Adolescent mental health and the issues of self harm.<o:p></o:p>
This assignment will explore what self harm is, and the complexities in creating a definition for self harm and self injury. It will explore the national guidelines for treatment and best practice, and then compare them with what is available at a local level, in the <st1:place w:st="on"><st1:City w:st="on">Cheshire</st1:City></st1:place> locality.
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It is important to note that self harm is a way of expressing deep emotional distress (MIND 2007). It is described as an inner scream, a way of coping with what cannot be put into words or even into thoughts. Self harm however is a rather broad term, some people may choose to injure themselves by cutting, burning, or banging into objects. Other people will instead choose to poison themselves with drugs overdoses or other substances such as bleach. ‘It may also take less obvious forms, including taking stupid risks, staying in an abusive relationship, developing an eating problem, such as anorexia or bulimia, being addicted to alcohol or drugs, or simply not looking after their own emotional or physical needs.’ (MIND 2007). people will choose to self harm for a variety of reasons, including a physical release of pain through the body, distraction from what is actually wrong, however its can also been seen as a way of self punishment if the individual feels guilty about a situation. Most professional and self harmers would agree that it is rather a private issue as most individuals will try to conceal their self harm and try not to draw attention to themselves. ‘It's worth remembering that most people behave self-destructively at times, even if they don't realise it. Perfectly ordinary behaviour, such as smoking, eating and drinking too much, or working long hours, day after day, can all be helping people to numb or distract themselves and avoid being alone with their thoughts and feelings’ (MIND 2007). A charity dedicated to self harm states that ‘few people who self-harm may go on to commit suicide - generally this is not what they intend to do. In fact, self-harm can be seen as the 'opposite' of suicide as it is often a way of coping with life rather than of giving up on it.’ (Selfharm.org 2007). Babiker and Arnold (1997), try to create a Definitional Approach to self harm. They state ‘We understand self-injury as an act which involves deliberately inflicting pain or injury to one’s own body, but without suicidal intent.’ (Babiker and Arnold 1997 P2). They go on to argue that self injury can be distinguished from other self destructive behaviours in many important ways, for example lethality, intention, purpose and whether mental illness is a focus or if deception is at play.
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At this stage it is important to note the other terminology for self harm; this can include deliberate self harm, self injury, attempted suicide, and self mutilation. Self harm however appears to be the main umbrella term that these other issues fall into. Self injury therefore can be defined as ‘the attempt to deliberately cause harm to one's own body and the injury is usually severe enough to cause tissue damage. This is not a conscious attempt at suicide, though some people may see it that way.’ (Thompson 1996). She goes on to explain that there are three main types of self injury, the rarest being server self mutilation which leaves permanent disfiguration i.e. castration or limp amputation. There is then stereo- typical self mutilation which can include head banging and eye gouging and biting. Finally and most common is superficial self mutilation which like mentioned above consists of burning, cutting hair pull, bone breaking and any other method of self injury.
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This assignment will now explore how common self harm is believed to be, according to selfharm.org the best evidence would suggest that, that self harm is most common is young people aged over 11 and increase with in frequency with age. According to the evidence it is uncommon in younger children but there have been accounts of children as young as 5 trying to self harm. It has also been noted that self harm is more common among young females with nearly three times more females self harming than males. During 2000 a study in <st1:City w:st="on"><st1:place w:st="on">Oxford</st1:place></st1:City> found that 300 in every 100,000 males and 700 in every 100,000 females aged 15 – 24 had to be admitted to hospital after an episode of self harm. In the same year a national survey carried or children and adolescents found that 5% or boys and 8% of girls aged 13-15 had said they had tried to harm, hurt or kill themselves at least once.
