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Working with individuals who self-harm The approach of the Crisis Recovery Unit SCOTTISH Personality Disorder Network.

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Presentation on theme: "Working with individuals who self-harm The approach of the Crisis Recovery Unit SCOTTISH Personality Disorder Network."— Presentation transcript:

1 Working with individuals who self-harm The approach of the Crisis Recovery Unit SCOTTISH Personality Disorder Network

2 SCOTTISH Personality Disorder Network Outline Setting the scene The unit ~ where we started Dilemmas How to work with the work The unit ~ where we are now Repetition and reparation

3 SCOTTISH Personality Disorder Network

4 SCOTTISH Personality Disorder Network

5 SCOTTISH Personality Disorder Network Self-harm - an act of religious devotion

6 SCOTTISH Personality Disorder Network Self-harm: a form of protest Shias stage anti-US protest Protests against the US presence in Iraq have been staged by Shias in the city of Karbala at the climax of a pilgrimage that has attracted one million people. Groups of marchers chanted slogans against a US-imposed government calling for unity among Shias. Many hit their backs with flails or cut their heads with swords in ritual self- flagellation.

7 SCOTTISH Personality Disorder Network Self-harm: a way of restoring health!

8 SCOTTISH Personality Disorder Network Definitions “ …. an individual intentionally damaging a part of his or her own body, apparently without a conscious intent to die” Feldman, 1988

9 SCOTTISH Personality Disorder Network Definitions “…intentional self-poisoning or injury, irrespective of the apparent purpose of the act”  NICE Guidelines, 2004

10 SCOTTISH Personality Disorder Network Definitions “…a deliberate act to damage yourself, without intending to die. This varies according to the situation the individual carrying out the act & is a means of getting away from intolerable thoughts or feelings” HOTUSH

11 SCOTTISH Personality Disorder Network The Unit ~ Where We Started

12 SCOTTISH Personality Disorder Network “The sufferer who frustrates a keen therapist, by failing to improve is always in danger of meeting primitive human behaviour disguised as treatment” Main,T. 1957

13 SCOTTISH Personality Disorder Network Inclusive definition Self-harm as a symptom

14 SCOTTISH Personality Disorder Network Self-harm & suicide Not about wanting to die Self-harm and suicide lie on a continuum Socially acceptable self-harm Suicide self-harm

15 SCOTTISH Personality Disorder Network Underlying principles Retention of Responsibility Short Term Risk Taking

16 SCOTTISH Personality Disorder Network Dilemmas Anxiety

17 SCOTTISH Personality Disorder Network Dilemmas Anxiety “ Unless anxieties can be identified, addressed & contained within the system it is likely that the system itself will produce defences that actively hinder rather than help therapeutic intervention” Menzies Lyth, 1970

18 SCOTTISH Personality Disorder Network Dilemmas Polarity of thinking and catastrophysing

19 SCOTTISH Personality Disorder Network Dilemmas Specialness

20 SCOTTISH Personality Disorder Network Dilemmas Specialness “These patients have the capacity to gain a unique position in the lives of their treaters, characterised by an intense, although mutually ambivalent, attachment on the part of the treater & the patient” Gabbard, G.1986

21 SCOTTISH Personality Disorder Network Dilemmas Seeking of ideal attachments

22 SCOTTISH Personality Disorder Network Dilemmas Insatiability and inability to get things right

23 SCOTTISH Personality Disorder Network Dilemmas Insatiability “leading people on & then letting them use us, we get people to dislike us by doing things to making them angry. Some of exhaust people with our intense relationships” “I don’t think you’ll ever get it right – it changes for me each time” HOTUSH

24 SCOTTISH Personality Disorder Network Dilemmas Abuser-abused

25 SCOTTISH Personality Disorder Network Dilemmas Abused/abuser “ they experience a sense of power through being in control of the shapes & forms their bodies assume, as a result of the physical injuries & abuse they inflict upon themselves” Welldon 1988

26 SCOTTISH Personality Disorder Network Dilemmas Abused/abuser “self-abusing & mutilating attacks in such patients may serve the double purpose of producing further additive, perverse excitement & also of a punishing attack on the ‘bad’ internal organs which have become contaminated by the identification with the excited, intrusive organs of the abuser” Milton 1994

27 SCOTTISH Personality Disorder Network Dilemmas Abused/abuser “the patient is at times in her current life the abuser, & then at times the abused. In fact the two are inextricable, as masochism involves the accompanying projection of sadism, forcing the other to be the helpless witness of suffering in which they are supposed to be implicated” Milton 1994

