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Self-Harm Awareness within the prison service

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1 Self-Harm Awareness within the prison service
Dr. Julia Rose and Lisa Gray

2 Aims To raise the awareness of Self-Harm
Explore underlying factors which can lead to self-harm Explore triggers that perpetuate the cycle of self-harm To build on existing knowledge Outline of therapeutic models for working with self-harm

3 Icebreaker Choose an object from the table which represents
something to you Then introduce yourself and the object stating why you chose it – also say where you’re going to work and past experience of working with self-harm and suicide

4 Background – Underlying Factors: The Effects of Rape, Sexual Abuse and Domestic Violence
Human beings are determined by their early experiences (Erikson, 1963) Children need good role models to learn coping strategies for every-day challenges These experiences impact on a person’s future: Evidence suggests that 21% girls and 11% of boys experience some form of Childhood Sexual Abuse 23% women & 3% men experience sexual assault as an adult 5% women & 0.4% men experience rape (Home Office, 2005/2006)

5 Background Research indicates that 95% of children who suffer childhood abuse/neglect go on to self-harm (De Young, 1982; Huband, Tantum, 1999)

6 Difference Between Rape and Sexual Abuse
Is like never having a life Can occur over a longer period of time and often for many years Is suggested to have a deeper impact on the survivor’s life Rape Rape is like having your life taken away Can occur on numerous occasions for varying amounts of time Is a crime of violence more than a crime of sexuality Is the most common violent crime in the US

7 Rape Statistics The local Rape Crisis team supports approximately 2 -3 thousand women and young people per year Nationally Rape Crisis centres reported 50,000 calls per year (2010) - 12% of these reported incidents to the police - 6 % of 12% reported gained convictions - For some, reporting it is like ‘the third rape’ 6% of the 12% of reported incidents gained convictions – this equates to a third of a man BUT – services are improving for example, specialist training is being implemented in police departments, specialists/barristers with knowledge of this area are allocated these cases in Law firms

8 Rape Statistics ,755 incidents of rape recorded by the police ,082 incidents of rape recorded by the police ,148 incidents of rape recorded by the police ,940 incidents of rape recorded by the police – 26% of recorded cases went to prosecution (4,208) and gained a 71% conviction rate BUT

9 Conviction Rate If a rape is reported, there is a 50.8% chance of an arrest If an arrest is made, there is an 80% chance of prosecution If there is a prosecution, there is a 58% chance of a conviction Of the 39% of attacks that are reported to the police, there is only a 16.3% chance the rapist will end up in prison Factor in unreported rapes and this drops to a 6% conviction rate (Rape, abuse and incest national network, 2007; Sexual Abuse Referral Centres, 2010)

10 Rape Victims Discussion - Women say some rape victims should take blame (Wake up to rape survey 15/02/2010) But What do you think?

11 Aftermath The video we are about to show was designed as a training video to depict the trauma and devastation a person experiences when they are raped

12 Aftermath - Exercise Exercise - Consider the Following Questions:
What was the lasting image? What are the short term/long term effects? How are you feeling after watching the film? How long has it been since the rape occurred?

13 Rape Trauma Syndrome (RTS)
RTS is a process which explains the stages of recovery a survivor goes through It was adapted by the Rape Crisis Centre and includes: The crisis stage – A reaction to what has happened The suffering stage – Experiences feelings associated with the loss The resolution stage – Accepts what has happened and learns to live with it Introduction into Rape Trauma Syndrome diagram

14 Recognise Effects on life
To Heal Deal with feelings Discover Learn to recognise Own / Admit Express Problems Relationship Sexual Eating Sleeping Self-Harm Humiliation Unable to cope and function normally Guilt Assess Losses Relationship – i.e.. family Friends perpetrator Confusion Panic Attacks Sweating Shaking Shame Depression CRISIS Self-Blame Flashbacks Spontaneous or triggered Situation Smell Sound Sight Powerlessness Anxiety Loss of Trust in Self and Other / Other Losses Mourn Anger Accept What has happened Learn to live with Fear Case studies: Susan (2 men) Linda (Spain) Jackie (Drug rape) Jane (Wheelchair) Rita (swallowing) Can’t Go Out / Cant Stay In Suffering Sadness Recognise Effects on life Regain control Isolation Make Choices Home, Work, Lifestyle Resolution (Burgess and Holstrom,1976) 14