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There are many reasons why a person self harms, Spandler (1996) points out that to merely describe self harm as attention seeking is simply inadequate. Her research with the <st1:Street w:st="on"><st1:address w:st="on">42<sup>nd</sup> Street</st1:address></st1:Street> project shows that there are many more explanations. She states that ‘the young people interviewed for this study tended to see self harm … more as intrapersonal than interpersonal’ (Spandler 1996 P.25), meaning seeing more of the effect is has for them rather than the effect on others. A lot of young people saw it as a release mechanism or a few hours break from what was really on their mind. ‘It’s like a release. I feel better after I’ve taken tablets and I feel better after I’ve cut myself to pieces’. (<st1:Street w:st="on"><st1:address w:st="on">42<sup>nd</sup> street</st1:address></st1:Street> member cited in Spandler 1996 P27). Many of the young people also discuss how self harm prevents worse things from happening. For instance self - harming to relieve the pressure instead of it building up and making the individual suicidal. Spandler (1996) notes how many people use self harm as a language, when they are unable to find the words to explain their emotions. Likewise the basement project (1997 P5), declare that ‘often it’s hard to express their feelings. Sometimes they self harm as a way of showing their hurt and sorrow.’ In both sets of research the young people discuss how their self harm is linked to a feeling of control. The self harm becomes the one thing that young people feel they have power, or control over. This can be especially true in cases where the young person has been abused. It may feel better to hurt themselves than have other people doing it. ‘It’s like a control thing. How deep, how often, where I cut – it’s all down to me. It’s my body and I’ll decide what to do with it.’ (Basement project member, cited in, The Basement Project 1997 P7). The <st1:Street w:st="on"><st1:address w:st="on">42<sup>nd</sup> street</st1:address></st1:Street> research also shows how important control is to a person who self harms. ‘Although people think self harm is about being out of control it’s something very in control that you do because it puts you in control’ (42<sup>nd</sup> street member, cited in, Spandler 1996 P32).
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The issue however becomes what is control, as in this context it can carry many meanings. For some people it could mean keeping themselves under control, for other being able to control something that other people can’t. Equally there is the issue that self harm is contradictory, meaning that once the self harm develops into a constant need to do it then the control has been lost. Obviously as Spandler points outs this can be very confusing because the control would come from not self harming, however the young person would then loose the benefits they associate with self harm.
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Williams (1997) describes the three aspects of the build up to <st1:place w:st="on">Para</st1:place> suicide or self harm. He states these are long term vulnerability factors, short term vulnerability factors, and precipitating factors. The long term factors are anything which forms the background to the shorter – term crisis. This can include early trauma, living in care, issues with schooling or education, and social isolation. Williams then give special consideration to sexual abuse as he states ‘ Several authors suggested that a high proportion of suicide attempts have had an even more acute disruption in early social relationships: they have suffered sexual abuse.’ (Williams 1997 P86). He explains how one theory states that many abuse victims try to commit suicide because ‘once a person has been abused, they often find themselves being the victim again’ (Williams 1997 P87). In a similar study it was noted how abused women can usually accurately predict the fact they will be suicidal in the future, this is worrying for people wishing to reduce this behaviour in them.
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Williams then moves onto explaining what he means by short term vulnerability factors, these are anything to do with the currant situation. Therefore they can be employment status, currant relationships, substance abuse etc. Hawton (1988), notes that within 15-24 years olds, substance abuse emerged as a key indicator of suicidal intention following a prior <st1:place w:st="on">Para</st1:place> suicide. This was mainly due to the fact that it gave the individual readily available means to overdose; also being ‘High’ reduces the feeling of risk associated with it.
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Finally Williams discuses the Precipitating factors, these are events with happen in the couple of days leading up to an attempt. These can include arguments with a partner or spouse, anxiety and work related issues. He also notes how special dates can trigger an attempt. For example, Valentines Day could be an issue to a person who has had multiple relationship difficulties. Putting these three stages together it becomes clear to see how a persons feeling can build up before a suicide attempt is made, this can help with treatment to be able to focus on specific issues and break down the cycle.
