RATIFIED VERSION
SELF-INJURY
A Recovery and Evidence Based
Tool Kit
January 2008
Compiled by: Maureen Burke, Nurse Consultant
David Duffy, Nurse Consultant
Gemma Trainor, Nurse Consultant
Mary Shinner, Consultant Clinical Psychologist
CONTENTS
Page Number1 / Background / 3
2 / Therapeutic Alliance / 5
3 / Assessment / 6
4 / General Interventions / 9
5 / Specialist Interventions / 12
6 / Supervision Support and Training / 15
7 / References / 17
8 / Appendices / 20
Acknowledgements
We wish to acknowledge the help and support of the following:
Dr Steve Colgan – Medical Director BSTMHT
Dr Mike Doyle – Nurse Consultant BSTMHT
Keziah Warburton – Ex Service User
West London Mental Health Trust Women’s Service
The North West Self-Injury Interest Group.
Dr Gary L Sidley – Professional Psychology Lead for Salford
1. BACKGROUND
As a Trust, we acknowledge that people who injure themselves are legitimate users of mental health services. One of the momentums for this tool kit is the 2007 Trust-wide Self-Injury Audit, where 100% of services in the Trust identified the need for a Trust-wide tool kit in the assessment, care and treatment of people who self-injure
Myths and Fantasies Surrounding Self-Injury
Arnold (1994) prompts us to dispel the following common myths, as they are unhelpful beliefs when providing care for people whom self-injure, and they mediate against the development, and maintenance of therapeutic alliance.
"Self-Injury is a sign of madness or deep mental disturbance".
"People who self-injure are trying to kill themselves".
"People who injure themselves are a danger to others".
"Self-Injury is about "attention seeking" ".
"Self-Injury is used to manipulate others".
"Self-Injury is just a habit to be stopped".
"People who self-injure enjoy or do not feel physical pain
Self-Injury – meanings and functions
Research
Catherine Allen (1995) points out that "Clients who harm themselves frequently describe a history of physical or sexual abuse in childhood".
Research has confirmed that the act of injuring one’s self provides a range of meanings and functions. This will differ from person to person, and even from injury to injury, but there does appear to be some commonalities in the research. (Arnold 1994, Brodsky et al 1995 Connors 1996(a), Favazza 1989, Haas 2006, Witchell 1991)
Another finding from the research is that people will hurt themselves in order to “feel real”, and this seems to be linked to high levels of dissociation, amongst people who injure themselves. It appears the act of injuring one’s self enables the person to connect back to the “here and now”, as it were, from their dissociated state.
Another function commonly found is that the injuring enables the person to either cope with, or find relief from, unbearable feelings. The feelings reported include predominantly rage, guilt, frustration and anxiety linked to earlier traumatic and invalidating experiences (Babiker and Arnold, 1997, Linehan, 1993).
Other people have said they injure themselves as a way of “surviving”. This is important to note in terms of understanding the meaning and function of a person’s injuring in order to differentiate it from an attempt to take one’s life.
Alongside, but separate from, the ridding of feelings of guilt, the injuring can also provide the person with a means to punish themselves for what they might understand as past misdemeanours, usually involving their being consumed guilt around earlier abuse.
Some people have said that scars on their arms enable them to show their internal scars, or their “war wounds” and that the injuries on their bodies reflects their internal pain.
It is possible there is also a biological perspective and research suggests that people who lacerate themselves experience an endorphin release that again provides an escape from what is felt to be unbearable.
Marc Feldman (1988) said that people whom self-injure have "more frequently experienced parental deprivation". He also says "patients have at times described a need to transform the psychological torment into a manageable physical sensation".
Types of Self-Injury may include:
Cutting Scratching
Burning Scalding
Head banging Inserting objects into wounds
Pulling own hair out Ligatures around the neck.