15 Why are these events associated with self harm?
Self-injury is often associated with extremely difficult and distressing life events or experiences often beginning in childhood. For example: abuse or maltreatment, bereavement or loss CHILDHOOD EXPERIENCES % ADULT EXPERIENCES Sexual abuse 49 Rape/sexual assault 22 Neglect Abusive relationship with male partner 14 Emotional abuse 43 Lack of support 13 Extreme lack of communication 27 Loss of baby/unable to have children 10 Physical abuse 25 Loss/separation Parental illness/alcoholism 17 15

16 This ultimately results in the
Effects Abandoned children are likely to suffer feelings of loss and to see the world as a dangerous place They are unable to meet their own emotional needs due to lack of good-enough care They are unable to internalise sufficient love and care to build up their inner resources There is no opportunity to learn from adults how to identify, communicate or self-soothe This ultimately results in the Absence of a secure attachment and secure base 1st point: If the children are not taught how to contain these feelings or how to comfort themselves these feelings become overwhelming. Think about how these experiences effect a persons way of relating to others and their sense of self Self-loathing – “I’m unlovable” Distorted body image Violence and abuse are ‘normal’ ways of responding Dissociation – either injure during dissociative episode or to facilitate return to reality. 16

17 What is Self-Harm? ‘Self-Harm’ has multiple names in the literature for example: self-injury; self-inflicted violence; self-injurious behaviour; self-mutilation; and parasuicide It is the act of attempting to alter a mood state by inflicting physical harm serious enough to cause tissue damage to your body ( Parasuicide is ‘deliberate self-harm which is not lethal’ (Sidley, 1998) Self-harm: can be defined as the deliberate, direct injury of one's own body that causes tissue damage or leave marks for more than a few minutes and that is done in order to deal with an overwhelming or distressing situation ( Self-harm is the deliberate damaging of body tissue, more often than not, without conscious intent to commit suicide. It has also been described as "self-mutilation", "self-injury", "auto-aggression“ and "delicate self-cutting“ ( Parasuicide, widely used term for all self-harm behaviour, (explicit or implicit intention) and many clinicians use the terms ‘deliberate self-harm’ (DSH) and ‘attempted suicide’ interchangeably (Rose, in press) Kreitman (1977) defines Parasuicide as any non-fatal act in which an individual deliberately causes self-injury or ingests a substance in excess of any prescribed or generally recognised dosage 17

18 Exercise In groups of threes, jot down ways people can harm themselves
Think broadly – Think about ways in which they behave that may cause them harm 18

19 Reported Methods

20 What is Self-Harm? Self-harm serves a function for the person who does it Exploring what functions it serves and helping someone learn other ways to get those needs met is essential to helping people who self-harm 20

21 Self-Harm The highest rates of self-harm behaviour in Europe are found in the UK (Bowen & John, 2001; Lowestein, 2009) Some of the most extreme forms of self-harm are found in in-patient and prison settings (Rayner and Shaw, 2003; Rose 2010) Public awareness has increased since self-harm has attracted a wider audience through media coverage (Shaw, 2002; Todd, 1996; Egan, 1997) 21

22 Self-Harm in Forensic Settings
There has been a dramatic increase in the levels of self-harm in HM Prisons amongst female offenders This has caused concern for the British Government and Prison officials (HMCIP, 1997) and has been an agenda item for the last two years (Milligan & Andrews, 2005) It is estimated that it occurs in up to 63% of sentenced or convicted women prisoners and up to 76% of women remand prisoners Explain that we are using prison statistics as in-patient care statistics are not easily available. Also there is a comparison between prison and in-patient care statistics England and Wales Age group – highest rate of self-harm By Gender – male female Most Frequent method used by males – cutting / scratching Females – cutting / scratching Nationality – male – white = highest / mixed ethnicity = lowest Female – white = highest / Asian = lowest UK nationals since 2004 have the highest recorded rates of self-harm So now we have looked at what self-harm is, how people self-harm and we have also looked at the foundations and what the underlying factors may be that cause a person to self-harm – it is time to move on to look at why people self-harm – we will start this with an exercise 22

