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TRANSCRIPT
Waseem Alladin, Head of Psychology
Honorary Lecturer in Clinical Psychology
Supporting Adults in
Residential Services to
Prevent Self-Harm & Suicide:
Recent Research &
Good Practice Guidelines’
Introduction
Self-harm and suicide are increasing in wider
society.
High levels of self-harm in some people, and to
a lesser degree the risk of suicide, are some of
the reasons for residential care for a proportion
of adults with ASD.
Why do people self-harm?
Why do some of them go on to commit suicide?
How do we tell the difference between those
who self-harm and will not likely commit
suicide and those who are at high risk of doing
so?
This presentation sheds light on these concerns.
There are a range of views, theories and
models of self-harm and suicide and
prevention approaches, some of which are
controversial.
Drawing from evidence based practice and
practice based evidence, this presentation
outlines recent research findings and offers
good practice guidelines which will assist
both carers and professionals better
unerstand and prevent self-harm & suicide.
In a nutshell… This presentation will include:
Barent Walsh’s concept of self-injury and the differentiation from suicide & classification.
The multiple functions of self-injury and suicide
Mark Williams’ ‘Cry of Pain’ Model
Waseem Alladin’s Practice-Based Helplessness-Hopelessness Existential Model
Therapeutic strategies for dealing with self-injury and suicidal ideation
Research Findings & Good Practice Guidelines
When the cry of pain is
drowned out or not heard
Suicide is better regarded as a ‘cry of pain’
(Williams 2010) rather than a ‘cry for help’
though sometimes it is both.
Self-harm and suicide prevention needs a
multidisciplinary team effort which puts the
person and their family centre stage.
Self-injury: Definition,
Differentiation from Suicide
and Classification Self-injury separate and distinct from suicide.
Self-injury is not about ending life but about
reducing psychological distress.
Self-injury is a unfortunately an effective
coping behaviour, albeit a self-destructive
one.
Self-injury, not self-mutilation
Manipulative?
Self-inflicted?
To maime? To cripple?
Majority of self-injury involves modest tissue
damage
Self-injury:definition
“Self-injury is intentional, self-effected,
low-lethality bodily harm of a socially unacceptable nature, performed to reduce psychological distress.” Barent Walsh
It is not useful for self-injury to be regarded as simply being manipulative and attention-seeking or necessarily suicidal in intent
More on self-injury
It is enacted because of its ability to modify and reduce psychological discomfort.
It is usually immediately and substantially effective and therefore often repeated.
Self- injurious behaviour is not intended to be suicidal though it can cross the boundary into unintentional suicide
It is psychologically motivated: a self-conscious, self-intentioned distress reduction behaviour.
Who is more likely to self-
injure and why?
• “NSSI might be best viewed as a means of reducing high- arousal negative emotions, and replacing them with low-arousal positive emotion such as calm and relief”’*
• Anger, anxiety and frustration – high arousal (-)
• Sadness,loneliness or hopelessness –low arousal(-)
•
• *Advances in Psychotherapy: Non-suicidal self-injury Klonsky et al (2011)
Who is more likely to self-
injure and why? “Self-derogation is reflected in both the personality traits of those who self-injure and the functions of NSSI”*
• low self-esteem…self-criticism
•“Individuals who self-injure exhibit a variety of social deficits that may increase vulnerability to NSSI”- difficulties in negotiating relationships/situations.
•Why ?” To punish myself, to express anger at myself”
•*Advances in Psychotherapy: Non-suicidal self-injury
•Klonsky et al (2011)
Differentiating self-injury from
suicide
“All too often self-injury is inappropriately labelled
as ‘suicidal’ resulting in poorly designed
interventions. The nine points of distinction
presented provide a practical roadmap for
determining whether a self-destructive behaviour
is suicidal or self-injurious.” B. Walsh
This distinction has major implications for the
assessment and treatment of self-injury.
Differentiating Suicide
attempts from Self-Injurious
Behaviours(SIB)
© Barent Walsh(2012)
Assessment Focus: 1. What was the expressed
and unexpressed intent of the act?
Suicide attempt: To escape pain, terminate
consciousness
SIB: Relief from unpleasant
affect(tension,anger, emptiness,deadness)
2. What was the level of
physical damage and potential
lethality?
Suicide attempt: Serious physical damage,
lethal means of self-harm
SIB: Little physical damage, non-lethal means
used
3. Is there a chronic, repetitive
pattern of self-injurious acts?
Suicide attempt: Rarely a chronic repetition;
some overdose repeatedly
SIB: Frequently, a chronic high-rate pattern
4. Have multiple methods of
self-injury been used over
time?
‘Suicide attempt: usually one method
SIB: Usually more than one method over time
5. What is the level of
psychological pain?
Suicide attempt: Unendurable and persistent
SIB: Uncomfortable, intermittent
6. Is there constriction of
cognition?
* Suicide attempt: extreme constriction:
suicide as the only way out; tunnel vision,
seeking a final solution
• * SIB: Little or no constriction; choices
available, seeking a temporary solution
7. Are there feelings of
hopelessness and
helplessness?
