Understanding &

managing anger &

aggression from

people who self-harm

Kelly Watt-McMahon Consulting Clinical

Psychologist

Safe & Secure Hospitals Conference

Sydney, October 21st 2014

OutlineSelf-harm : a diagnostic indicator of borderline personality

disorder (BPD)

The features of BPD & prognosis

Stigma

Why do they self-harm?

Why do they get angry?

What helps & what doesn’t?

General management strategies for frequent flyers

Self-harm : a feature of borderline

personality disorder (BPD)

BPD is a severe mental disorder

that makes up 1-2% of the

general population & 20% of

psychiatric treatment

populations, mostly females

Chronic self-harm & suicidal

actions are a significant feature

Diagnostic features of BPD Marked by a pattern of behaviours that usually begin in

early adolescence. At least 5 of the following:

frantic efforts to avoid

abandonment

identity disturbance

chronic feelings of

emptiness & boredom

impulsive acts

recurrent suicidal

behaviours and/or self-

harm

Emotional dysregulation

Inappropriate & intense

anger

Dissociation / transient

psychosis

Unstable relationships

marked by over-valuing &

de-valuing the other

Attachment problems in BPD: BPD a disorder of attachment:

Some diagnostic criteria are a function of the person having a

disrupted attachment to caregivers early in life

This means they did not receive attuned caregiving - for

example:

mother did not form an attachment

unresponsive, neglectful, or critical parenting

trauma or abuse

Child does not internalise the ability to manage their emotions,

and has a poorly formed sense of self

BPD Prognosis

Hopeful

With treatment, better prognosis

than schizophrenia

Treatment of choice is medium

to long term psychotherapy

Specialist treatment

Stigma

Self-harming patients are stigmatised

Clinicians can experience strong negative emotions

The community finds it hard to understand

Stigma negatively impacts the patient’s ability to

recover

Why do they self-harm?

The functions of self-harm are often UNCONSICOUS

Self-harm functions to

regulate emotions

self-punish

turn emotional pain into physical pain

ground the person out of a dissociated state - make

them feel ‘real’

communicate how bad things are

Why do they get angry?

History of trauma & abuse

Extreme sensitivity to rejection

Heightened state of arousal

Expecting to be controlled / punished / abused

Can sometimes unconsciously set up situation so

this will occur

What helps?

Monitoring our own emotional reactions & how we

respond

Authentically showing an interest & care

Listening & trying to understand even if you don’t

non-controlling management - talk to them

Asking the patient what they think would help right now

Usually, custodial interventions & involuntary status

is unhelpful

What helps?cont

When there are other services involved, get to know the perspective

of other clinicians:

Know who else is involved - community supports & treating

professionals

Is there a service-wide management plan?

Does the management plan cover aggression, and if not, who

can we ask about it?

If there’s no management plan:

Be mindful of your reactions

Be authentically interested & show care

Take a collaborative approach, even with anger & potential

aggression

Thank you …

Questions please