23 Who does it? Women are 3-5 times more likely to self-harm than men
Mostly in teen, 20’s and 30’s – although can be younger and older Women are constantly embattled with their bodies More likely to be victims of abuse Society does not allow/tolerate women expressing negative feelings e.g anger Women historically have been disempowered by society

24 Why Self-Harm? Exercise – Why Self-Harm?
In groups of three write down as many reasons as you can of why people self-harm? Examples: A client was bullied at school both emotionally and physically. When walking home from school the bullies used to push her into the oncoming traffic. The client ran home one day crying and was so angry with herself for letting them beat her again and make her cry that she threw a vase against the wall. The vase shattered and a piece cut the clients leg, she described feeling such relief from this that she began self-harming. Another – I’d rather feel physical pain than mental pain release anger turn emotional pain into physical pain (which is easier to cope with) communicate distress and express anger punish oneself for events (which may have been out of their control in the first place) Myths, Reactions to Self-harmers Link To Childhood trauma 95% CSA (Huband, Tantum, 1999; de Young, ) 90 % Heroine/Crack Cocaine Relief, Stress, Tension, Anger, Comfort relieving guilt & hatred Frustration, Blood, Cleansed, Calm, Internal Chemistry, Symbolic Representation Control/Out of Control Feel Alive – real Inflict pain, punishment (Towl & Snow, 2000; Snow, 1997) Survival – unbearable experiences – alternative suicide 24

25 Physiological and psychological arousal is reduced
A strong uncomfortable emotion is felt and they, don't know how to handle it BUT they do know that hurting themselves will reduce it quickly Self-harm can bring levels back to a bearable baseline level almost immediately They may still feel bad (or not), but they don't have that ‘panicky jittery trapped feeling’; it's a ‘calm bad feeling’ 25

26 Deliberate self-harm as a form of self-punishment:
People may believe that they are evil or bad (they may have been told this directly by the person who harmed them or they may believe this was why they were being harmed) and deserve to be punished For many individuals, the behaviour acts as a re-enactment of past experiences where they have been traumatized and abused Harming the self is a way of delivering the punishment that they feel they deserve for being 'bad' and to blame 26

27 Deliberate self-harm as a means of validating the self:
Self-harm is a way of testifying to the enormity of their experience and a way of remembering events that others may have forgotten or denied For some it is a way of confirming that what they suffered really was as traumatic as they remember 27

28 Problems with neurotransmitters may play a role:
Research suggests that problems in the serotonin system may predispose some people to self-harm This tendency toward impulsive aggression, combined with a belief that their feelings are bad or wrong, can lead to the aggression being turned on the ‘self’ 28

29 To change a mood state or emotion or as an expression of anger:
A mood state can be positive or negative, or even neither; some people self-harm to end a dissociated or unreal-feeling state, to ground themselves and come back to reality People learn that hurting themselves brings them relief from some kinds of distress and eventually turn to it as a primary coping mechanism Many feel anger is unsafe or unacceptable. Many experience intense anger directed at self Self harm can be a means of inflicting anger without hurting anyone else. Anger; frustration

30 Self harm as a form of Self-care:
Feeling reality ‘It’s like pinching myself awake’ Opportunity for self-nurture – the time after injury might be the only opportunity for care and comfort – ‘When I take care of my burns it’s like a real reason to love myself, as though I’m saying “there, there” to myself’ 30

31 Relationship with others – elicit care:
Communication – injury may serve to communicate a feeling or experience that cannot be communicated verbally. Some have learnt that verbalising gets them nowhere. ‘I wanted someone to ask me why I was doing it. Then I would have been able to talk about my past’ ‘I always had to drastic things to get my mum’s attention, and so I carried this on into adulthood. I don’t think people will believe me if I just tell them how I feel, so I do this to show them’ 31