28 SCOTTISH Personality Disorder Network Dilemmas Difficulty in thinking & feeling

29 SCOTTISH Personality Disorder Network Dilemmas Behaviour Practitioners impelled: “towards action rather than towards contemplation” Heimann, 1950

30 SCOTTISH Personality Disorder Network Dilemmas Breaking of boundaries

31 SCOTTISH Personality Disorder Network Dilemmas Projection/countertransference

32 SCOTTISH Personality Disorder Network Dilemmas Countertransference “The psychiatrist cannot avoid hating them & fearing them, & the better he knows this the less will hate and fear be the motives determining what he does to his patients” Winnicott, 1947

33 SCOTTISH Personality Disorder Network Dilemmas Countertransference “ Though it is acknowledged that at times countertransference hate may be justified, the more justifiable it seems, the more likely the therapist is to act it out in a non-therapeutic fashion” Progers 1991

34 SCOTTISH Personality Disorder Network Dilemmas Breaking of boundaries

35 SCOTTISH Personality Disorder Network Dilemmas Boundaries The Professional Boundary Treatment Boundary Self Disclosure Boundary Safety Boundary Boundaries and Individuality

36 SCOTTISH Personality Disorder Network Dilemmas Boundaries "The skin ego is the interface between psyche and body, self and others" Anzieu 1989

37 SCOTTISH Personality Disorder Network How to work with the work Protocols Mutli-disciplinary working Staff support/supervision Relationship with the institution Risk Assessment Understanding who owns the problem Communication Boundaries

38 SCOTTISH Personality Disorder Network The Service 3 components In-patient unit (Crisis Recovery Unit) Self-harm Outpatient Service (SHOP) A national training programme

39 SCOTTISH Personality Disorder Network The Unit

40 SCOTTISH Personality Disorder Network Over 18 years Non-psychotic Not dependent on alcohol or substances No significant learning difficulties Not homeless Referral criteria

41 SCOTTISH Personality Disorder Network Exhausted local services Enmeshed teams Loss of professional boundaries High levels of anxiety Desperation Why referred

42 SCOTTISH Personality Disorder Network “Psychologically minded” Contemplating change A degree of adult functioning At assessment

43 SCOTTISH Personality Disorder Network Provisos Reporting Outreach Voluntary admission Post assessment

44 SCOTTISH Personality Disorder Network Timed admission Work not care Responsibility Relationships Tolerance of self-harm Work on internal damage not SH management Admission

45 SCOTTISH Personality Disorder Network Community Repetition then change Conflict Group Individual Creative therapies Practice at home Admission

46 SCOTTISH Personality Disorder Network Family therapy All part of day are work Finishing relationships Post discharge group Responsibility for handover to local workers Admission

47 SCOTTISH Personality Disorder Network Community group Coping skills Projective art Creative writing Movement group CRU group Weekend planning The programme

48 SCOTTISH Personality Disorder Network HOTUSH Negotiation Planned meetings Safety planning Evening activity Evaluation Occupational therapy The programme

49 SCOTTISH Personality Disorder Network No use of alcohol or illicit drugs No violence towards others No assisting others in their SH Deliberate damage to property paid for Consideration for others Keep to provisos Ground rules

50 SCOTTISH Personality Disorder Network Report SH 2 hours (sooner if severe) Accept treatment Complete an incident form Consider handing in implements Dispose of sharps correctly Clean up blood spillages Boundaries for self-harm

51 SCOTTISH Personality Disorder Network Immerse burns in cold water for 20/60 Not to share implements Not to involve others in self-harm To continually assess severity/frequency of your SH with the team Report when feeling suicidal Boundaries for self-harm

52 SCOTTISH Personality Disorder Network Aims To develop alternative, healthier ways of coping To improve interpersonal communication To have a sense of self To move away from eliciting help through behaviours only To move away from services

53 SCOTTISH Personality Disorder Network Average number of self-harm incidents per month in consecutive series of patients admitted to CRU, (n=66)

54 SCOTTISH Personality Disorder Network The breaking of boundaries When provisos are broken then the resident goes on reflective boundary leave

55 SCOTTISH Personality Disorder Network Staff containment Selection: psychologically minded why undertake this work? No secrets Work as a team Work with the anxiety Work within the countertransference Supervision ++++ Challenge each other Encounter then evaluate