However, the most common type of Self-Injury is cutting oneself (Arnold 1994)
Self- injury is often linked to suicide and the term "para-suicide" is sometimes used to label the behaviour. In this pack we would like to make it clear that most people who self-injure do not wish to commit suicide, rather, they want to find some tangible way of relieving their emotional pain and distress.
Marc Feldman (1988) supports this view when he highlights that Self-Injury involves "individuals intentionally damaging a part of his/her own body apparently without a conscious intent to die"
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It is worthy of note, however, that there will be times when a person who self-injures feels genuinely suicidal and this would need to be differentiated from the “survival” injuring, and treated accordingly.
Each act of self-harm is a unique experience to the individual and that needs to be recognised and understood to enable more positive outcomes.
Sutton (2005) provides us with the 8 Cs of self-injury. These are:
§ Coping and crisis intervention
§ Calming and comforting
§ Control
§ Cleansing
§ Confirmation of existence
§ Creating comfortable numbers
§ Chastisement
§ Communication
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2. THERAPEUTIC ALLIANCE
The research confirms (Arnold 1994, Connors 1996, Warm et al 2002) that what people who injure themselves find most helpful is a relationship in which they are listened to and supported, not judged, where the boundaries are clear and where those relationships can support them over a long period of time.
Within the overall aim of achieving a delicate balance of not being too far away relationally from the person who injures themselves, therefore being unable to offer safe empathetic and trusting relationships, and not being too intrusive or punitive in your responses to need, which will severely hinder recovery, the challenge for staff is one of being a friendly professional and not a professional friend.
The task in establishing and maintaining a helpful therapeutic alliance with a person who injures themselves is to ensure we remain mindful and aware of our own emotional and intellectual responses (Clarke et al 1998, Fallon 1993, McAllister 2002, Wilstrand 2007) in order to guard against the possibility of professionals inadvertently repeating earlier abusive relationships and experiences.
It is imperative that when life appears incredibly bleak for the person who is injuring themselves that professional carers involved remain hopeful and sustained by therapeutic optimism.
On a team level there can be marked polarisation in professional opinion on how to most helpfully provide interventions for the people who injure themselves. This, if not properly attended to, can have profoundly negative effects on working relationships, and on the team’s ability to provide services in the most helpful, and containing, way for the person injuring themselves Under these circumstances external advice and support should be sought in order for those professional relationships to be sustained.
Obviously, this is not generalised but hopefully demonstrates the dilemma for both the client and the professional. The conflict needs to be readdressed and a shared understanding reached in order to progress in a more positive or helpful way. Unresolved conflicts can be counter-therapeutic for the client and can contribute to “burn-out” for the professionals involved in the delivery of care.
As all interventions need to be undertaken under the premise that the clinical judgement is based on full understanding of the function of the person’s self injuring, the formulation should guide all interventions, the risk management plan and the collaborative care planning. All clinicians involved need to be signed up to this way of working.
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3. ASSESSMENT
We restrict our discussion here to assessments that are specifically about Self-Injury. Clearly there would need to be the broader assessment that includes the wider biopsychosocial components.
It is a continual process of gathering information in order to establish the needs of the person. It requires the clinician to have the following skills:-
Interpersonal skills
Listening skills
Questioning skills
Observational skills
Reasons for Assessment
It ensures specific problems are identified.
It helps to establish what is normal for the person (be aware of cultural differences).
It serves as a basis for evaluating the person's progress and the effectiveness of care.
It facilitates a deeper understanding of the person who self-injures.
It can measure progress and clinical effectiveness, when repeated.
It ensures objectivity.
Key Points
Ideally the same clinician should complete the assessment. This will promote consistency and develop rapport between the clinician and the person who self-injures.
Some assessments will need to be completed by a specific member of the multi-disciplinary team and it is the responsibility of the team to agree where and by whom, in the care pathway, these assessments take place.
It is preferable to complete the assessment on a one-to-one basis in a quiet environment where disturbance is unlikely.
