Working with individuals who self-harm SCOTTISH Personality Disorder Network.
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Transcript of Working with individuals who self-harm SCOTTISH Personality Disorder Network.
Working with individuals
who self-harm
SCOTTISHPersonality Disorder Network
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
SCOTTISHPersonality Disorder Network
Self-harm
“ …. an individual intentionally
damaging a part of his or her own
body, apparently without a conscious
intent to die”
Feldman, 1988
SCOTTISHPersonality Disorder Network
Self-harm
“…intentional self-poisoning or
injury, irrespective of the apparent
purpose of the act”
NICE Guidelines, 2004
SCOTTISHPersonality Disorder Network
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
SCOTTISHPersonality Disorder Network
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
SCOTTISHPersonality Disorder Network
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
SCOTTISHPersonality Disorder Network
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
SCOTTISHPersonality Disorder Network
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
SCOTTISHPersonality Disorder Network
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
SCOTTISHPersonality Disorder Network
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’
SCOTTISHPersonality Disorder Network
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)
SCOTTISHPersonality Disorder Network
Relationships
SCOTTISHPersonality Disorder Network
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
SCOTTISHPersonality Disorder Network
Clinical dilemmas
Staff/client relationship
Punishment and attack
Mindful or mindless
Anxiety and fear
A player in a play
The community as a vessel
SCOTTISHPersonality Disorder Network
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
SCOTTISHPersonality Disorder Network
Staff/client relationship
“External figures are often recruited in
ways which support the internal
psychic structures”Evans, 1998
SCOTTISHPersonality Disorder Network
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
SCOTTISHPersonality Disorder Network
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
SCOTTISHPersonality Disorder Network
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)
SCOTTISHPersonality Disorder Network
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
SCOTTISHPersonality Disorder Network
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
SCOTTISHPersonality Disorder Network
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
SCOTTISHPersonality Disorder Network
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
SCOTTISHPersonality Disorder Network
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
SCOTTISHPersonality Disorder Network
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