Issue: - Volume 12 Number 1 Feb 2000
Page Number: 48-53
Authors: Michael Crowe; Jane Bunclark

The forms of self-harm described here are somewhat different from those detailed in the other papers in this volume. The degree of risk is usually less than that which is present in most cases of parasuicide, and the aim is usually that of reducing tension rather than of ending life; although in many cases parasuicidal behaviour such as overdosage may also occur. However, the frequency of the typical self-harm is often much greater than even that of repeated parasuicide, and the work engendered in accident and emergency (A&E) departments by each individual may be great. It is a problem which traditionally has been seen as difficult to treat in both general psychiatric settings and in the medical and surgical wards where many of the patients are treated.

There are a number of syndromes under the heading of self-injury, as reviewed by Favazza (1996). They are all characterized by repeated
self-harm, but the reasons given for the self-harm are very different in the various groups. Favazza interviewed a large number of self-harmers and found that those who were psychotic or depressed tended to give religious or sexual explanations for the behaviour, whereas personality disordered or neurotic individuals blamed either anger against self or others, the need to relieve tension or the wish to impress on others the degree of their own pain. In other groups there may be more manipulative motives, such as the wish by long-term prisoners to be transferred to the hospital wing. In the case of some patients with learning disabilities the self-harm may be an integral part of the disease, as in Lesch-Nyhan syndrome. In yet others the self-multilation has a recreational or cult value (Musafar, 1996), and there are also culturally sanctioned forms of self-harm such as ritual self-castration in certain groups in India.

Repeated self-harm is included in a number of diagnostic descriptions in ICD-10 and DSM-IV. In both of these influential manuals it is a defining criterion for 'emotional personality disorder (borderline type)' and there are also specific entries under the categories of 'external causes of morbidity' for various forms of self-harm including cutting or burning. The diagnosis of the syndrome of self-injury as a personality disorder is not very satisfactory, since many of the patients are not obviously personality disordered, but cannot otherwise be characterized except by the specific consequences of their self-harm. It would probably be preferable to use a diagnostic label which simply describes the self-harming behaviour, as suggested by Kahan and Pattison (1984).

The syndrome of 'self-wounding' has been reviewed by Tantam and Whittaker (1992) in a wide ranging article. They estimate from a variety of British articles that self-injury sufficient to take the patient to hospital occurs in 1 in 600 of the population, but this may be a slight overestimate because it includes many who took overdoses of tablets on one occasion only. Self-harming behaviour is likely to begin in adolescence, and to continue into middle life, but there are some cases in which the behaviour begins in adults for the first time following a bereavement or a difficult childbirth, or in the of a depressive illness.

Neither self-poisoning nor self-injury are necessarily carried out with suicidal intent, and in many repeated self-harmers the explanation given may be that of relief of tension, which may last for up to 24 hours. The aetiology of self-harming behaviour may be divided into predisposing, precipitating and maintaining factors. In most cases there is guilt and self-blame, and the individuals will usually also experience low self-esteem. In some of the patients there are also command hallucinations, and in others there are delusions as part of the syndrome. There is a high prevalence of reported childhood abuse, both sexual and physical--up to 80% in some reports (Tantam & Whittaker, 1992) and certainly 60% in our own series (Crowe, 1997). However, this does not mean that the abuse is necessarily the main cause of the self-harm, because many other adverse childhood factors (such as time spent in care) may be present in those with an abuse history. Psychodynamic explanations (Feldman, 1988) include aggression turned inwards, the need for control and a wish for self-punishment for sexual impulses.

The precipitating and maintaining factors include the relief of tension, the shedding of blood, the pain experienced, the need for punishment and in some cases the response of others. In forensic settings there is more of a likelihood that there will be some gain from the self-harm such as the privileges involved in medical treatment. One of the most striking aspects of repeated self-harm is the apparently addictive quality of the behaviour, and this goes together with the frequent coexistence of self-injury with other impulsive behaviours such as drug addiction or alcohol abuse (Lacey & Evans, 1986).

The overall course of the self-harming behaviour (Tantam & Whittaker, 1992) shows that the majority begin in their teens, and that the repetition of self-harm is associated with a forensic history, living alone, regular abuse of alcohol or drugs and being out of contact with parents (Kreitman & Casey, 1988). The risk of completed suicide is between 13 and 16% over a five-year period (3% per annum); which, although well above the population norms, may seem surprisingly low in view of the undoubted risks often taken in serious forms of self-harm. In the same time period the proportion of patients rated as improved was 50%.

The management of repeated self-harm is never easy. One of the difficulties is that the patients are often articulate and apparently balanced, and yet carry out acts of self-mutilation which horrify their carets and seem to require measures to protect them from themselves. This can have the effect of raising anxieties in the staff, and may result in splits between those staff members whom the patients treat as special 'allies' and the others who are trying to treat all the patients fairly and equally. Main (1957), in his classic paper on the topic, advocates open discussion between staff members about their disagreements over these 'special' patients and the avoidance of any secrets kept between a patient and one selected staff member.

Feldman (1988) suggests that excessive restrictions on self-harmers are seldom effective, and lead to conflict with the patient and also to an abdication by the patient of responsibility for their own safety. In extreme cases however it will be necessary to restrain or detain the patient for a period which should be as short as is compatible with the maintenance of safety.

For the individual patient there are many forms of psychological therapy which have been advocated. The most widely used is psychodynamic therapy, in which the patient is encouraged to understand the origins of the behaviour in the unconscious and to verbalize their feelings. Many authors emphasize the need to avoid premature interpretations (Feldman, 1988) and too much intensive therapy (Kernberg, 1987). In addition, the therapist needs to be clear about boundaries and rules, because the borderline individual is particularly prone to develop a strong dependence on the therapist, seeking to know details of the therapist's personal life, to telephone out of hours and to form a strong alliance together against the world. In most cases this would be seen as inappropriate, but it may be helpful for a therapeutic team member to be available by telephone out of hours, thus providing cover for emergencies without breaking the normal boundaries of therapy.

Modifications of the psychodynamic approach have been developed in relation to this group of patients. Ryle et al. (1989) in cognitive-analytic therapy, use a 16-session structured course of treatment in which the client explores the origin and maintenance of the problem, using psychodynamic understanding, diagrams of conscious and unconscious pressures on their thinking, and cognitive strategies to overcome the behaviour. The approach was developed with personality disorders in mind, and may be of special usefulness in self-harmers.

Kraupl-Taylor (1969), under the name of prokaletic therapy, used the establishment of a supportive and non-ime-limited relationship with the patient as the basis for a number of specific interventions designed to 'countermanipulate' the patient's manipulative side. These might include the prediction of self-harm before the next meeting (leading to abstinence in order to prove the therapist wrong), a refusal to show optimism ('you are very ill and it will be a long hard struggle for you') in order to reassure the patient that their problems are not being dismissed, and the challenging interpretation in which the self-wounding is said to be a masturbatory equivalent. This method was designed specifically for self-harming patients and still has some important lessons for treatment today.

Cognitive approaches were employed by Salkovskis et al. (1990) in a group of patients who repeatedly attempted suicide. They used a 'problem solving' method, in which the negative thinking was replaced by positive self-statements and a reduction of the frequency of repetition resulted.

Linehan (1993), in her 'dialectical behaviour therapy', encourages the client to develop a strong dependent relationship on the therapist, which may include telephone contact out of hours, but only if self-harm has not just occurred. This is designed to extinguish the parasuicide risk, and is accompanied by a far-reaching therapeutic method in which there is an encouragement of alternative strategies of coping, including adjusting to life and thinking more positively.

Group therapy has been used by Walsh and Rosen (1988), based on the usual group dynamic format but with more structure, including the inculcation of interpersonal skills, the discussion of self-harm as a means of obtaining intimacy and nurturance, and giving patients the ability to obtain the care they need in other ways.

The majority of regular Self-harmers give a history of prior sexual abuse, and although this is not the only cause of the self-harming behaviour (Mullen, 1993) there may be a close connection in the patient's mind between the two. The sexual abuse may be seen as a past traumatic stress, as a result of which the patient develops post-traumatic symptoms such as flashbacks and nightmares, as well as perhaps avoiding situations (such as a current sexual relationship) which bring to mind the previous trauma. In other cases, however, the patient may seek out abusive relationships in the present, as if to use these as a further form of self-harm.

In the management of self-harmers who have been abuse victims, a good relationship needs to be built up with the therapist before active therapy begins. Dolan (1991) has developed a combination of cognitive and problem-solving therapy, in which negative, self-destructive expectations are replaced with a positive yet realistic vision of the future. A wide variety of techniques is used, including the management of feelings towards the abuser and towards other family members, and ensuring safety in the current situation.

The use of medication is widely discussed in the literature (Feldman, 1988; Tantam & Whittaker, 1992) and the mainstay of treatment is the use of antidepressants, particularly fluoxetine (Markovitz, et al., 1991). There is also some support for the use of lithium, carbamazepine and (particularly where there are psychotic symptoms) antipsychotics. ECT is rarely used, unless k is unavoidable because of unresponsiveness to antidepressants.

An inpatient unit for self-harmers was formed at the Bethlem Maudsley NHS Trust in 1992, mainly for those who repeatedly cut or burn
themselves, but also for those who repeatedly take overdoses or use blood-letting as their form of self-harm.

We use medication as necessary, prescribed in consultation with the residents, who are asked to share responsibility for accepting it, and may often request a particular drug. The medication is mainly in the form of antidepressants, mood stabilizers and, where appropriate, small doses of antipsychotics. Attention is also given to the many physical symptoms experienced by this group of patients, including those that result from the self-harm.

The model of multidisciplinary working we have developed is based on our understanding of self-harm is being symptomatic of some greater
distress: our therapeutic aim is to enable individuals to develop alternative, more healthy ways of coping and of gaining a better understanding of themselves.

Two therapeutic strategies are central to the process of self-understanding:

(1) Retention of responsibility. In order for individuals to make the choice between further acts of self-harm or developing alternatives, the choice needs to remain open. If staff ensure complete safety in the short term, as we attempted to do when the unit was first opened, this choice is removed, and in our experience this makes progress difficult. The acceptance of responsibility by the resident helps staff to be clear about who owns the problem.

(2) Therapeutic risk-taking. In the short term this can lead to an escalation of self-harm as residents become accustomed to a degree of
responsibility that may be unfamiliar.

Individuals referred to our unit have often had extensive contact with conventional psychiatric services, which they may subjectively feel to have been unhelpful and abusive. Often the referral has been initiated only when the referring team are desperate to become disengaged from the enmeshed situation that they and the patient find themselves in.

Referred individuals attend for an assessment of their level of risk, willingness to contemplate change and psychological ability to engage in therapy. The assessment, which includes a full history of the self-harm, as well as meeting staff and residents on the unit, aims to reflect the milieu of the unit. As such it can be a distressing and thought-provoking encounter, in which the individuals are asked to maintain their own safety, and all the anxieties are held at a verbal level. Some patients have to be excluded at this stage, for example those with a recent history of arson or interpersonal violence, those with severe psychosis or severe substance abuse and those unwilling or unable to refrain from extreme or dangerous behaviour.

At the time of assessment, many of those referred are formally detained and under nursing supervision. The patient and their team are supported by us towards the removal of these restrictions, because to enter the unit as residents they need to do so informally and from choice. Admission is planned to last six months (including any periods spent at general hospitals for physical treatment). We feel that six months is the minimum time needed to undertake the work. A fixed period for admission enables everyone to keep focused and removes some of the rivalry within the resident group about who is 'most ill', as frequently the length of admission is equated with specialness. We see each of the patients as special, special in unhelpability, damage and being misunderstood. As described by Gabbard (1992), 'these patients have the capacity to gain a unique position in the lives of their treaters, characterised by an intense, mutually ambivalent attachment on the part of both the treater and the patient'.

The majority of the residents have one or more of a range of other damaging behaviours such as drug or alcohol use, eating disorders or involvement in abusive relationships. The unit's environment has been created to allow specialized treatment for self-harming individuals, but also attempts to reflect the outside world. There is greater permissiveness (toleration of deviant behaviour) than in conventional units, allowing residents to express their disturbance, and this is only possible through the staff's ability to contain, hold and work with the disturbance. Bion (1967) defined 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'.

The unit's work has elements of a psychosocial model, as we attempt to view the residents holistically, looking at and addressing interpersonal, group, familial and social levels of being, each person having functioning and non-functioning aspects. The limits of what the community can contain and tolerate are defined and serve to make the unit a safe forum for work.

The structure of the day is of a diverse programme of events, boundaried by strict timing. This adherence to time provides limits and safety and helps create a focus on what is occurring. The social environment is constructed to echo the external world, with a 9 to 5 working days and social activities outside these times. However, all parts of the day are 'work' and are used towards residents gaining understanding of themselves, for growth, change and reflection.

The work undertaken is a mixture of individual and group. There is a daily (Monday to Friday) community group which is attended by all residents and available staff. Residents each come to the group with their own history of difficulties within relationships and difficulties in tolerating themselves, and this is frequently mirrored in their relationships within their peer group and with staff. Hence relationships are the major focus of the group. There is also a weekly coping skills group aimed at distress tolerance, improvement in assertiveness, changing restrictive patterns of thinking and learning interactive skills.

Many self-harming individuals find verbal communication difficult and consequently use their bodies. We provide a range of alternative means of expression which individuals have the opportunity to attempt during their stay. These include creative writing, creative art, drama therapy and projective art. This variety enables different individuals to find different alternative means of expression.

The unit enables individuals to undertake the work themselves, rather than providing care. Staff maintain the milieu and act as containers of anxiety. Residents negotiate their own needs, learn to anticipate difficult situations and tolerate the fact that others have needs too.

Each evening nurses and residents engage in leisure activities. Rivalrous feelings, difficulty in having fun, winning or losing all emerge. We attempt to reflect the external world and enable individuals to encounter difficulties. The tools of our therapeutic engagement are limit setting and confrontation, but also nurturing and stimulation.

The unit is a living learning environment where staff and patients learn from each other. We use a problem-solving approach in which residents' crises are managed by the community. Roberts (1994) states that 'coherent thought and the capacity for problem solving are possible only when depressive anxieties can be tolerated'. As a way of promoting this we use 'emergency' groups, which can be culled by anyone to use the resources of the community to 'brainstorm' solutions to crises.

The advantage of a collaborative approach is that staff are not constantly reconfirmed as 'omnipotent', nor are patients seen as passive recipients or exploited victims. Similarly, residents offer support to each other, which additionally gives them an insight into how it feels to witness someone else's distress, and confirms that self-help is possible.

Once a week a residents' group is held in which past residents can also participate for the first three months after discharge. This enables everyone to discuss the difficulties post-discharge and realize that there is no automatic cure, but that the ongoing struggle is worth while.

A period each evening is spent evaluating the work of the day. This enables staff to give feedback not only to each other but to residents too. Open communication about achievements, frustrations and disappointments are thus modelled and differences addressed.

Family therapy is offered to most residents in the later stages of their stay, aimed at improving understanding and communication within the family, such that relevant support may be available after discharge. It is systemic in approach, and in some cases might not actually include the family if they are unable or unwilling to participate.

Many residents have had abusive experiences in early life. We have moved away from specific abuse counselling centred on past events, and prefer to discuss the ways in which past abuse is relived in current relationships.

Self-harm, as we have learned from experience during the early months of the unit's existence, is impossible to extinguish by the traditional methods of close supervision and prevention. The most that can be achieved is to reduce either the frequency or the severity, since patients continue to harm themselves secretively or in subtle ways, or gain harm through their contact with staffs and also revert immediately to full self-harm as soon as the restrictions are removed. They have made it clear to us on many occasions that in most cases self-harm is not about death, but rather a means of continuing to live.

Through discussion with the hospital we have negotiated an approach which is based on harm minimization rather than abstinence. In practice this translates into a tolerance of self-harm, within limits, whilst enabling residents to find alternative, healthier, means to communicate and cope. Often self-harm is a 'knee-jerk' reaction to distressing thoughts and feelings. The initial step we work towards is for the individual to tolerate some time between the impulse to harm and inflicting the injury. This allows opportunity for the emotion to be recognized and tolerated and the individual to make a conscious choice whether to harm him/herself or not. In successful cases this interval is gradually increased, and residents are assisted also to find alternatives, which may be:

*alternative means of expression, e.g. talking about feelings or 'painting' them.
*postponement tactics, e.g. going for a walk.
*making difficulties for themselves, e.g. handing blades in to staff.
*the use of the 'healthier' part of the individual to give wiser counsel, e.g. by pre-recorded tapes.

