Living through distress

Deliberate self-harm or non-suicidal self-injury (NSSI) presents a serious concern for individuals who engage in the behaviour, their families and friends and for the professionals who attempt to offer support. In Ireland, there were 11,485 self-harm presentations to hospitals made by 8,909 individuals in 2016 (NSRF, 2016). This is a phenomenon that has increased in frequency of occurrence in recent years. GPs are often the first port of call and are potentially the first to raise concern. For professionals working with people who are engaging in self harming behaviour the experience can be anxiety provoking, confusing and overwhelming. This article seeks to provide information on deliberate self-harm and to suggest possible options for how to best respond.

What is self-harm?

While reports of deliberate injury behaviours have appeared for thousands of years, it appears that there has been a dramatic increase in deliberate injury in the past few decades (Nock, 2009). NSSI has been defined as the ‘direct and deliberate destruction of one’s own body tissue in the absence of intent to die’ (Nock, 2009) and includes behaviours like cutting, burning, scratching, hitting, or drinking toxic substances such as bleach (Manning, 2011). While there are differences between NSSI and suicidal behaviour, 33-37% of adolescents and 16-25% of adults who have a history of NSSI also reported at least one suicide attempt (Hamza, Stewart, Willoughby, 2012). 

There is a need for a balanced response to deliberate self-harm; not to treat it as suicidal behaviour while also not dismissing its significance and potentially harmful effects. Nock (2009) presents a four-factor model to explain NSSI, which suggests that the behaviour is maintained by a few factors; it decreases or distracts from aversive thoughts or feelings, generates desired feelings or stimulation (feels good), facilitates help-seeking or it allows the person to escape from undesirable social situations. 

Self-harm affects 13-29% of adolescents and 4-6% of adults (Hamza et al, 2012) and does not appear to differ based on gender, ethnicity or socio-economic status. (Nock, 2009) 

Why do people self-harm?

As yet, it is not known what might make NSSI effective for emotional regulation and a complicated picture is emerging. One component could be distraction - the pain demands attention and there is a task required to manage the wound. There may also be a biological component, Reitz et al (2015) found reduced amygdala activity and normalised functional connectivity with the superior frontal gyrus in patients with borderline personality disorder after an incision into the forearm. This means that NSSI can produce changes at a neurological level that result in reduced emotional arousal and an increase in activity in an area linked to self-awareness. 

Often self-harming behaviours provide short-term relief from high emotion, however, over the long term they can inhibit establishing more adaptive coping mechanisms. They can become caught in a cycle of achieving short-term relief from negative emotions that can interfere with long-term life goals. A commonly held belief is that NSSI has been seen as a means of gaining attention or a ‘cry for help’. 

Research in self-injurious behaviour, originally conducted with individuals with disabilities (Iwata et al, 1994), suggests there may be a number of functions related to NSSI behaviour that may vary depending on the situation (Nock, 2009). Therefore, presuming the function of the behaviour may block us from understanding the individual’s specific reason for engaging in it.  

Individuals may not disclose that they are engaging in these behaviours and injure hidden parts of their bodies such as hips, thighs and the inside of their upper arm. A majority of studies have found help-seeking rates in young people who engage in self-harm of less than 50% (Michelmore & Hindley, 2012). Some researchers believe it can be socially contagious in that people learn about its function as a coping mechanism from each other; it tends to appear in clusters and people who engage in self-harm report having friends who do it too (Heilbron & Prinstein, 2008). 

Who is more vulnerable?

In Ireland in the past year the highest rates of self-harm occurred between the ages of 15 – 19 for women and 20 – 24 for men. This should not blind us to the fact that individuals of all ages and backgrounds engage in self-harm. In the ‘Living Through Distress’ programme in St Patrick’s Hospital, we view self-harm as the individual’s best attempt to cope with overwhelming adversity. We work to support people in building new skills to increase alternative coping strategies to reduce dependence on self-harm.  

Research indicates that individuals who engage in NSSI display elevated physiological arousal to stressful tasks and elect to escape that task significantly sooner than non-injurers (Nock & Mendes, 2008). They also report a greater effort to suppress aversive thoughts and feelings in everyday life (Najmi, Wegner & Nock 2007). Some research has also found that they have deficits in social problem-solving and communication skills (Hilt, Cha & Nolen-Hoeksema, 2008). There are higher rates among individuals with mental health difficulties and historical risk factors such as childhood abuse and a genetic predisposition to being emotionally reactive or prone to emotional outbursts also play a role (Nock, 2009).  

How to respond?

It can be difficult to know what to do when someone has harmed themselves but there are certain things we can do directly. Remaining calm will help the person feel safe which in turn means that they are more likely to share what is happening for them. We can also validate that they are experiencing significant distress and are trying to find ways to cope with the situation, even though these may not be helpful in the long-term. Expressing a willingness to talk about it when they feel able to do so is also another way in which we can help them. There can be an urge to ask a lot of questions but the person might find this overwhelming initially. 

Familiarise yourself with support services and potential referral options. St Patrick’s University Hospital run a programme called ‘Living Through Distress’ that focuses on teaching skills to replace the urge to engage in NSSI or para-suicidal behaviours. Some alternative behaviours we teach to manage emotional dysregulation include holding ice until it melts as a form of distraction. Intense exercise such as running at a fast pace or doing compound exercises like burpees can help with rumination and physiological arousal. Paced breathing, exhaling for a longer than we inhale, (for example inhaling to a count of five and exhaling for a count of seven) can also reduce some of the arousal associated with the flight, fight or freeze response. 

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