Some Principles that allow me to understand Self-Injury.

With 12,000 people attending Irish hospital emergency departments in 2010 due to self-harm (Ring, 2011), it is important that ways of alleviating its prevalence in society are addressed. Furthermore, it is believed that cases which present to hospital are only the tip of the iceberg. Unfortunately there is no panacea to ameliorate the suffering of the person who self-harms, and it would be naïve of me to assume that the following principles alone would be enough to suffice for an approach to understanding and responding to self-injury. Nevertheless, they stand out amongst others.

        
The first of these principles is that 'the injury is not the problem'. You would be by-passing a host of problems if it was only concern for the person’s actual injury. Having an erroneous assumption that the injury should be the focal point of attention would only be delivering a lump of verbal refuse to the client.

             

There should instead be a focus on their feelings before their behaviours. Most of the 'problems' with self-injury are nothing to do with the person who hurts themselves. While the scars may be psychologically detrimental to them, underlying deep seated issues should be regarded as a lot more insidious. The injury has to be viewed as an outward expression of their inner pain.

Jacques Laçan once talked of emotional suffering analogous to that of tearing a whole in your jacket, you may stitch up the hole and get on with life, but the tear will always be there. The indelible scars may be very salient to the worker but the client’s emotional 'baggage' needs an outlet of its own.

The injurer might have been a victim of abuse or neglect or have suffered loss, bereavement or some other form of trauma. They may feel anger or hatred towards a perpetrator or shame from being alienated by racism (Spandler and Warner, 2007) or prejudice. All or any of the above can leave an individual ''haunted and damaged'' (O’Brien, 2010). Further, the emotional and psychological abuse may also be worse than the physical because of its invisibility. I feel that the person who self injures needs to be heard. Their deep seated issues and mental distress has probably become a part of their fabric of life. They need someone that can empathetically listen, understand and reassure them that their difficulties can be overcome. I don’t think that they should be peppered with questions but instead simply allowed to tell their story.

In trying to help a client besieged by problems or at their lowest ebb, I would like to portray an understanding that lets me engage with them in an honest way. In my own view, I would also feel that they should try and be as completely transparent with me as possible, in attempting ''to determine the needs that the behaviour fulfils'' (Peterson, 2008). Again, I think there should be an avoidance of trying to clarify questions. They might find it difficult to articulate in a one to one setting, feel vulnerable in discussing their injuries or maybe they don’t even know the answer themselves. They need to be treated as a person and not a patient. It would be advisable to examine any external factors that may be having an effect on their need to injure themselves. Or do they have any other support group that they can talk to? There should also be an assessment to whether any suicidal ideations have been present however top heavy or tentative the question may feel.

In a world of quick fixes, I do not think that you would want to presuppose what the client’s problem may be and just go through the motions. On this premise, there should be an avoidance of diagnosing the individual with Borderline Personality Disorder. This only adds further stigma and tarnishes their reputation. How can a psychiatrist understand the client who probably cannot even understand themselves? My own personal indignation of this diagnosis being confirmed as a joke was when I was enlightened that ‘Darth Vader’ from Star Wars fits six of the nine BPD criterion outlined in the DSM-IV (Bui et al., 2010).

If a client opens up about their self-harming; calmness, not being overwhelmed and being comfortable discussing it is imperative. In this way you would be able to avoid making it seem to them like an even bigger issue thus compounding the problem. Finally, it is important not to just continue with the discussion without acknowledging what they have said, but to reflect upon it and accept their admissions.

A second principle is knowing that 'self-injury has meaning, purpose and functions'. Not all self-injury eventuates from depression. Self-injury serves as a coping mechanism for distress. This response can give the individual an outlet for numerous anxieties.
 

They may feel that it helps them gain a sense of power or control. If the person had experienced prior physical abuse, I would look at their injuries as someone trying to reclaim their body. They may feel that through the physical abuse their bodies were never fully 'theirs', but their self-injury gives them back a sense of ownership. Self-blame may also be at the root of why they injure themselves (Babiker and Arnold, 1997). Some form of childhood suffering or lack can give rise to a torrent of inexpressible emotion. But for the harmer, it is in this anodyne act that respite is found.

Self-harm can be further understood as an escape. From a historical viewpoint, it reminds me of those who had to endure the rituals of trephination to release their 'inner demons' . It may help the individual temporarily dislocate themselves from reality. Or in contrast, help them to associate themselves with reality, to feel real. I agree that some people might be numb to trauma that has occurred in their past and that this inability to feel emotion can motivate self-harming ''to feel something'' (Horne et al., 2009). This behaviour should be reassured to them to be a normal reaction so as not to further degrade them.

