Abstract
The act of harming oneself, causing pain, injury and scarring, can in a similar way to suicide appear deeply puzzling. It stands in stark contrast to more acceptable and seemingly understandable urges to protect and care for oneself. Yet violence directed against the self is common, and when an individual is in a disturbed and less rational state of mind, as described in the quote above from A Little Life, this action can seem reasonable. This chapter will explore the motivation, theoretical understanding and management of self-harm, with the aim of increasing understanding and improving outcomes.
Self-harm encompasses a broad spectrum of behaviour that is the ‘final common pathway’ [2] of many different emotional difficulties. Although it is most frequently associated with Emotionally Unstable Personality Disorder (EUPD) the majority of self-harm does not occur in those who have been diagnosed with mental illness of any sort, and as much as 80–90 per cent may not come to the attention of professionals [3]. For some patients, the behaviour is comparatively brief and discrete during a stressful time of life; for others, it is chronic and intertwined with the way they perceive themselves.
Introduction
He remembered the sensation, the satisfying slam of his body against the wall, the awful pleasure of hurling himself against something so immovable. …
… he soon grew to appreciate the secrecy, the control of the cuts. … When he did it, it was as if he was draining away the poison, the filth, the rage inside him.
The act of harming oneself, causing pain, injury and scarring, can in a similar way to suicide appear deeply puzzling. It stands in stark contrast to more acceptable and seemingly understandable urges to protect and care for oneself. Yet violence directed against the self is common, and when an individual is in a disturbed and less rational state of mind, as described in the quote above from A Little Life, this action can seem reasonable. This chapter will explore the motivation, theoretical understanding and management of self-harm, with the aim of increasing understanding and improving outcomes.
Self-harm encompasses a broad spectrum of behaviour that is the ‘final common pathway’ [2] of many different emotional difficulties. Although it is most frequently associated with Emotionally Unstable Personality Disorder (EUPD) the majority of self-harm does not occur in those who have been diagnosed with mental illness of any sort, and as much as 80–90 per cent may not come to the attention of professionals [3]. For some patients, the behaviour is comparatively brief and discrete during a stressful time of life; for others, it is chronic and intertwined with the way they perceive themselves.
Definition
Self-harm is a term that serves as a catch all for a wide range of self-destructive behaviour that even in a single individual can mean different things at different times. Psychological and psychiatric professional bodies use different definitions of self-harm and apply a variety of exclusion criteria. For example, NICE defines self-harm as [4]:
an expression of personal distress, usually made in private, by an individual who hurts him or herself. The nature and meaning of self-harm, however, vary greatly from person to person. In addition, the reason a person harms him or herself may be different on each occasion, and should not be presumed to be the same.
The terms ‘intentional’ and ‘deliberate’, which were previously used as part of the definition, are rarely used now. They are not favoured by patient groups or professional bodies, as they imply purposeful, conscious, rational determination. This implication can interfere with the therapeutic alliance, and contribute to the stigma suffered by those who have self-harmed.
Self-harm describes a spectrum of behaviour that includes apparently non-suicidal self-injury and serious attempts to die by suicide. Views differ as to whether these two groups indicate discrete aetiologies and should be considered separately [5]. Two of the UK’s leading academics on self-harm, Professors Keith Hawton and Nav Kapur, believe that dividing the group creates a false dichotomy and can lead to a dangerous underestimation of suicidal risk [6]. What is agreed is that a degree of dissociation, or temporary disconnection from reality needed to cross the body boundary in order to harm oneself is the strongest indicator for future death by suicide [7]. The risk of dying by suicide in the 12 months following a presentation of self-harm is around 30 times higher than the expected rate in the general population [8, 9]. Almost half of those who end their life by suicide have previously harmed themselves [6, 10] and the more violent the method of self-harm, the greater the chance of completed suicide [11].
There are two international manuals used to classify mental disorders; the Diagnostic and Statistical Manual (DSM), and the International Classification of Diseases Manual (ICD). A diagnosis of non-suicidal self-injury is included in the 2013 version of the former under the section: Conditions for further study. This provides a somewhat limited framework for diagnosis; however, it does recognise the need to identify self-harm as separate and distinct from other mental disorders.
Types and Methods
Self-harm encompasses a wide range of activities that include:
Those conducted in a less acutely dangerous manner that can be habitual such as cutting, burning, asphyxiation, poisoning, head banging, inserting, bloodletting and swallowing
The severe and bizarre such as disembowelling
The clearly life-threatening and suicidal, including overdosing, stabbing and hanging
The method used will have an unconscious meaning for the patient. Self-cutting and self-poisoning with medication are among the most common methods of self-harm in high-income countries such as the UK [12].
Epidemiology
Self-harm largely occurs in the community so accurate epidemiological figures are hard to establish, with the majority of incidents never coming to the attention of services. Research has shown that 10 to 20 percent of people worldwide report having self-harmed at least once and it is three times more common in women than men [12, 13]. There is evidence over recent years of a threefold increase in reported self-harm across the population of young people in general, and women in particular. The reason for this increase is not clear and could represent an increase in self-harm or an increase in reporting [8].
