Self Harm for Staff

8/19/2019 Self Harm for Staff

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UNDERSTANDING SELF INJURY

1. INTRODUCTION

Self- injury is an enormously difficult behaviour to manage and to work with. It cancause distress, anger and frustration amongst all kinds of staff, whether or not they

have health-care or psychological training. This leaflet provides information for allstaff who come into contact with people who injure themselves. It aims to help staff:

• understand why people injure themselves

• respond in ways that are helpful and realistic.

This leaflet should be read in conjunction with the relevant Prison Service policy

documents (eg those relating to the 2052SH process).

2.

UNDERSTANDING SELF INJURY

2.1 What is sel f-injury? `Self-injury’ refers to any act that involves purposeful infliction of pain, injuries orwounds to oneself. Other terms used are ‘self-mutilation’, ‘cutting-up’, ‘self-abuse’

or ‘self-harm’.

A wide range of behaviours may be described as self injury. They vary in medical

severity. Some result in mild damage to the body, requiring little or no medicaltreatment. Others may leave permanent physical scars or are life threatening. People

may injury themselves only once in response to an event or experience, or they may

do so repetitively.

The most common method of self-injury is cutting, usually of the arms or wrists,although other areas are cut such as the face, torso, legs, abdomen. Other methods

include biting, picking, burning or scratching one’s skin. Some people pull out theirhair (including eyebrows or eyelashes). Others tie ligatures or attempt hanging orself-strangulation. Still others punch, hit or kick themselves to cause pain or bruising.

Some insert foreign objects into themselves; either in bodily orifices or in cuts orwounds. Others take overdoses of medication or dangerous liquids or substances

(such as bleach or weed killers).

2.2 I s ̀self in ju ry' the same thing as ̀self harm?'

People use these terms in different ways which can be confusing. However, generallyspeaking `self-harm’ is a broader, more inclusive term than `self injury'. It includes

other (usually more socially acceptable ways) of inflicting harm or injury to one’s body such as substance misuse, overeating, excessive exercise or smoking. So `selfinjury' is a type of `self harm.'

2.3 How common is self in jury?Self- injury is very common, especially in prisons. One reason for this is that it is used

by some people to manage distressing feelings or as a way of coping with problems inthe absence of other methods (such as drugs or alcohol). Another reason is that self-

injury is associated with various mental health problems (such as personality


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disorders and psychosis), both of which are more common in prisons than in thecommunity.

Self- injury is particularly common amongst women and young offenders, although

men (both adults and young offenders) do injure themselves. During 2000, 5277

incidents of self-injury were reported to have occurred in prisons in England andWales. Almost a fifth of these (17.8%) were by women. As women make up only

5.6%1 of the prison population, they are substantially over-represented in self-injuryincidents. Similarly, 1356 incidents (26.0%) were by prisoners aged 15-20 years (who

make up 16.6% of the prison population1).

2.4 Why do people inj ur e themselves? - Past pain ful exper iences

People injure themselves for many different reasons. An individual may have mixedor confused motives and their motivations may not be exactly the same on each

occasion.

People who self injure have usually experienced difficult or painful events orcircumstances in their lives. The self injury may be a way of `dealing with' the painof these experiences.

Self- injury often occurs amongst those who have experienced difficulties duringchildhood. Common negative experiences include:

•

Communication problems within the family;

• Unmet emotional needs;

• Economic or social disadvantage;

• Having had a physical illness;

• Having experienced bullying, racism or ostracism;

•

Having a parent with emotional or alcohol/drug-related problems;

•

Experiencing the loss of a parent (through death or separation);

• Being taken into care;

• Neglect,

• Emotional, physical or sexual abuse.Sometimes there is no single event or cause or self-injury, but rather a series of what

may seem to be less serious events.

Sometimes self-injury occurs as a result of negative experiences or events in

adulthood. These include:

•

Being rejected or undermined by a partner;• Being trapped in an unhappy or abusive relationship;

• Experiencing the death of a partner or loved-one;

• Being physically or sexually assaulted or abused.