 ''The (immediate) influence of behaviour is always more effective than that of     words'' (Frankl).

I also see self-injury functioning entirely as a pure form of communication. It’s not that they are trying to declare themselves as some form of autonomous marginalised part of society. More so, they may be marginalised by factors such as religion, sexuality, disability, gender or race. By harming their body, it may be their way of expressing inner frustrations that they can’t seem to express verbally.

 

With a myriad of reasons as to what self-injury means to the person, I believe it is not a best practice method to try and prevent it from happening. It would only be creating an incubation for distress if you were to take away their primary coping mechanism. Medical staff that are focused on preventing it need to be made aware of the reasons for the self-harm and not to have a frivolous view of these people’s injuries compared to others. Further, trying to control it by habitually observing the cutter is not going to help either. Nor should they be admonished for doing it as this may only exacerbate matters (World Health Organization, 2010).

The prison services also need to understand the functions that self-injury has for inmates. They need to be made aware that they are dealing with people who may be emotionally ''very damaged'' (Green, 2007). Problems like these can be addressed through training, awareness, education and looking outside the medical model.

The third principle is that of 'harm-minimisation' and the importance of 'slowing it down' for safety reasons. The self-harmer should be given the empowerment of being allowed to injure themselves in safer ways. This gives them back choice and control.

The promotion of self-care can greatly help the individual. The idea of a safe kit is an alternative to self-harm but in a nonthreatening and meaningful way (Moyer, 2008). While some people might dislike the idea of supplying clean blades to make self-harm 'safe' (Birch et al., 2011), clinical settings could at least try to synthesize the idea of it somewhere. It could be an optimal way of helping a self-harmer to maintain their own hygienic continuity of care in addition to perhaps mitigating post-injury pains. Further, they should be given knowledge about high risk and 'safer' cutting areas. It is not that they would have to be meticulous with the injury that they are to inflict. Instead, they could at least know that an impulsive injury will be less dangerous than without a safe kit. It can help in preventing infections, reduce the chances of any irrevocable damage from occurring and perhaps even unintentional suicide.
 

The individual should not feel any shame in having a safe kit with them when they are outside of their comfort zones. In a Utopian society we could all live in such a way that there would be no problems or stresses. Who cares if they have to bring a safe kit around with them? Everybody on some level has their vices to cope with the omnipresent problems of day to day living, whatever the magnitude or however trivial. Whether its; dependence on alcohol, smoking cigarettes, comfort eating, or prescription medication, these ‘by the way’ types of self-harm all function on some level to keep fronting people’s carefully crafted social veneers. I think it should be seen as a positive sign that they are willing to try and curtail their self-injury behaviours. The scars from 'careful' cuts on their body, compared to previous impulsive cutting scars, may serve as a poignant reminder to how far they have come and they should be feted for this attempt to minimise harm and cope better.

The A & E departments are sometimes the first point of contact for those who self-harm (Nadkarni et al., 2000). In which some may be exposed to experiences of 'hostile care' (Harris, 2000), being told that they are ''time wasting'' or ''attention seekers'' (Pembroke, 1998). With this in mind, the implementation of a safe kit can act as their own personal safeguard free from the judgement of others.

The Self-Injurer should also review what they keep in their safe kit on a regular basis. Additions could include substitutes such as a stress ball, a pen and paper (to express their feelings) or a red marker to smear on the 'living canvas' of their arms. I personally believe that the psychological benefits of a safe kit could outweigh any counter arguments. However, it is only one such method in attempting to eventually live without the need to injure. The worry that everything will be fine without this coping mechanism 'crutch' is obviously hard for some people to imagine. But harm-minimisation could be beneficial to those unwilling to forego their self-injury behaviours.

Self-injury is a multifaceted behaviour. I have selected three principles as being the ones I believe to be paramount. However, I do feel that an eclectic approach to self-injury that incorporates other principles is vital, including the use of creative ways to explore the person’s strengths enabling them to express feeling and emotion. Obviously there would be questions as to how much of this could be put in place but I would argue that it would be essential to start with some fundamental concepts. Anyone with a rudimentary system could surely find benefits in applying the aforementioned principles as primary starting points to understanding and responding to self-injury.