56 SCOTTISH Personality Disorder Network Staff containment Ongoing risk assessment Challenge perversity Discuss sadistic, maternal etc. feelings Training Similar model to residents Health attachments Role model emotions Challenge & conflict Limit setting

57 SCOTTISH Personality Disorder Network CASE HISTORY

58 SCOTTISH Personality Disorder Network History of cutting Aged 12: piercing & picking with dress making pins Aged 13: superficial wrist cutting whilst boarder. Introduced to cutting by school peers. Unsuccessfully concealed Aged 14; Referred to psychiatrist Short period of abstinence Aged 15: Cutting returned

59 SCOTTISH Personality Disorder Network Cutting behaviour on referral Forearms - from elbow to wrist Legs - from the inside of thigh to hip Areas covered by clothing. Clean razor blades/scalpels Important to cut in a ritualistic manner Cutting: slow & controlled, enabling  regain control over emotions  achieve a sense of calm

60 SCOTTISH Personality Disorder Network Cutting behaviour on referral Fascination with cutting & injuries Deliberate bleeding: release of “bad stuff” Self-competitive: cuts need to be deeper & longer each time When to stop? severity of damage or duration of cutting episode

61 SCOTTISH Personality Disorder Network After cutting Experiences a range of feelings including:  Euphoria  Restoring herself to “happy normal C”  Sense of relief & feeling 'spaced out' Latter two feelings last about hours (although decreasing over time)

62 SCOTTISH Personality Disorder Network Wounds & Suturing Wounds always require suturing Frequently sutures own wounds Scarring  Wishes that she did not have them  Upset they are becoming worse  Conspicuous wounds get in way of life  A strong motivation to stop

63 SCOTTISH Personality Disorder Network Damage Severed 3 veins requiring surgical repair Damaged a tendon in her arm X 1 & exposed tendons on two other occasions Has permanent loss of sensation

64 SCOTTISH Personality Disorder Network Bloodletting Started aged 16 years Use of syringes & tourniquets 2 x 50ml syringes of blood Daily x 2 for a period of a week, stops for a while & starts again Up to 4 x per day, (i.e. 400mls per day) Helps her to feel in control Denied deliberate attempt to decrease Hb.

65 SCOTTISH Personality Disorder Network Treatment for blood loss 3 blood transfusions since May 2006 Lowest Hb. 4 June 2006: treated with ferrous sulphate after Hb. dropped to 7

66 SCOTTISH Personality Disorder Network Medication overdoses First overdose aged 16 years overdoses in total Overdoses associated >suicidal intent Normally plans in advance Researched on Internet 2 types:  Small: Paracetamol or Aspirin  Large: 100 Pro-Plus tablets, Paracetamol or Aspirin

67 SCOTTISH Personality Disorder Network Treatment of overdoses Low mood  wanting to O/D  informs CPN More prone to seek help if she has consumed alcohol Often too afraid to ask for help Has tried to discharge herself against medical recommendation

68 SCOTTISH Personality Disorder Network Swallowing sharp objects Swallowed crayons aged 10 Swallowed dressmaking pin aged 18 Pre CRU admission: X 2 swallowing sharp objects, as an inpatient:  Swallowing a razor blade while alcohol intoxicated.  Swallowed smashed glass

69 SCOTTISH Personality Disorder Network Other forms of self-harm Burning  burnt herself with a cigarette  last incident in July 2006  did not particularly ‘enjoy’ as character of pain different & hurts > cutting Harm from others (inc. rapes) Running into traffic

70 SCOTTISH Personality Disorder Network Disordered eating Aged 13:restricting intake to 1,000 cals/day & purging Aged 16 years: 4 months restriction  weight dropped to 8 stone. Amenorrhea At assessment: BMI 21.Reported binge eating + self-induced vomiting No formal treatment for her disordered eating

71 SCOTTISH Personality Disorder Network Alcohol First started drinking aged 13, with peers at school Aged 14 – 15: getting drunk with friends at parties Aged 17:  consumption socially & on own  ½ a bottle of vodka once weekly  didn’t see her drinking as problematic  to relax in social situations Alcohol increases severity of self-harm

72 SCOTTISH Personality Disorder Network Drug use Cannabis:  regular since age 15  2 joints per week  Often took 'skunk' recreationally with friends Snorted heroin on three occasions Smoked crack cocaine twice

73 SCOTTISH Personality Disorder Network Early development & schooling Breach birth, no complications Normal development Frequent school moves: father’s work 3 primary schools - bullied secondary boarding schools Education severely disrupted between due to SH No clear hx of conduct problems, had friends Gained 2 A-levels (grade A)