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This assignment will now explore the relationship between self harm and suicide. As mentioned before it is dangerous to overlook self harm as merely failed suicide. That is because it misses the point of what self harm is for many young people. In fact for many self harm can be a means of avoiding suicide. For the young people of the <st1:Street w:st="on"><st1:address w:st="on">42<sup>nd</sup> Street</st1:address></st1:Street> project it would appear that self harm is the next best thing. ‘ I was really miserable…and wanted to be dead, and I thought im not going to kill myself so what’s the next best thing so I can just get out of this for a few hours’ (42<sup>nd</sup> street member cited in Spandler 1996 P35). This therefore means that self harm can in some circumstances be seen as a positive copping strategy. Maris (1971) agues that women who repeatability self harm should actually be seen as using a life preserving technique, because they are only engaging in partial self destruction aimed at making life bearable rather than ending it. Favazza and Favazza (1988) state that suicide can be adverted when a person makes the decision to sacrifice a body part instead of the whole body. Thankfully many young people notice that while their self harm is mostly an act for survival in some circumstances, the feelings underlying the self harm could become so bad that it could lead to long term damage or even death. Walsh and Rosen (1988), also argue that there is a clear distinction between what self- injury is and what is self harm or parasuicide. This is an obvious one that in parasuicide there is a intention to kill ones self, however in regard to self injury this intention is not there. However, Babiker (1997) agues that simply adhering to this view alone can be problematic, as some issues that get presented as a suicide attempt for example a overdose do not always have suicidal intentions connected with them. There is also the issue that an individual may have complex and ambivalent views of their own intentions. Also individuals who self injure may at other times in their life’s do the same acts but with the intent of suicide. Other clinicians such as Brire, 1996 and Tantam 1992 argue that there is a issue where self harm does not get viewed as seriously as a suicide attempt. This can be dangerous as some individuals can have such self hatred and despair that they will try and destroy any form of the self in order to be able to function.
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This assignment will now explore some of the perspectives on around self injury and self harm, starting with the Psychiatric diagnosis of self harm. This view point tries to be able to classify or label behaviour. In people who express server mental distress though their body it is more than likely they will receive one of two diagnoses. the first being that of a Borderline Personality Disorder if they show signs of self harm, or Somatization Disorder if they do not self harm. The diagnosis of Borderline personality is one of much controversy. This is because as Babiker (1997) argues, that the term borderline is its self fraught with complexity as many practitioners do not fully understand what it actually refers to. Gunderson and singer (1986) also argue that many people are miss diagnosed with this disorder, this is because the result of a behaviour is self destructive rather than the intent of that behaviour. They state ‘generally borderline patients do not regard these behaviours as self destructive, self degrading or guilt provoking’. (Gunderson and singer 1986 cited in, Babiker and Arnold 1997). The next approach this assignment will explore is the clinical approach. This approach pathologizes self injury viewing it as a disorganisation or normal functioning or illness. Tantam and Whittaker (1992) argue that this model helps by trying to remove labels such as personality disorder because ‘ the attribution of upsetting behaviour to abnormal personality tends to blunt the normal caring response… Too often, further inquiry into the reasons for the self wounding stops once a diagnosis is made’. (Tantam and Whittaker 1997 cited in, Babiker and Arnold1997). This approach recognises that self mutilation or self harm is a symptom of underlying, distress and serves as a way for the individual to release that pain, however the over riding view is still that this symptom is of a mental illness that must be treated. An issue with this approach is that while it seems straight forward in helping individuals that are suffering, it focuses on the one aspect of their symptoms that professionals find particularly difficult. ‘Of all disturbing patient behaviour, self mutilation is the most difficult for clinicians, to understand and to treat… The typical clinician treating a patient who self mutilates is often left felling a combination of helpless, horrified, guilty, furious, betrayed and sad’ (Frances 1987). Under this model treatment would involve medication and psychotherapy to control the self harm and thoughts around it. This treatment is usually based on the continued abstinence from self injurious behaviour. Obviously this causes problems for the client because they risk loosing their support network if they injure.
This assignment will now explore Psychoanalytical think around self harm. This approach does not present a single approach; rather it covers a selection of views. Menninger (1938), classified self mutilation as a huge range of behaviours, including nail biting at the low end through to polysurgery at the server end. He goes on to explain self harm as a partial suicide or a compromise, from the real thing. Within this he discusses Freud’s theory of the ‘death instinct’, whereby self harm is able to dilute this instinct and therefore preserve life. Psychoanalytical writers view suicide as having three, aspects, the wish to kill, the wish to be killed, and the wish to die. Mollen (1996) writes ‘The person who is deliberately cutting the body has entered a private world of omnipotence in which, s/he is both abuser and abused… Overwhelming rage is this way discharged on the body, which is thereby punished for being a victim’ (P71). Fonagy and Target (1995) argue that this self harm or violence shows a failure in the individual being able to conceptualise issues. They suggest that in some patients the underlying issue is the same, ‘a wish to attack thoughts, in oneself or in another’ (Fonagy and Target 1995). They go on to say how people who self harm have to use it as a language because they are unable to communicate server emotions in any other way. This theory like the clinical approach does not focus on the functions of self harm; this means that its interpretation is often classed as being offensive or irrelevant.
