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

Working with individuals

who self-harm

SCOTTISHPersonality Disorder Network


Outline

Working with self-harming clients; what

are we working with?

Encountering dilemmas

Supporting staff

Managing ourselves and others

Reflection and returning to work


Self-harm

“ …. an individual intentionally

damaging a part of his or her own

body, apparently without a conscious

intent to die”

Feldman, 1988


Self-harm

“…intentional self-poisoning or

injury, irrespective of the apparent

purpose of the act”

NICE Guidelines, 2004


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


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


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


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


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


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


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’


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)


Relationships


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


Clinical dilemmas

Staff/client relationship

Punishment and attack

Mindful or mindless

Anxiety and fear

A player in a play

The community as a vessel



Staff containing aspects of the patient;

communication, projection (anger, fear)

Dilemma of being controlling/neglectful

Staff member as a passive or impotent

figure



“External figures are often recruited in

ways which support the internal

psychic structures”Evans, 1998


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


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


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)


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


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


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


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


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


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

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

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