Motivation
It can be challenging to make sense of the motivation that underlies self-harm. It can be helpful to recognise the variety of unconscious intentions that include:
1. A means of communicating: the ability to put feelings into words, to ‘mentalise’ [14], is a developmentally complex task. A feeling usually starts as a somatic response to an internal or external event. This bodily experience can be very painful and frightening. To create a mental representation in a word for this embodied experience requires symbolic transformation. This experience can then be contained linguistically and expressed. So, for example if someone experiences their heart beating very fast, their chest as tight and a sense of constriction around their throat, they may recognise this as anxiety. When identified as anxiety this state can be identified as familiar and expressed both to the self and others. This process is cathartic and frees up the internal world. It also allows the experience to be stored in semantic memory where it remains located in time and place. If there is a difficulty in symbolising emotions (alexithymia) then mentalising is compromised and an individual is left easily overwhelmed by feeling states that are physically and psychologically painful. In these circumstances a way to communicate this pain to oneself and to others is through self-harm.
Case example:
Alan was admitted to a psychiatric ward after presenting to A&E. He had taken a life-threatening overdose after an argument with his partner. He was a young man who seemed very composed and articulate. He shocked the team by coming into his first ward round in a T-shirt exposing bright red cuts and old scars interweaving up both arms.
In this case Alan both communicated and projected his distress into the ward team and in this way let them know how cut off he was from his own emotional experience. These scars also served to warn the staff, who were exposed to the full force of the disturbance through their countertransference, not to be deceived by his apparently self-possessed facade.
2. To regulate overwhelming emotions and regain a sense of control: individuals who have a reduced capacity to mentalise can displace and transform their emotional pain, when overwhelmed, into physical pain. This physical pain is then contained in a primitive way by the body and the mind is freed of fragmentation and mental control is regained.
3. To contain traumatic memories: self-harm often occurs when individuals become overwhelmed by deep undigested traumatic memories from childhood [15]. A recurrence of this ‘original pain’ [16] is triggered in the present by less substantial events. This existential pain can be substituted and temporarily released by the self-harm, the pain of which also resolves the numbness and dissociation that accompanies these disturbing memories. This allows a past traumatic event where individuals previously felt powerless and helpless to be re-enacted in the present with subjective control.
4. A dysfunctional method of eliciting care: self-harm can be triggered by fear of abandonment or neglect in relationships. The self-harming behaviour then performs the function of eliciting care from others. If successful in extracting care in this dysfunctional and perverse manner, damaging spirals can ensue where the violence and frequency of the self-harm increases.
5. As an addictive behaviour: recent literature suggests that repeated self-harm can be understood as an addictive behaviour that has features in common with other addictions such as gambling and substance misuse. The self-harm itself is thought to release endogenous opioids and stimulate the dopamine reward pathway. This explains why self-harming can become compulsive, entrenched and prevent more functional methods of communication being developed [17]. Some authors also comment on the masochistic excitement resulting from the cruelty inflicted on the body and describe how there can be ‘a frenzy of self-harm not unlike sexual satisfaction in some cases’ [16].
6. Protection both of the self and others: Some people suggest that self-harm is a mechanism by which they reduce the intensity and impulse to act on suicidal thoughts [18, 19]. Various analysts perceive self-harm as a manifestation of the defence ‘anger turned against the self’ and, when managed in this way, prevents an attack on others [16, 20].
7. Defence against intimacy: those who have been traumatised and/or abused can have a terror of intimacy. Evidence of self-harm can serve to keeps others at bay.
8. Maintaining coherence: Anna Motz, a consultant clinical and forensic psychologist who has worked with women who are perpetrators of violence, argues that self-harm reflects a split and divided self [21]. When the ego becomes overwhelmed by ‘toxic’ thoughts and starts to fragment, a way of retaining coherence is for it to split into ‘good’ and ‘bad’. The ‘bad’ is projected into the body where it can become other to the self, attacked and punished for its aggressive and violent feelings. Motz emphasises that nursing the wounds often plays an important role in the ritual of self-harm. She argues that as well as protecting the ego from disintegration self-harm allows for a reunion where the attacking self then becomes the caring, nursing self.
Theoretical Understanding
Emotional dysregulation
Neuroscience
Early trauma has been found to affect the development of the brain by modifying the neural structures that underly emotional regulation. The result is an emotional system which, when triggered, responds to stimuli with greater speed and strength than in those who have not been traumatised [22–24]. This leads to emotionally overload and a dynamic change in the brain functioning where the more mature left hemisphere of the brain shuts down leaving the more primitive right side of the brain to respond.