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This assignment will now explore so of the principles for working with young people who self harm and effective working practice. The main problem for professionals working with self harmers is that it can be presented in so many settings including hospitals, General Practices, mental health teams, children’s homes, prisons, counselling services, help lines and a range of other settings. First of all it is important that all these professionals have a clear understand of self harm and the ways it may present. The National Institute for Clinical Excellence (NICE), guidelines for self harm, state that through this awareness medical professionals can give people who self harm the same level of dignity and respect as any other patents. The guidelines also state how caring for people who self harm can be emotional demanding so a high level of support is needed within the team to stop staff burning out. A clear point that the guidelines set out is that even when dealing with a person who has repeatedly present with self harm the practitioner should treat each case separate as I could have a different trigger or meaning.
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‘Self-harm is poorly understood by many NHS staff.’ (NICE,2004) and therefore ‘All staff that come into contact with people who self-harm need dedicated training to improve both their understanding of self-harm and the treatment and care they provide. Effective collaboration of all local health organisations will be essential to develop properly integrated services.’ This should be done by allowing individuals who self harm, to plan the training sessions with the professional staff. The guidelines discuss how each individual service should manage people who self harm but for the purposes of this assignment we shall only explore the issues that effect working with children and young people. Due to their added vulnerability, children and young people should be treated slightly differently by service although physical treatment will be the same as that for adults. ‘Children and young people under 16 years of age who have self-harmed should be triaged, assessed and treated by appropriately trained children’s nurses and doctors in a separate children’s area of the emergency department.’(NICE 2004), these staff should be trained in early management of mental illness and the assessment and management of young people that self harm. Another change when working with young people is that the young person should be kept in hospital over night for observation and further assessment the next day, under certain circumstances this can be in a young person mental health unit or a social services children’s home. One issue with this service arises because parental consent is needed before a full mental health assessment can be carried out, obviously in some situations, e.g. if the parents are abusing the young person this can hold up the process of care and treatment until other legal consent can be found. Once treated either by the GP or Emergency Department the young person should be referred to a Community Adolescent Mental Health Service (CAMHS). <st1:City w:st="on"><st1:place w:st="on">Arnold</st1:place></st1:City> (1995) agrees with the guidelines that it is important to tackle the root cause of the self harming behaviour. For this to happen effectively the person’s needs and wishes should be assessed, and appropriate treatment negotiated with them. Both <st1:place w:st="on"><st1:City w:st="on">Arnolds</st1:City></st1:place> and NICE state how it is important to only raise the underlying issues as much as is needed so that the individual does not self harm while in treatment.
- If a person wish to self harm and is stopped they will eventually find away to do it anyway, which will usually be more secretly, this could also be more dangerously, for example of a individual had their cutting ‘tools’ removed they may try to overdose instead or use dirty blades to cut with.
- If the individual has no other coping strategies there is a greater risk of suicide.
- It will remove the individuals control and autonomy over their live.
- It gives out a message that the individual has no rights regarding what happens to their body. This would reinforce messages the individual may have got if they have been abused.
- It makes self injury a powerful ‘weapon’ or means of asserting oneself towards staff. This is obviously counterproductive and decentralises self harm from the individual.