It is essential for the clinician to be aware of alternative resources available and to have the assertiveness to seek guidance and support when necessary.
During assessment consider and explore (as discussed earlier) the following possible functions of acts of Self-Injury:
§ Expression of an unbearable psychological state
§ Self punishment/guilt
§ Emotional regulation
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§ Release of tension
§ Response to psychotic stimuli
§ Wanting someone to care
§ Control
§ Symbolic
§ Cultural
§ The possibility of ending life
§ Sexuality
It might be that the person who self-injures cannot verbalise what drives the behaviour, just that they experience a sense of relief or reduced tension. Also, the person may say at different times that the reasons for Self-Injury differ. What is likely is that there is some kind of external or internal stressor and it would be useful to establish this as part of a person's individual assessment.
Assessment Tools
Diaries
Diaries are a useful way to gain more in-depth knowledge about people's feelings in relation to their self-injurious behaviour. For clinicians a diary may be a good way to gain empathy and understanding about why that person self-injures and how that person was feeling before, during and after the episode of self-injury. We have provided an example in Appendix 1 of a Diary of Thoughts document.
Diaries can also help people reflect on their actions and describe their thoughts in a way they were, at the time, unable to verbally. It may be a useful way for a person to begin to look at other ways in which they can cope rather than self-injuring. By using a diary on a regular basis it can enable someone to identify possible trigger factors or stressors, which have caused them to injure. Once these factors have been acknowledged, there may be interventions, which can be implemented to help reduce the risk of self-injury.
A diary can be a positive way to reinforce times in which the person has coped well with difficult situations and they can reflect back on these times and use the same coping techniques in the future.
They can also provide a very helpful focus for any one to one session- be that nursing or more formal therapies
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Specific Self-Injury Assessment Tool
It is possible that a service user might be able to engage in a more detailed analysis of the triggers, functions and short and longer term consequences of their Self-Injury, and be able to generate ideas about ways of identifying when they are vulnerable and things to do or ask of others to reduce the risk. They could also generate ideas about what they and others can most helpfully do after they have self-injured. An example of a form that could be used by service users for this purpose, with or without the support of others, is in Appendix 2.
It is important to note, however, that there are likely to be times when this kind of exercise is more or less manageable by service users; it is unlikely, for example, that someone in a state of acute distress wouldn’t find it very easy to work through such a process. Additionally, the willingness and ability of a service user to make use of support offered to develop these ideas will vary according to a number of factors, including the quality of the relationship with the person offering support.
Once completed this very detailed picture should add depth to any planned interventions, as they will be based on this comprehensive analysis.
A further wide range of other, potential, assessment tools, with descriptions, are in Appendix 3.
Risk Assessment
In addition to the specific self-injury assessments to enable the deeper understanding of the person’s risks, some mental health service users may also be at risk in other ways. It is essential that all risks be assessed to ensure the person’s safety and well-being. In their publication “Best Practice in Managing Risk” (2007) the Department of Health recommends a range of evidence-based tools, for example:
· FACE – Functional Analysis of Care Environments
· START – Short Term Assessment of Risk and Treatability
These tools provide a structured way of assessing multiple risks for mental health service users. Another approach is to offer practical training to equip staff with the ability to assess and manage risk. Two examples are:
· ASIST- Applied Suicide Intervention Skills Training
· Storm- Skills Based Training on Risk Management
Finally, the Department of Health recommends a number of specific suicide risk assessment tools. These are:
· BHS- Beck Hopelessness Scale
· SADPERSONS scale
· SIS - Suicide Intent Scale
· SSI - Scale for Suicide Ideation
The Department of Health guidance also states that structured professional judgements are the best means of developing formulations and risk management plans.
(For further details of these, and other, assessment tools see the Department of Health guidance.)
4. GENERAL INTERVENTIONS
4.1 Recovery Approach
All interventions for Self-Injury should be informed by the Recovery Approach. This is governed by the following eleven principles: