November 20, 2008

Identifying and preventing deliberate self-harm


Deliberate self-harm is an acute non-fatal act of self-harm carried out deliberately, in the form of an acute episode of behaviour by an individual with variable motivation.
• The National Office for Suicide Prevention’s annual report outlined that there were 11,000 presentations of self-harm to emergency departments  (EDs) in Ireland in 2007.
• There were 481 suicides in Ireland in 2005. Ireland’s rate of youth suicide is the fifth highest in Europe. Suicidal behaviour is a source of substantial morbidity and an increasing cause of mortality in Ireland’s youth placing a huge burden on the Irish medical services. Internationally, an increase in suicide rates has been reported over the last several decades
• A national strategy on suicide prevention was launched by Health Minister Mary Harney in 2005.
• The total suicide rates for males are higher than those for females in every country reporting to the WHO health statistics annual. The 24 to 34 year age group has the highest relative mortality risk from suicide.
• There is a consensus that the aetiology is multifactorial involving biological and psychosocial predisposing factors.
• Those recently discharged from psychiatric care; those with a past history of parasuicide and young men are groups at particular risk of completed suicide.
• Work by Mann et al proposed a stress-diathesis model in which the risk for suicidal acts is not determined merely by a psychiatric illness (the stressor) but also by a diathesis. They suggested that the diathesis is reflected in tendencies by an individual  to experience more suicidal ideation and impulsivity and therefore more likely to act on suicidal feelings. They identified a constellation of aggression, alcoholism, substance abuse and impulsivity that were more common in suicide attempters than non-attempters independent of mental illness status.
• Manns research group surmise that low serotonergic activity may, to some degree underlie all three problems and may mediate genetic, and developmental effects on suicide, aggression and alcoholism.

Therapeutic interventions (a)

1. Competent risk assessment
• Any triggers for the behaviour? Situational? Biological? i.e. relapse of a mental illness. Psychological?;
• Suicidal intent: High, medium, or low?;
• Risk management plan, immediate and medium to longer term. Ideally this risk management plan should be discussed with the patient.

2. Agreement on procedure if individual feels like acutely self-harming

• Best done at start;
• Written down;
• The agreement takes precedence over anything else;
• Practical issues i.e. make sure you have name of GP, next-of-kin;
• Explain the limits of confidentiality, for example, the need to break confidentiality if you feel someone is at immediate risk of serious harm to themselves or others. It is important to explain this at the start otherwise you risk damaging the therapeutic relationship.

3.Validation of individual’s current coping strategies

• They are doing the very best they can in dealing with their emotions;
• They wish to become more skilful at managing their emotions;
• They may not have created all of their own problems but they have to solve them anyway;
• New emotion skills and behaviours need to be mastered.

Therapeutic interventions (b)

1. Managing emotions

• Recognising and naming emotions;
• Making a link between problematic behaviours and emotions/situations/thoughts;
• Not complete agreement but most researchers describe nine primary emotions: joy, love, interest, sorrow, surprise, fear, disgust, guilt, and anger;
• Secondary emotions: Not related to an adaptive response in a given situation, e.g. feeling shame for feeling fear. Secondary emotions are moulded by experience i.e. boy told not to cry as an adult when he feels sad. He may try and cut off his emotion therefore not validating his primary emotion;
• Often secondary emotions don’t help you adapt, they are judgements about how we are “supposed” to feel in a given situation.
Exercises for the individual include:
• Practicing naming emotions and situations;
• Linking emotions and situations with thoughts;
• Differentiating primary and secondary emotions.

2. Practicing mindfulness to emotion

• Mindfulness is the practice of being fully awake in your life, paying full attention to the here and now. It takes practice. It is a concept that is used in meditation and is used in dialectical behaviour therapy and cognitive behavioural therapy as a therapeutic tool;
• Assist the individual with set practice i.e. mindfulness to body, (shower), during exercise, eating, driving, music;
• Spend some time observing and describing emotions in a mindful way.

3. Challenging self-talk

• Negative automatic thoughts identifying them;
• Recording of thoughts;
• Practicing challenging these negative automatic thoughts.

4. Lifestyle changes for improving coping skills

• Caffeine reduction;
• Exercise increase;
• Managing physical health and mental health issues optimally;
• Sleep management.

5. Self-soothing techniques

• Listening to music;
• Taking a bath;
• Exercise;
• Reading;
• Cinema;
• Gardening etc.

6. Crisis management

• Plan for it;
• Make an emergency self-soothing kit;
• Practice “setting aside thoughts”;
• Crisis network of family and friends to contact if in difficulty;
• Agreed crisis strategy with therapist/doctor.

7.  Recommended reading

Depressed and Anxious: The Dialectical Behaviour Therapy Workbook for Overcoming Depression and Anxiety. Thomas Marra PhD.
• Linehan M M 1993b Skills Training Manual for Treating Borderline Personality Disorder.
Overcoming Depression. A self-help workbook. Chris Williams.