74 SCOTTISH Personality Disorder Network Occupational history Worked as a waitress during secondary school Unemployed prior to admission to CRU Currently due to take up place at uni.to study History of Art

75 SCOTTISH Personality Disorder Network Family Mother aged 51 part time French teacher & housewife described: caring, kind & religious the less dominant of parents, forgiving Father aged 61 retired after 35 years Navy (Rear Admiral) now CEO for charity described: strict, rigid, remote

76 SCOTTISH Personality Disorder Network Sisters ~ both older Eldest sister works for large commercial company treated for OCD described as ‘fragile’ Younger sister junior doctor tendency to over-exercise described as ‘successful and angelic’

77 SCOTTISH Personality Disorder Network Past psychiatric history Aged 14 - parents arranged psychiatric assessment Aged 15 - school organised psychiatric assessment Aged 16 - prescribed Fluoxetine, then Sertralline Admitted aged 16/17 after an overdose. 2 years of psychodynamic psychotherapy Several other short lived attempts at family therapy & CBT

78 SCOTTISH Personality Disorder Network Mental state examination Well kempt, cooperative, normal speech Wearing a pedometer. BMI 22.5 Euthymic Ongoing resistible suicidal thoughts Over valued ideas of thinness & range of angry cognitions towards self, parents & professionals No evidence of other overvalued ideas, delusions or obsessions

79 SCOTTISH Personality Disorder Network Summary 20 year old Caucasian female History of self-harm from 12 years History of food restriction, binging & self- induced vomiting Alcohol & substance misuse Raped X 2, reckless risk taking SCID II  Obsessive Compulsive Disorder  Borderline Personality Disorder

80 SCOTTISH Personality Disorder Network Summary High risk to self Heavy use of services ward admissions including 1 year on s3 ‘burnt out’ care coordinators frequent attendance to A&E Polypharmacy: Antidepressant, Benzodiazepine, Antipsychotic

81 SCOTTISH Personality Disorder Network Progress on unit Family therapy x 6 sessions  First time she felt parents showed “an emotional response” to her problem  Felt a greater understanding their way of coping with her problems Reduced and discontinued diazepam

82 SCOTTISH Personality Disorder Network Self-harm on unit bulimia Overdose of Stelazine & Quetiapine Occulogyric crisis Swallowed razor blades X 2 Serious overdose in December grams of Quetiapine (internet order) 2 seizures, intubated discharged after 48 hours residual memory loss

83 SCOTTISH Personality Disorder Network AdmissionMid-treatmentDischarge BDI BAI CORE-OM total 2.79 (3.04) 2.21 (2.46) 1.47* (1.68*) W3.532 P * F * R Social F n 3012

84 SCOTTISH Personality Disorder Network After care No self-harm since December Discharged off all medication Currently working in shop prior to starting course in Sep. Follow up with care coordinator Team “not good enough” v’s “specialness” of CRU Post discharge once weekly group for 3/12

85 SCOTTISH Personality Disorder Network Repetition or reparation “within relationships our experiences also lead us to self-harm. We have memories of being hurt, abandoned, rejected & neglected by others. This has left us feeling lonely, empty, uncared for & have problems in trusting” HOTUSH

86 SCOTTISH Personality Disorder Network Repetition or reparation Reparation is “the wish to put right, reinstate or repair the object that has been damaged or destroyed” Klein 1945

87 SCOTTISH Personality Disorder Network Repetition or reparation “Some of us need to be cared for, need to be ill & can’t allow ourselves to be happy. We don’t know how to NOT to be hurt by ourselves or by others” HOTUSH

88 SCOTTISH Personality Disorder Network Repetition or reparation ‘‘We repeat patterns, in our minds, our bodies & in relationships” HOTUSH

89 SCOTTISH Personality Disorder Network Repetition or reparation “The ego is first & foremost a bodily ego” Freud 1923 ‘‘as an attempt to master the trauma through recreating the original situation but hoping for some resolution of the conflict” Motz 2001

90 SCOTTISH Personality Disorder Network Repetition or reparation “demolish any capacity for trust & foster transference distortions such that supposedly strong & helpful figures are seen as weak, malicious & dangerous” Stone 1987

91 SCOTTISH Personality Disorder Network Repetition or reparation “at those times when you feel most pressure to act, to do something which seems logical, urgent & necessary. STOP, take space & think. It is probably the case that you are caught up in some form of re-enactment”

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