The left and right sides of the brain develop at different speeds and have different functions. Different rates of development of the hemispheres mean that memories are stored differently at different times of life. The right side, active from birth, functions in a less developmentally mature way. It is responsible for emotional and sensory memory. The left side, responsible for language and temporal memory, develops around the age of three and it is only after this time that memories can be stored linguistically and sequenced in time (see Chapter 16). Before the age of three, memories tend to be housed in body memory in a sensory form, without mental representation. When overwhelmed in the here and now, the left side of the brain can turn off and the right side be turned on. The capacity for language, mediated by the left hemisphere, needed for emotional regulation, is blocked. Individuals are then left to relive childhood memories in the present as a bodily experience mediated by the right hemisphere [15]. This increases the experience of emotional overload and emotional dysregulation. Self-harm is the method on hand to acutely manage this psychological pain.
Attachment, Attunement and Symbolisation
The quality of early childhood attachment is vital for the later capacity to mentalise and regulate emotions. Language development depends on having an attuned carer who can recognise and put into words the child’s emotional experience. These words can then be learned by the child and used to store this experience in memory. Difficulties in this primary relationship can lead to an incapacity to put feelings into words. This inability to mentalise is related to insecure attachment. This is illustrated by research that shows that over 70–75 per cent of those who self-harm has an insecure attachment style compared to 15–20 per cent in the group that do not. [2, 25, 26].
Attachment System Activation
For those with insecure attachment objectively minor events in the present can elicit strong emotionally dysregulated responses. These ‘trigger’ events elicit unconscious memories of past trauma and therefore may be perceived as overly abandoning or rejecting. A delayed reply to an email or text can be the spark that lights an emotional fire and causes activation of the attachment system. When stimulated, the attachment system generates a powerful drive to seek care and closeness to the primary attachment figure ‘… at highest intensity, when distressed and anxious, nothing but a prolonged cuddle will do’ [27]. This works well in securely attached individuals but less well with insecure attachment where proximity can be sought to the source of the maltreatment. In later life clinging, controlling (perceived manipulative) or panicked behaviour can elicit re-enactments of the original trauma and a vicious cycle ensues.
Case example:
Ellen had been seriously neglected as a child, and was removed from her mother’s care and placed with foster parents. She had a history of self-harm and had recently been referred to her local mental health team for depression. She met for the first time with her new keyworker, Claudia, who had little experience of self-harming behaviour. She found Ellen appealing and during this meeting Ellen felt especially understood and cared for. Ellen found it very difficult to leave the appointment and go home to an empty flat. She felt anxious and abandoned. She tried phoning Claudia to seek reassurance. When Claudia did not answer her calls, Ellen’s emotions overwhelmed her. She cut her arms very deeply and sought care for these wounds at the A&E department. Claudia had thought that she had a good session with Ellen and was surprised to get a call from the mental health team in A&E. She felt confused, let down and angry. She did not want to talk to Ellen next time she called and gradually withdrew from contact. Ellen felt rejected and abandoned, her self-harm increased and she had a brief hospital admission.
In this case Ellen’s attachment system was activated by the intimacy with Claudia, leading to emotional dysregulation and self-harm. Claudia’s difficulty in fully formulating the case left her ill-equipped to manage her own feelings of rejection and disappointment and she withdrew.
Anthony Bateman and Peter Fonagy, leading academics in the treatment of emotional instability and borderline personality disorder (BPD) and pioneers of the development of Mentalization-Based Treatment (MBT), describe how a lack of attunement and inaccurate mirroring in the early caregiving relationship leads to an ‘internalisation of representations of the parents’ state rather than of a usable version of the child’s own experience’. They call this internalisation ‘the alien self’. This ‘alien self’ is an incongruent aspect of the child’s identity that has been projected into them by their caregiver. This is experienced as part of the self but does not seem to belong, and disrupts the sense of coherence ‘which can only be restored by constant and intense projection of this alien self onto another’. This keeps a fragile equilibrium. When the recipient of the projection is absent, temporarily or permanently, the equilibrium breaks down and can be restored only by projection of this alien self onto the body. This act is carried out in the mode of ‘psychic equivalents’, which means that symbolic capacity has broken down and the body is experienced as ‘isomorphic with the alien parts of the self’. The hatred felt towards the abandoning attachment figure can then be externalised and violence enacted. They comment that the sense of despair is not from the loss of the object, who normally would not have been a genuine attachment figure in the first place, but the anticipated loss of self-cohesion [22].
Case example:
George, a psychiatric nurse, was accompanying Amy on a home visit. They were on the bus. Amy was calm and chatty, and George was wondering why she had been admitted to hospital. She was smiling and looked very relaxed. She looked down at her phone having received a text. Within a second something profoundly changed. She opened her mouth in a silent scream, grabbed the back of the seat in front of her and shook herself backwards and forwards, she then started scratching the back of her wrists with her nail and gradually calmed down. This happened so quickly that George was shocked and frightened. He felt he could not manage with Amy by himself and they returned to the hospital. He found out later that the text was from Amy’s mother telling her that she could not visit that afternoon.
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