‘host’ or ‘other’

12. Relationships Self-harm and attempted or completed suicide take place within a relationship: • Individual’s relationship with parts of self (internal) • Relationship with key others (internal / external)

13. Relationships

14. Relationships “By opening up the surface of the skin, aspects of the dynamics of the internalised experience are repetitiously evoked, though not consciously recollected” Gardner, 2001

15. Clinical dilemmas • Staff/client relationship • Punishment and attack • Mindful or mindless • Anxiety and fear • A player in a play • The community as a vessel

16. Staff/client relationship • Staff containing aspects of the patient; communication, projection (anger, fear) • Dilemma of being controlling/neglectful • Staff member as a passive or impotent figure

17. Staff/client relationship “External figures are often recruited in ways which support the internal psychic structures” Evans, 1998

18. Punishment and Attack • Self-harm as punishment of part of self • Attack on self preventing attack on another • The externalisation of the attacking internal object • Sense of punishment : staff <-> clients • Attacks on care and thinking

19. Punishment and Attack The patient may launch “an attack on any mental process that might threaten to bring awareness of human need and potentially healthy dependency” Jackson, 1992

20. Mindful and Mindless • A battle to prevent thinking from taking place • Pandora’s box: open it up and what will you discover? Sense of danger • Projection of anxiety and confusion • Permissive states of mind (client/staff)

21. Mindful and Mindless “Even the most bloody examples of self-destructive provocative behaviour may be an attempt to prevent some catastrophe which the patient perceives as even more destructive to his or her own integrity – engulfment, psychosis, violence or complete despair”Campling, 1996

22. Anxiety and Fear • Anxiety is inherent in this work • Sense of danger, fear and anxiety present • Projection of clients’ anxiety into staff • Defences against anxiety (and hopelessness) may lead to a blasé or indifferent approach

23. Anxiety and Fear Some level of anxiety is required to be able “to recognise, appreciate and react to actual situations of danger in external situations” Segal, 1973

24. A Player in a Play • Staff being engaged in the repetition of the patient’s past experiences • Self-harm as an attack re-enacted • Recreation of familiar scenarios • Awareness of a script in which the worker is invited to take up a certain role

25. The Community as a Vessel • Clients’ struggle to contain anxiety and powerful emotions. • Similar difficulty can be experienced by staff • Need for structures to be in place to contain and process the distress and disturbance

26. The Community as a Vessel Containment as “the need for the ‘vessel’ in the form of the community and the worker to be able not only to hold on to the disturbance but to digest and process it” Bion, 1967