Managing Deliberate Self Harm

By Stuart Sorensen - RMN

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. This article explores some alternative notions about deliberate self-harm and examines ways that support workers can make a difference in a genuinely difficult situation.

First of all bear in mind that you are not alone. No single person can do everything. Whilst deliberate self-harm does not necessarily lead to suicide these things do happen and it's always a good idea to liase with other, specialist professionals. A decent GP, Psychiatrist or community psychiatric nurse will be worth their weight in gold. It is important that you and the resident, together with input from other professionals, perform a thorough risk assessment. Agree how to manage future problems and when to seek outside or emergency help.

All that aside though, there is much that support workers can do on their own. Deliberate self-harm is not usually an attempt to manipulate others

Contrary to popular belief, deliberate self-harm is not usually an attempt to manipulate others. Nor is it usually a 'cry for help'. Most people are quite able to ask for help without self-harming and the secrecy that often accompanies self-harm demonstrates that something else is going on. That 'something' is known as 'Dysthymia'.

Many people, particularly those diagnosed with Post-Traumatic Stress Disorder or Borderline Personality Disorder experience emotions in a particular way (Kroll J. 1988). When under pressure they may find it impossible to make sense of what they feel and become 'Dysthymic'. This means that they experience all emotions at the same time but no single emotion in particular. This, understandably enough, is difficult to bear.

One way to 'reset' the emotional balance is through physical pain. Self-harm prompts the brain to produce endorphins, a kind of natural opiate, which overcomes Dysthymia and allows the person to feel better. So when a resident deliberately self-harms it's likely that they're feeling stressed and overwhelmed. It doesn't matter how stressful others believe their situation to be. Different people have different coping abilities and what may be no problem at all for one person might well overwhelm another (Zubin & Spring 1977).

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 outline the ways in which certain types of interaction increase stress, reduce coping and lead to the conditions which encourage psychological and behavioural problems including deliberate self-harm.

These include

High Expressed Emotion
Aggression and hostility
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.

It clearly would be inappropriate for project workers in supported housing to undertake full-scale psychotherapy. However, attention to the concepts of expressed emotion and the invalidating environment is appropriate and can make a huge difference. Remember that befriending is an extremely effective method of supporting people, with or without external therapy.

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





Be hostile or aggressive
Be emotionally over involved

Gently challenge the resident 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 residents 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 resident and risk-assess
Call for assistance if necessary
Discuss coping with the resident and and monitor the situation as closely as is appropriate

Mild Deliberate Self-Harm

Ignore this
Over-react to this

Ensure the resident has access to appropriate first aid if applicable
Discuss this with the resident 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 resident
Co-operate with emergency services
Discuss the situation and begin to plan for future care with the multi-disciplinary team and the resident as soon as is possible once the initial emergency has passed

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