32 Summary: Why Self-Harm?
Affect modulation (distraction from emotional pain, ending feelings of numbness, lessening a desire to suicide, calming overwhelming/intense feelings) Maintaining control and distracting the self from painful thoughts or memories Self-punishment (either because they believe they deserve punishment for either having good feelings or being an "evil" person or because they hope that self-punishment will avert worse punishment from some outside source Expression of things that can't be put into words (displaying anger, showing the depth of emotional pain, shocking others, seeking support and help) Expression of feelings for which they have no label -- this phenomenon, called alexithymia (literally no words feeling), is common in people who self-harm Often the body's natural 'pain killers' will take over so that when a person harms themselves they frequently do not feel 'realistic' pain. Euphoric state a non verbal form of communication in which feelings are expressed through self-injurious actions, where they can be dealt with in a more visible way, yet because of its very visibility, self-harm is often treated with mistrust and prejudice. One thing to remember is that self-harm is not something that people do for attention. More often than not, people will go out of their way to hide their scars and they are likely to lie about how they got them. They will try their hardest to avoid being found out and will hide, or destroy, blood-stained clothing. The most important thing is to realize that people who harm themselves are not trying to commit suicide. On the other hand, many self-harmers may have attempted suicide in the past and now harm themselves as a way of controlling suicidal thoughts. Physical pain is better than mental / emotional pain 32

33 What can we do – Carousel
Carousel is a unique self-harm programme that draws predominantly on Cognitive Behaviour Therapy (CBT) to reduce self-harm behaviour, an approach recommended by NICE guidelines. Carousel also uses elements of Personal Construct Psychotherapy (PCP) with Humanistic underpinning

34 Carousel Carousel is a rolling group-treatment programme originally catering for female remand prisoners who self-harm Each week was designed to be self-contained, enabling participants to enter or leave the programme at any stage Carousel consists of: Group therapy, individual counselling, physical exercise, relaxation, psycho-education and therapeutic art. It focuses on the development of alternative coping skills and problem solving techniques are key elements running throughout the programme Carousel is a psychotherapeutic approach that combines a range of research-based methods

35 Carousel “Systematic safeguards should be put in place so that good practice approaches like Carousel are not lost” (Ministry of Justice, 2008)

36 Carousel Topics included within the programme:
management of impulsivity, behavioural regulation, alternative constructs of self-harm, worldviews, development and awareness of pro-social skills, personal protective factors, as well as education around drug and substance abuse Psycho-education offers opportunities of learning and insight from the shared experience of group members The use of cognitive behavioural and personal construct theories enables an appreciation of the ‘self’ in relation to others, increasing emotional intelligence and pro-social skills thus encouraging behavioural regulation and contingency management Distraction using art, story-telling, poetry or other activities the client likes Encourage them to talk to staff members, to identify when they are feeling the need to self-harm and tell staff about it – our reaction to this then can determine the effectiveness of this technique Such as the gym – can use it to get out emotions such as frustration, anger etc. Often writing down the problem (or using a dictaphone for those less capable) can help to relieve some of the pressure. Also acts as a form of self-reflection as client can go back over it and determine where they can improve or what else could help them Use of happy box can serve to distract the client but also emphasize the positive aspects, it can also give them something to strive towards and not have a set back with a self-harm incident Relaxation techniques can be completed anywhere by anyone. Deep breathing, guided imagery, contrast muscle relaxation can distract and calm Sensory techniques such as having a warm bath, wrapping the person in a warm towel, hand or head massage, listen to calm music Could also exercise vigorously, shout, laughter therapy, punch a cushion or mattress, squeeze a stress ball

37 Carousel – Participant Views
Key theme was new coping strategies for managing self-harm and violence Before I would have sworn, cut up, lost my temper. Now I can let it go over my head I used to just go off, but now I go and talk to staff instead or write in my journal – distract myself I keep an anger diary. If I feel like cutting, I write it down instead I've never asked for help before – find it much easier now I’ve realised that things are not my fault that I thought were Its brilliant, amazing – I wasn’t expecting it to help, but it did I used to beat people up – now I don’t Thank God for Carousel

38 Overview We have a broader awareness of self-harm
We have looked at underlying factors for why people self-harm We have explored the Rape Trauma Syndrome (RTS) cycle/healing cycle people go through We learned about Carousel - a therapeutic framework to help people who self-harm

39 Last Thoughts The function of self-harm is not one-dimensional and can serve many functions for someone Human beings as determined by their early experiences (Erickson, 1963) “Home is meant to be the safest place, But for some, it is the most frightening place of all” “Paradoxically, the home is the place that most people run to, ‘to escape fear and violence.’ Yet some women are living with the ‘most frightening violence of all’ violence that occurs in the family home”, states Wilson (Wilson, 1983 cited in Smith 1989:2) HMSO 39

40 Questions

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