No alternative is always successful; however many individuals have had no previous experience of resisting the impulse or sense that they have a choice whether to harm. When self-harm occurs, staff take a mid-line approach, being neither disappointed or punitive nor excessively comforting or alarmed. Residents are assisted to care for their own injuries as far as possible. All self-harm has to be reported and vital treatment accepted.

There are however limits to our ability to tolerate some forms of self-harm and the accompanying anxiety. These limits are clearly stated in the form of protocols known to the residents. Burning with naked flames, non-reporting of overdoses, excessive weight loss, severe substance abuse and excessive blood loss are some examples. These boundaries are clearly addressed with residents but are nevertheless occasionally broken. Experience has shown us that the use of close supervision by staff has limited helpfulness, unless there is an immediate threat to life or health. In such an eventuality the supervision is usually the prelude to return to the referring unit. Nursing supervision or detention put the individual into a state in which they have no responsibility for themselves and compete with staff about who has control. The other patients too may be unable to tolerate their feelings that someone else is receiving more care, and their self-harm and limit testing can increase such that they too need to have full 'parental' care.

In these circumstances we have developed an approach, when such boundaries are broken, of suspending the individual from the unit (usually to their own home, providing that safety is at a reasonable level) for a prescribed period of time. This time out enables them to regain some control, and to think how they will manage their distress in future without resorting to these extreme measures. The suspension also allows them to change while away from the unit; something which may be difficult if extreme positions have been taken up. The suspension may feel like the rejection they have been anticipating, but the relationship with the unit is not completely broken and reparation is possible.

The majority of physical care of injuries occurs on the unit, so there is a minimum loss of therapy time. Suturing, treatment of burns or overdoses can be managed with the help of duty doctors, using a protocol devised on the unit (Wright & Crowe, 1998). There are however circumstances in which individuals need to attend the local A&E department. As this can sometimes involve a form of secondary self-harm (eliciting punitive responses from staff or refusing treatment) we hold regular meetings with the local A&E staff to maintain a working relationship and to prevent 'splits' between the two teams.

Some behaviours, such as interpersonal violence, result in immediate discharge, since there must be some boundaries in a unit which depends so completely on residents' co-operation.

Supervision and support are vital in our work, if we are not to become crippled with anxiety. Menzies Lyth (1970) points out that 'unless anxieties can be identified, addressed and contained within the system it is likely that the system itself will produce defences that actively hinder rather than help therapeutic intervention'. We employ external psychotherapists to assist us with this on a weekly basis. Staff supervision and reflection, in which different perceptions of the same resident's problems are analyzed, help the whole team to understand the problems more clearly and to feel more confident in dealing with difficult behaviour.

Staff are assisted to understand their own expectations of the work. Do they wish to be helpful parents who repair situations or relationships, raising patient expectations of the parental role, or are they so appeasing that little change can be achieved? We need to understand the great array of emotions that patients evoke in us and distinguish those which are ours from those which arise from the patients. Staff need to be sufficiently 'attached' but not overwhelmed by the patients' neediness. Residents' previous abusive/harmful experiences can lead them to the belief that there are only two roles on offer: the abused or the abuser. Staff may also be experienced as abusive or may be abused. Supervision helps staff to avoid re-enacting the chaotic, critical, divided and abusive families that many patients have experienced.

Some outcome data are available, based on the first four years of the unit's work (Table 1). Self-mutilators make up more than half of the total, and it should be emphasized that the degree of handicap both psychologically and socially in the group is very high.

Conclusions

Our approach tolerates disturbance within limits, but also educates, seeks for alternatives and attempts to offer encounters with staff and other residents in which reparative work can be undertaken. Throughout their stay the residents are asked to take responsibility for both their feelings and their behaviour. Support and help is available, but more in the interests of encouraging self-help than in taking responsibility away from the resident. With good general management and the minimum of stigmatization it is possible to help even the most entrenched and self-destructive patients towards rehabilitation, and it is to be hoped that in future a more humane and less punitive attitude will emerge towards this disadvantaged group of patients.

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