2.5 Why do people inj ur e themselves? How these experiences can lead to self

injury.

Self injury can fulfil a number of different functions:

1 Elkins, M., Gray, and Rogers, K. (2001) Prison Population Brief England and Wales, June 2001.

Home Office: London.


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People who intentionally injure themselves often say that it enables the m to manageor cope with painful or difficult experiences or memories. Some say that it gives them

great relief from tension, stress, anger, guilt or frustration (sometimes caused by their painful experiences).

Others say that injuring themselves can seem the only way in which to releasefeelings; unable to talk, cry or shout, or unheard, self-injury people sometimes let out

their anguish by harming themselves1. In this context can be understood as a means ofcommunication, because they feel unable or are unwilling to express themselves in

other way. A person may make their pain visible to themselves or others throughinjury. This may be directed towards others as a way of showing them that somethingis wrong and that they need help.

Others use self- injury as a way of gaining control. It is likely that this reason has

particular significance in prisons, since almost all opportunities for self-control aretaken away from individuals. In this context, people who injure themselves say that

self-injury is a way of gaining control over at least some aspect of their lives.

Some people self- injure as a way of blaming or punishing themselves for events that

may have happened in their lives (the death of a parent for example). In this situation, people sometimes feel that they ought to be punished, and self- injury is one way ofachieving this.

Others injure themselves because it gives them ‘permission’ to nurture or look after

themselves.

For those who have experienced physical or sexual abuse, self-injury may serve very

specific functions. Abuse often leaves a person feeling ‘dirty’ or ‘contaminated’ andself- injury can be used as a means of ‘cleansing’. People often say that the physical

pain caused by self-injury reduces the emotional pain that they are experiencing.

Others have managed the emotional or physical pain they experienced by ‘numbing’

or ‘shutting-off’; in this situation, self-injury (and the pain it causes) may helpsomebody feel alive or real. People who have been abused sometimes injure

themselves to change their overall appearance or the specific parts of their bodies thatthey associate with prior abuse.

2.6 Ar e people who injur e themselves trying to commit sui cide?The crucial difference between attempted suicide and self- injury relates to the issue of

intent. When somebody actually attempts suicide, they intend to die. Whensomebody injures themselves (without suicidal intent) they do not want to want to endtheir lives. Self- injury, particularly when it is repeated, is often a way of carrying on

with life and not ending it2. Self-injury can sometimes reduce suicidal feelings in theshort term by reducing feelings of tension, frustration or anxiety.

Nevertheless, it is essential to bear in mind that an individual’s motivations maychange over time, or they may be unsure about whether they want to live or die – they

may be ambivalent . It is also important to remember that people who injure

themselves are usually very distressed. Although the self injury may, in the short-term, help them to deal with that distress, something may happen to make the distress


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more than the person can cope with. They may then decide that dying is the only wayout. This may be one reason why people who injure themselves are much more likely

than those who have never injured themselves to die by suicide.

Staff in prisons are under pressure to identify those prisoners who are suicidal.

Unfortunately, there is really no way of finding out what someone intended withoutasking them, listening carefully to what they say and observing them over time. You

cannot tell from the extent of the injury what someone intended to do.

Indicators that the act was intended as suicideThe person:

• expected the act to cause death. (A non lethal dose of drug may have been thought to

be lethal.)

• is disappointed to be still alive

• made concrete plans (eg for their possessions after death, note to other people)

• took precautions not be to found

•

planned the act for at least several hours

• feels hopeless about the future; that things won't get much betterThe expression of regret that the act did not lead to death greatly increases the chance thatthe person will try to kill themselves again in the near future.

If a person is clear that their self injury is a way of helping them deal with problemsand they do not intend to kill themselves, it may not be appropriate to put them onfrequent observations in order to stop them from doing something they don't intend to

do. However, the individual should be offered help to deal with the problems that aretriggering the self injury (if this is possible). They should also be considered to be

someone who may become suicidal at some point in the future, if the pressures uponthem become greater. They need extra support. Risk of suicide should be assessedfrom time to time.

2.7 Are people who injure themselves mental ly il l?

Staff often believe that, if someone injures themselves "something must be wrongsomewhere." Someone who injures themselves "just can't be normal".

However, although self-injury is a sign of overwhelming distress, it is not, in itself, asign of mental illness. Some people who self injure do not have a mental disorder or a

personality (behavioural) disorder. Some people who self injure hold down

responsible jobs and care for families - (as do some people with a mental illness).Some people who self injure are nurses, doctors teachers and Prison Officers.

While some people who self injure do not suffer from mental disorders, others do.

People who have a psychotic illness may hear voices that command them to injurethemselves. People who use self injury to cope with emotional pain may also sufferfrom depression and/or anxiety for which help should be offered. Some people who

injure themselves suffer from a number of `personality' or `behavioural' disorders.You might suspect the presence of this additional problem if, in addition to the self

injury, the individual experiences sudden, extreme swings of mood, relates to othersin disturbed ways (for example, saying one minute that you are wonderful and the

only one who has ever been interested in helping them; but responding to a small set-


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back by claiming that you are useless, hypocritical and don't care for them at all), or isvolatile and injures others as well as themselves.

Because some people who injure themselves do suffer from mental or behavioural

disorders, it is important that they receive a full assessment of their needs. They

should be offered care and treatment for the full range of their problems.

There are leaflets available in this series that give information to staff on psychoticdisorders and on personality/behavioural disorders.

3. MIS-UNDERSTANDING SELF INJURY

3.1 M isunderstanding 1: Self-in ju ry is attenti on-seeking and should be ignoredThe view that self- injury is merely ‘attention-seeking’ is both simplistic and mistaken.Although for some self-injury is only way they can draw attention to the fact that

something is very seriously wrong, others go to great lengths to hide their injuries; for

them self-injury is much more about coping with their distress than attaining theattention of others. The view that people injure themselves only to attain the attentionof others means that those who injure themselves are often dismissed, which mayresult in further distress. People in the community who harm themselves are 100

times more likely to kill themselves in the year following their act of self harm thanthose who do not. Self-injury should never be ignored.

3.2 M is-understandi ng 2: Self-in jury is carr ied out to manipulate othersThere is a very common view that self-injury is used by prisoners to manipulate ‘the

system’ or individuals within it. Like many other things, self- injury can sometimes beused to manipulate others. However, by far the most important reason that people

injure themselves is to deal with unresolved distress or emotional needs. People injurethemselves for the effect it has on them, not other people. It is only seldom and neverexclusively carried out solely to manipulate others or gain attention.

3.3 M is-understanding 3: People who injur e themselves either enj oy or do not

feel painThis is a common misconception that can sometimes lead medical staff to crueltreatment, such as stitching wounds without anaesthetic. Although some people do

not always feel pain straight away, it is not the case that they feel no pain at all. Some people injure themselves as a means of self-punishment – because they think they

deserve to feel pain. Others injure themselves because the physical pain they feel on

infliction of injures is far less than the emotional pain they feel.

4. RESPONDING TO SELF INJURY - WHAT SHOULD YOU DO?

This section outlines general principles and some practical ideas. Not all ideas willwork for everyone. Any approach should be tailored to meet the different needs of

individual prisoners.

4.1 Immediate crisis managementIf there is any danger to life, resuscitation should be carried out ensuring that airways

are clear, breathing is taking place, circulation is adequate, there is no excessive

bleeding, there is no immediate risk from flames , and burns (whether from heat orchemicals) are irrigated with cold water. Death by asphyxiation from a ligature


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round the neck may take several minutes, allowing time for resuscitation, oxygenationand heart-massage, as required. Another leaflet in this series contains first aid

information on for staff who are first on the scene.

Referral to the health care centre will usually be necessary even where the physical

injury is mild. Severe and life-threatening injury and self-poisoning would normallyrequire attendance at A&E.

Whether immediate treatment of the wound takes place in A&E or the prison health

care centre, it is important to treat the patient with respect and care. They should betreated as someone who is communicating distress and not as someone who is notserious about suicide or who is wasting the time of staff.

For infected wounds the use of antibiotics should be kept to a minimum, with good

hygiene and antiseptic dressings instead wherever possible.

4.2 Assessment All people who injure themselves should have a full assessment of their needs,including mental health needs. This should be undertaken as soon as possible after

the incident and should be done sensitively and professionally. It is important thatthe underlying reasons that have contributed to the individuals’ distress are explored.The presence and seriousness of suicidal intent should be determined, as should the

risk of future self-injury. It is important to ask the person if they feel suicidal, evenwhen self-injury has been repeated many times and a non-lethal method has been

used. Motivations for self- injury and risk of suicide change over time; consequently,risk assessments should be repeated at intervals. Discussing suicide will not make the

person more likely to attempt suicide. The types of help or support that may be

beneficial to the individual should be explored.

4.3 Practical help on the wing or educationAs in cases of attempted suicide, it is very important to develop management plans for

prisoners who have injured themselves, to get them safely through the period of

distress. The plan should be multi-disciplinary, involving as many different staff whohave day-to-day contact with the prisoner as possible. The person themselves should

also be involved. The care plan must be realistic, in the sense that that the resourcesneeded to deliver it must be available. Practical ways of offering help and supportinclude:

•

Cell-sharing: Young people in particular may find that being temporarily‘doubled-up’ with someone helps. It is essential that care is taken in choosing a

suitable cell-mate; ensure that they are not placed with a cruel or manipulativeindividual who may encourage them to self-harm.

• Location: Consider a move to a different wing or other location in the prison, if

this is in the individual’s best interests.

•

Monitoring: ensure that the person concerned is monitored for the possibility of

bullying, threats of violence, problems with debts or other problems with otherson the wing. Also monitor for reaction of possible stressful events, such as visits

from children, etc.

• Explore alternatives: facilitate alternative coping strategies (see section 6 below).

•

Be aware of important dates that may trigger self-injury, such as children’s birthdays, dates of index offence, etc.


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5. RESPONDING TO SELF INJURY - HOW SHOULD YOU DO ITThe way in which people respond when somebody has injured themselves has a very

powerful effect on the individual. It is vital that staff are professional, courteous and

sympathetic and, above all, that they REASSURE the individual concerned. The

following suggestions are intended to help you understand and support people in yourcare.

DO:

R espond sensitively and with empathy. Think about what you say before you say it

Explore the reasons that the person has injured him or herself. Even if there isnothing that you do can to help solve the problems that have led up to it a ‘listeningear’ will probably be very much appreciated.

Accept the self- injury may continue for some time. The aim is to understand andsupport the individual in their distress, to help them gain more control over theirfeelings and increase their self-esteem.

Support the person (emotionally and practically) following self- injury. Make sure itis clear that support is available whether or not they are trying to control their self-

injury.

Seek support for yourself; talk to colleagues, ask for help if you don’t feel able tomanage. A multi-disciplinary team should be involved in supporting the person.Understand that self-injury is underpinned by distress or unhappiness of some kind.It is would be very unusual for somebody to injure themselves solely for its effect on

others.

R ecognise that self-injury is a mechanism that is used to manage problems, feelingsand experiences. It may take time to be replaced by alternatives.

Examine associated problems such as bullying, bereavement or relationshipdifficulties.It is vital that the person is recognised as an individual and not simply as a ‘problem’.

In this sense, you should ACCEPT the person and what they have done. Bearing thisin mind, it is very important that you:

DON'T:

Accuse the person of being manipulative or attention seeking. It is simplistic tothink that self- injury is carried out as a way or manipulating the system or individualsin it. It is very unusual for people to injure themselves simply to gain ‘attention’.


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Criticise the person for what they have done. This will make them feel worse and islikely to be counter-productive.

Conclude that the person is a ‘lost cause’ and nothing can be done to help them.

Expect too much of yourself. It is very unlikely that you will have all the answers.You are not expected to `get to the bottom' of the individual's problems or to be ableto solve it.

Put pressure on the person to tell you about underlying factors if they don’t want to.

Threaten to take away your support if the person harms him or herself again.

6 WHAT THE INDIVIDUAL CAN DO TO HELP THEMSELVES

It is important to emphasise that if self-injury is repetitive, it is likely that the behaviour will continue for some time. Perhaps the person has used self- injury as ameans of managing distress for a lengthy period of time. If so, it is possible that they

regard it as the only way of managing these feelings; there are, however, a number ofalternatives that can be encouraged. These include:

• Talking through their feelings with someone they trust.

• Encourage a focussing of energy in as positive way as possible; for example,drawing, painting or writing about thoughts and feelings.

• Taking part in some kind of physical activity or exercise.

• A temporary change of environment.

• Establishing what self- injury does for the individual. Suggest that they keep adiary to record their feelings just before they injure themselves and discuss

possible alternatives (such as punching pillows, taking exercise, talking tosomeone).

There are a number of techniques that can be used to reduce a person’s likelihood offuture self-injury, although there are few specialists trained in the area. The Prison

Service is currently piloting various interventions, and it is anticipated that at leastsome will be introduced in the near future. In the meantime, it is vital that people

who injure themselves are responded to as positively as possible. They should belistened to, accepted and cared for, not judged, blamed or criticised. It is important

that you are honest with the person; if you do not feel able to help, refer them tosomebody who can. A multi-disciplinary approach should be taken, with theinvolvement of as many staff as possible, including wing staff, teachers,

psychologists, Samaritans and health care staff.

7. USEFUL R ESOURCES/ORGANISATIONS

The Basement Project: PO Box 5, Avergavenny, NP7 5XW. Tel: 01873 856524.

Publications, training and workshops.

Bristol Crisis Service for Women: PO Box 654, Bristol, BS99 1XH.

Helpline (0117 9251119, Friday and Saturday evenings 9.00pm – 12.30am). Information, publications and training.


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Childline: 0800 111111.

24hour helpline for children and teenagers.

Eating Disorders Association: 1st Floor, Wensum House, 103 Prince of Wales Road,

Norwich, NR1 1DW. Helpline (01603 621414, Monday – Friday 9.00am – 6.30pm),Youthline (01603 765050, 4.00pm – 6.00pm).

Information and support on eating problems, details of local groups.

MIND: Granta House, 15/19 Broadway, Stratford, London, E15 4BQ. Information Line (0208 522 1728). Information on mental health problems, services, rights, local groups.

National Drug Helpline : 0800 776600

Confidential 24 hour service, advice, information, referrals, counselling.

National Self-harm Network: PO Box 16190, London, NE1 3WW.Survivor Organisation.

SHOUT: PO Box 654, Bristol, BS99 1XH. Newsletter for women who self-injury.

Books and ArticlesThere are many books about self-injury, mostly aimed at people working in the area.

They include:Babiker, G. and Arnold, L. (1997) The Language of Injury. British Psychologicalsociety.

Favazza, A.R. (1987) Bodies Under Siege. John Hopkins.

Harrison, D. (1996) Viscous Circles. Good Practices in Mental Health.

Pembroke, L (Ed) (1994) Self-Harm: Perspectives from Personal Experience.Survivors Speak Out.

Walsh, B. and Rosen, P. Self-Mutilation: Theory, Research and Treatment . GuildfordPress.

1 Bristol Crisis Service for Women, Understanding Self-Injury, Booklet No. 2.

2 Babiker G and Arnold L, 1997, ‘The Language of Injury’, British Psychological Society

Self Harm for Staff

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