A training workshop on Self-Injurious Behaviour with some useful ideas about categorising self-injurious behaviour.

1. Self-injurious
behaviours
ANNIHILATION & SURVIVAL

3. Before We
Start…..
• Is this about a “Them”?
• Or could this also be about “Us”?
• Is there a clear difference between a
group of people who engage in
behaviours that are ultimately
harmful as a way of coping with
feelings – and then the rest of us
who are well-adjusted and able to
freely express our difficult feelings
all of the time?
• Question? Are we describing two
binary populations? One set that
self-harms and another that does
not?

4. Before we start
….is this about “Them” or “Us”?
• Do you agree with the assertion that we all self -harm in some
way, albeit long a continuum of behaviour and severity?
• If so, can you identify ways in which you self-harm and whether
there are common situations that might trigger this – particularly
feelings you find difficult to express?
• What are the implications for this in working with self-harm in
therapy, and in recognising the risks that might be present?

6. Definitions – NICE
does include
Suicidal Intent!
• Self-harm is any act of self-poisoning or self-
injury carried out by an individual,
irrespective of motivation. This commonly
involves self-poisoning with medication or
self-injury by cutting.
• Excluded from this definition: harm to self
arising from excessive consumption of alcohol
or drugs. Starvation. Accidental harm.

7. Most of us would see it as separate from
Suicidal Intent
 Self-harm is an act which involves deliberate
inflicting pain and/or injury to one’s body but
without suicidal intent.
 It can be directed against the body – for example
cutting or burning – which might be termed self-
injury.
 Include behaviours without immediate impact,
such as eating disorders, risky sexual behaviour.
 Be planned and form part of an habitual pattern,
or may be unplanned and spontaneous
 Be about coping, living, surviving and self-worth.
 Have a relationship with suicide potential,
particularly in the context of other risk factors.

8. Risks – What is the most helpful expression?
Self-Injury Self-Harm
Direct and Immediate
Consequences
Indirect and Deferred
Consequences
Cutting
Burning
Banging
Ingestion of substance/medication
Over-exercise
Eating disorders
Smoking
Alcohol
Drug Use
Sexual Risk-taking

9. Where would
you place the
following?
• Paragliding?
• Hair Pulling?
• Reckless Driving – 70mph in a 30mph
zone
• Workaholism
• Cosmetic Surgery
• Tattooing
• Slapping your own legs and telling yourself
to get moving.

10. What are the reasons that we
self-harm?

11. Coping and Crisis Intervention
Calming and Comforting
Control
Cleansing
Confirmation of Existence – I Exist
Creating Comfortable Numbness
Chastisement
Communication
Compulsion and Habit

12. What are the challenges that face us?
• The need for careful and
accessible contracting
• An understanding of your
organisation’s policy
• Some good underpinning
theory.
• A relational understanding.
• A sense of our own position
in the matrix.
• To be willing to engage in
active and meaningful
conversations.
• To look underneath – with
compassion – and with good
structuring.

13. The Risk Continuum
Low Lethality
High Secondary Gain
- Individual is seeking support
- Individual is attempting to
communicate something
- Seeking something from the other
in this process.
High Lethality
High Secondary Gain
- Very dangerous
- The payoff of a Game?
- Angry Act
- Punishing of others.
- Demonstration of something
Low Lethality
Low Secondary Gain
- Private, well-contained acts
- Independent act
- Secrecy problematic?
High Lethality
Low Secondary Gain
- Very dangerous
- High risk of death
- No interest in attention or
intervention from others.
- Dangerous, secret events.
High
Lethality

14. Box 1. Beth has been seeing her counsellor, Alice, for
several weeks. At assessment Beth talked about she has cut
herself for some years following family estrangement and
physical abuse perpetrated by her mother. She did not
particularly want to discuss her self-injury in the sessions,
saying it was part of her – and more the symptom of
problems, rather than the problem itself. As far as Beth
was concerned she managed her self-injury well; rather, she
wanted to look at the historical issues that she felt were
more relevant and pertinent.

15. Box 2. As the counselling progresses Beth talks
about some quite distressing material. She
reports to Alice that her self-injury has got worse
and sometimes she feels really bad. She is still
reluctant to talk about her self-injury and tells
Alice that she has read online that sometime self-
injury can get a little worse as the person begins
to explore the issues that are causing the
distress.

16. Box 3. Beth arrives at a session quite distressed. She says that
she feels her self-injury has gone out of control. She say that she is
cutting most days and sometimes a couple of times per day, and
that the cuts are getting deeper. She is frightened about going to
hospital for treatment as she is fearful of what they might say, but
some cuts have not stopped bleeding and she doesn’t know what
to do. She fears that some might also have become infected and
has been feeling quite unwell, fever, disturbed sleep, no appetite
and occasionally vomiting.

17. • Self-harm may be the opposite to suicide
– and it might be keeping the client alive.
• Self-survival or self-annihilation.
• Be alert to dissociative processes.
• Be alert to transference and who you, as
therapist, might have become in the
transferential matrix.
• Shame and secrecy are endemic.
Finally