Impact Training

Responding to a Person who Harms Themselves

    by Stuart Sorensen, Associate Trainer

Working with people who hurt themselves can be a confusing and bewildering experience. It is often extremely frustrating and distressing for the staff who may well be at a loss to understand why their resident keeps on injuring themselves. Traditional views about 'manipulation' or a 'cry for help' may bring some limited sense of explanation but they do little or nothing to help prevent future self-harm.

First of all bear in mind that you are not alone. A decent GP, Psychiatrist or community psychiatric nurse will be worth their weight in gold. As a team, complete a thorough risk assessment and agree how to manage future problems and when to seek outside or emergency help. 

All that aside though, there is much that workers can do on their own.

A resident's ability to manage is greatly enhanced by good support from their surroundings and social group (British Psychological Society 2000). In supported housing this means that the staff can influence significantly the resident's coping skills.

Back in the 1950s George Brown began studying the effects of families and social groups on coping and mental health (Brown G. et al 1965? & Brown GW 1985). This research led to the concept of 'High Expressed Emotion'.

A few decades later in the USA Marsha Linehan came up with the concept of the 'Invalidating Environment' (Linehan M. 1993, 1 & 2). Both these concepts show how types of interaction increase stress, reduce coping and lead to the conditions which encourage (among other things) deliberate self-harm:

 

High Expressed Emotion

• Aggression and hostility
• Criticism
• Emotional over-involvement

 

The Invalidating Environment

• Erratic, inappropriate responses from significant others to the individual's thoughts, beliefs and emotions.
• Oversimplifying the ease with which problems can be solved.
• Blaming the individual for not solving difficulties with ease.
• A chronic and classical 'double bind' scenario in which the individual cannot 'win' whatever he or she does.

Attention to the concepts of expressed emotion and the invalidating environment make a huge difference.

Deliberate self harm is likely to represent a coping strategy. For many people it is the only effective strategy they know.

 

The sweet shop analogy

Often in training sessions I use the analogy of a small child in a sweet shop. They can have anything they want but there's a problem. The lights are turned off and all they have is a small 'pen' torch – the kind with a very narrow beam that only illuminates a small area of the shop.

Whatever they can see in the torchlight they can have but it's a very limited choice. Most of the sweets are effectively invisible. Clearly the child will choose from very limited options – not because the other sweets aren't available but because he doesn't know about them.

In one sense this is what it's like for people with limited coping skills. The other coping strategies are available to them but they don't know about them or they don't believe that they will work. The coping strategies are the sweets in the shop and your job is to turn the lights on.

 

What to do now

Don't waste time attacking the only coping strategy the service-user knows. If you remove the only coping skill a person has then they may see no alternative but suicide. It is no coincidence that service-users who harm themselves are around 50 times more likely than the general population to kill themselves (Royal College of Psychiatrists leaflet: 'Self Harm').

Instead work on discovering and experimenting with other, less injurious methods of dealing with stress. It may well be that to begin with this will amount to nothing more than some slightly less injurious methods of self harming but this is a step in the right direction. Build upon what you can and remember that overt criticism of the service-user is likely to create a barrier between you that may never come down again.

 

Don'ts and dos

The chart below outlines some of the things support workers can do to support people who self-harm and suggests responses to likely situations.

 

	Don't	Do
Environmental	Criticise Be hostile or aggressive Be emotionally over involved Invalidate	Gently challenge the service-user to consider their actions objectively. Be assertive (stand up but don't fight). Respect their choices. Respect their rights, their opinions, their emotional life Treat service-users as adults Do the best you can for them Expect the best from them
Thoughts of Deliberate Self-Harm	Ignore this Over-react to this	Discuss this with the service-user and risk-assess. Call for assistance if necessary. Discuss coping with the service-user and monitor the situation as closely as is appropriate.
Mild Deliberate Self-Harm	Ignore this Over-react to this	Ensure the service-user has access to appropriate first aid if applicable. Discuss this with the service-user and risk assess Call for assistance if necessary If not necessary discuss coping options and practical needs. Discuss this with the multi-disciplinary team as soon as possible
Serious Deliberate Self-Harm	Ignore this	Get emergency help immediately. Monitor the service-user. Co-operate with emergency services. Discuss the situation and begin to plan for future care with the multi-disciplinary team and the service-user as soon as is possible once the initial emergency has passed.

 

 

References

British Psychological Society (2000) Recent Advances in Understanding Mental Illness and Psychotic Experiences British Psychological Society, Leicester

Brown G. et al (1962) Influence of family life on the course of schizophrenic illness British Journal of Preventative Social Medicine 16, pp.55-68

Brown G. W. (1985) The discovery of expressed emotion: induction or deduction in

Leff J. & Vaughn C) Expressed Emotion in Families Guildford Press, New York

Kroll J. (1988) The Challenge of the Borderline Patient Norton & Company, New York

Linehan M. (1993) 1 Cognitive Behavioural Treatment of Borderline Personality Disorder Guildford Press New York

Linehan M. (1993) 2 Skills Training Manual for Treating Borderline Personality Disorder Guildford Press New York

Psychiatrists (undated) Self Harm  rcpsych.org.uk

Zubin J. & Spring B. (1977) Vulnerability – a new view of schizophrenia. Journal of Abnormal Psychology Vol.86, No.2, pp.103-124