* Suicide attempt: Hopelessness and
helplessness central
• * SIB: Periods of optimism and some
control
Part II
Clinical and risk assessment of self-
injurious behaviour
A biopsychosocial model of self-injury
Some therapeutic strategies for dealing with
self-injury and suicidal ideation
Self-injury: Clinical
Assessment and Checklists
All clinical assessments must be based on
1.Accurate observations of relevant
behaviours
2. Be factually descriptive (objective) and
specific
3. The frequency (how often) and the intensity
(how severe) of relevant behaviours
Self-injury, not to be mixed up
with parasuicide. Self-injury may be an attempt to prevent
suicide.
Self-injury should always be taken seriously but should not be mixed up with parasuicide.
Walsh (2008) recommends that we avoid using suicide terminology when dealing with self-injury
Parasuicide and suicide
Attempts to commit suicide should always be taken
seriously and risk assessed.
In some cases there may be an element of secondary
gain (so-called ‘attention seeking’) but this must be
addressed and still taken seriously
Suicide attempts are better regarded as a cry of pain
and not just a cry for help.
Parasuicide and suicide It is essential that hope is instilled (and depression
assessed thoroughly) since hopelessness is a strong predictor of both attempted suicide and successful suicide.
Suicidal attempts are more likely when the person is less depressed or no longer depressed
People who have committed suicide have often talked about it
A Biopsychosocial Model of
Self-Injury
The model proposed by Walsh (2008) has five
dimensions which are best regarded as functioning
in an interdependent and inter-related manner.
There are obviously multiple pathways to self-
injury.
A Biopsychosocial Model of
Self-Injury
A cognitive approach to self-injury can often help
to dramatically improve self-injury attempts.
It is NOT recommended that a client be required to
STOP self-injuring as part of a behavioural or
cognitive programme or as a requirement for
treatment to be provided.
To do so shows a lack of understanding of the
dynamics of self-injury and is not good practice.
A Biopsychosocial Model of Self-
Injury
The model proposed by Walsh (2008) has five
dimensions which are as follows:
1. Environmental dimension
2. Biological dimension
3. Cognitive dimension
4. Affective dimension
5. Behavioural dimension
Good practice guidelines
Walsh (2008) stresses the importance of the interpersonal demeanour of the therapist or carer.
He cautions against responding in affectively charged behaviours
In other words there must be a neutral or non-emotional and non-judgemental approach
Some treatment considerations &
good practice guidelines
There should be NO outward signs of:
Intense concern and effusive support
Anguish and fear
Recoil, shock and avoidance
Condemnation, ridicule and threats
Always work with a team and NEVER on your own
in dealing with self-injury
Ensure there is regular supervision for yourself and
your team and continuing support for your
client/patient.
If you are a parent ensure you get professional help
or at least someone who is knowedgeable and
experienced in successfully dealing with the issues.
.
Self-injury and suicide are complex issues that
require more than one perspective and should
never been dealt with on your own.
Use a low-key dispassionate demeanour which
will contain distress and instil perceptions/feelings
of control and security in your client and in your
team and convey that you are in charge.
Contingency management of self-injury: this
requires expert help from a behaviourally trained
professional so that a system of realistic rewards
and gentle shaping of behaviour can be planned
and implemented.
The aim is to help reduce self-injurious behaviour
not demand that it be STOPPED IMMEDIATELY
via a behavioural contract.
Therapeutic Strategies for
Dealing with Self-harm and
Suicidal Threats
Some therapeutic modalities
Replacement Skills Training
Cognitive Behavioural Therapy
Mindfulness
Dialectical Behaviour Therapy
Learning mindfulness &
mindfulness based cognitive
therapy
Learning to re-lax and let-go
Mindfulness based cognitive therapy
Replacement Skills Training
• Negative Replacement Behaviors
• Mindful Breathing
• Visualization
• Physical Exercise
What you are up against and
need to understand
(from Barent Walsh, 2008)
Internal Psychological Elements
Self-injury works; it (temporarily) reduces
tension and restores a sense of
psychological equilibrium.
Self-injury has powerful communication
aspects. Self-injury provides a sense of
control and empowerment
Replacement Skills Training
• Writing
• Artistic Expression
• Playing or Listening to Music
• Communicating With Others
• Diversion Techniques
Dimensions of the Self:
Me, Myself and I and
sometimes I wonder about
thee…
Are you hurting? Or is it really your ego and
your pride?
Mindfulness : being truly alive
to the present
It involves a new way to relax, to relate to
yourself and your relationships- professional and personal
Is the ‘process of being truly alive to our present experience and reality’
It is a scientifically based, easy to learn approach combining eastern and western approaches.
Mindfulness
It balances your heart with your head in a
more satisfying and energizing way so that
you can find peace and contentment
amongst ‘the dirty dishes, red lights and
traffic jams’
Mindfulness : less is more
“We are constantly engaged in doing, then we
fall into bed exhausted, wake up the next
day, and start more doing, more
running…Very often we feel cut off from
our own experience and feelings. We are
driven by the mind,by thought, by
expectations, by fear,by wanting to get
somewhere else.” Jon Kabat-Zinn
Mindfulness : Hello? Is
anybody home?