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As we have seen earlier in this assignment many self harmers are usually disempowered by what they have been through, it is therefore important that services treat these individuals as capable, resourceful people who can be responsible for themselves. ‘it is important that services do not further disempower people, but encourage them to take charge of their own lives and development.’ (Babiker & Arnold 1997 p89). In this way it is important to allow people who self harm to some control over their treatment as compulsory treatment can lead to further self harm and lack of cooperation from the young person. Tantam and Whittaker (1992) point out that compulsory treatment is ‘sometimes inescapable, that very occasionally it helps and that quite often it makes subsequent self harm worse’. With this said however the hand over of control for professional to patent may take some time to happen if the client is already fixed in a passive role. It is also important, that the interventions used teach the patient how to cope for the rest of their lives and not just while they are in service. Babiker and Arnold note that where possible it is essential that services do not interfere with individuals self harm in the short term as this can aggravate the long term situation. They go on to give many reasons for this including:
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Within a Medical setting it is likely that an individual will be offered some form of medication to aid their treatment. This however can be problematic, mainly because it reinforces the issues at the root cause to self harm. That being ‘that complex emotional and personal distress is best dealt with through immediate physical solutions’ (Babiker and Arnold 1997). This may then encourage the individual to depend upon drug treatment if no other support is offered.
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This assignment will now explore the therapy for people who self harm. A therapist needs to remember that self harm serves a good purpose for coping with intolerable levels of anxiety or depression, and acts as a distraction from the emotional pain, because if this self harm is particularly reinforcing and therefore difficult to give up. The other main problem is that self harm can be a complex act of self destruction, with a need to destroy on one hand and a need for victimisation on the other. The individual’s knowledge of one aspect may be greater than another aspect. <st1:place w:st="on"><st1:City w:st="on">Arnold</st1:City></st1:place> (1997) adds a philosophical position to therapy stating that ‘self mutilation is not an illness, the therapist dos not intervene in the self mutilation, the therapist is able to discuss self mutilation, self mutilation has a meaning.’ These are important points because the self injury itself is not usually what needs treating but is the outcome of an underlying issue which needs to be addressed. Likewise the self injury can become the language for showing that underlying issue.
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<st1:City w:st="on"><st1:place w:st="on">Arnold</st1:place></st1:City> also goes on to add a theoretical perspective. It has been proven that there is a strong link between self harm and previous maltreatment or loss in the individual’s life. The therapy should try to make this link more explicit. However this is not always the case as the individual may view self harm as a new coping strategy for a currant issue. The therapy should pay clear attention to the role that self harm plays in that individual’s life, especially in relation to the present setting and previous coping strategies. <st1:place w:st="on"><st1:City w:st="on">Arnold</st1:City></st1:place> (1997) notes that the physical pain of self harm may serve a function on its own; therefore it is important that a therapist explores the function of self harm and the function of its pain separately. This is because it has been argued that self harm may produce a analgesia effect on the body through the release of endogenous opioids, and therefore a altered state of consciousness. This has lead to the theory that people who self harm may become addicted to is a powerful reinforcer, however to only view self harm in this way is to ‘pathologies the process unnecessarily.’ (<st1:City w:st="on"><st1:place w:st="on">Arnold</st1:place></st1:City> 1997). From here the therapist can point out that feelings of anxiety and distress do not have to be made to go away, but it is instead possible to face it and make it tolerable.
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The Cheshire Community Adolescent Mental Health Service (CAMHS) works effectively with young people who self harm. Although there are some significant issues which still need to be addressed. The main one being that ‘There are significant difficulties in providing a specialist CAMHS on-call response for self-harm and mental health crises, in part due to the lack of appropriate in-patient crisis facilities for mentally ill young people.’ (Nixon 2000). There is also little evidence however to suggest a need to justify 24 hour cover by the CAMHS. The report also notes how on average 2-3 self harmers are referred to the service each week. It clearly state like the NICE guidelines that these young people should be given a emergency bed for over night observation. Unfortunately as Nixon points out ‘
A frequent concern raised is the apparent mismatch between what the in-patient units’ offer and the needs presented by children and young people…indeed many national facilities are not able to take severe, high-risk cases that require an increased level of physical security.’ It does appear however that once these issues are cleared up then the service will provide adequate support and care for young people who present with self harm. <o:p></o:p>
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In conclusion this assignment has shown that self harm is extremely complex both in its causes and its meaning, therefore it is important that any form of professional help acknowledges these complexities and responds to them. <o:p></o:p>
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Bibliography<o:p></o:p>
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