If you always want to be some place else, then
you are never actually where you are, and
therefore not fully alive. Nor are you
capable of dealing with the pressures and
difficulties that arise if your mind is
inattentive and is half not there.
Mindfulness: Are you driving
fast in the fog?
“In stressful or threatening situations, your reactions
will be highly conditioned and automatic. The
deeper levels of your intelligence and wisdom that
come from clear and full seeing will not be
available to you because of this foggy cloud in the
mind.”
“Mindfulness is very powerfully healing for
suffering of all kinds.” Jon Kabat-Zinn
“
Mindfulness : a way of being
In mindfulness … “the mind becomes very still and very calm.The mind is not running to the past and to the future, but instead has a quality of stability and stillness, and actually rests in the experience of the moment.” Sharon Salzberg
“Mindfulness is not only something you do during your meditation practice…it is a conscious and effortless way of being… non judgemental with yourself …and the world.” Waseem Alladin
Mindfulness :
Coming to your senses!
‘Strictly speaking mindfulness is not a
technique or method…it is more…a way of
being, or a way of seeing, one that involves
“coming to ones senses” in every meaning
of that phrase.’ Jon Kabat-Zinn
The ABC of Functional
Analysis :
Why do a functional analysis?
• * Covariation and illusory correlation
• * Antecedents & Consequences of
Behaviour
• * If you can’t find the cause, undermine
the maintaining factors
Cognitive behavioural therapy
• Identifying Triggers and Using Them to
Practice Replacement Skills
• Identifying Automatic Thoughts,
Intermediate Beliefs, and Core Beliefs
that Support Self-Injury
• Replacing Negative Cognitions with
Adaptive Thoughts and Beliefs
• The Key Role of Body Image
What is Dialectical Behaviour
Therapy? DBT understands problem behaviors in
terms of the biosocial theory.
The central idea is that people with
significant difficulties with self-destructive
behaviors, control of emotions, depression,
aggression, substance abuse, and other
impulsive behaviors often have problems
with their emotion regulation system
What is Dialectical Behaviour
Therapy?
“These emotional problems are a result of a
person’s biological makeup as well as the
persons’ past experiences.”
DBT is effective for self-
injurious behaviours
“In controlled outcome trials, DBT has been
shown to be effective in reducing self-
injurious behavior and inpatient psychiatric
days in women diagnosed with BPD’’
DBT is effective for self-
injurious behaviours
“ It has also been shown to be helpful in
reducing anger and improving social
adjustment.
DBT’s approach balances therapeutic
validation and acceptance of the person
along with cognitive and behavioral change
strategies.” Lew, Matta, Tripp-Tebo, &
Watts (2006).
DBT Modules
1. Mindfulness
2. Distress Tolerance
3. Emotional Regulation
4. Interpersonal Effectiveness
© Marsha Linehan
The Dialectical World View
The Principle of Interrelatedness &
Wholeness- a systems perspective of reality
Reality is not fixed but dynamic
Change is the only constant since
everything changes…now you know why
happiness never lasts (neither does
sadness!)
The Dialectical World View
The Principle of Polarity: reality is not static
Consists of internal opposing forces(thesis
and anti-thesis) out of whose integration
(synthesis) evolves a new set of opposing
forces
The acorn is the tree.
The Dialectical World View The Principle of Continuous Change:Thesis,
Anti-thesis & Synthesis
The tension between self-preservation(I don’t
want to change) and self-
transformation(getting out of your comfort
zone and becoming what you can be) so…
the acorn is the tree, the chrysalis is the
butterfly.
The ABC of Functional
Analysis :
• * REINFORCERS may be used to increase or
decrease a particular behaviour
• * ANGER is the fasting way to get attention
* CONTROL AND PARADOX: “don’t look
now but there’s a fat man behind us!”… “Wet
paint…do not touch”
The ABC of Functional
Analysis :
Fuzzy or Non-Behaviours
• * What did he say? Oh, nothing much
• * What did she do? She was pathetic!
* What do you want? I don’t mind.
• * For a functional analysis the problem should be: SPECIFIC, BEHAVIOURAL, UNAMBIGUOUS & UNDERSTANDABLE ON ITS OWN
The Power in Your Hands
* Placebos and the power of belief
• * Expectations and beliefs can work wonders
• * Nocebos and the power of negative expectancies “It ain’t gonna work but I’ll try it if you wish…” stop dragging your feet!
• * Talk to yourself….positively : the power of verbal self regulation
New Lamps for Old
* Reframing and changing the context
• * Shaping & Reshaping: No need for
plastic surgery!
• * Take another look…Re-Vision
• * Paradox and psychological judo
© Copyright
Acknowledgements
The author wishes to acknowledge
Professors Barent Walsh, Jon Kabat Zinn,
Mark Williams, Marsha Linehan and
Klonsky and colleagues for the use of
selected quotations and copyright material.