Adolescent Deliberate Self Harm (Cutters)
>> Following the high number of enquiries from parents regarding this page, I'm planning on running a one day training workshop for parents of adolescents who deliberately self harm. I'm most likely to run this in Southampton, UK, in mid-July 2013. Please email me at NLP@hotmail.co.uk to register your interest. Thank you. <<<
Deliberate Self Harm (DSH) is a regretably common phenomena that has gain increased publicity with the development of social networks on the internet.
Back in 1993-1995 when I worked in A&E as a nurse, Deliberate Self Harm was not recognised as it is today, and such patients were classified as "suicidal gesturing with or without suicidal ideation/intent."
Back then the "culture" of deliberate self harm hadn't fully formed and as such these casualty attendees didn't really understand it either.
With increased electronic communications the culture of deliberate self harm has solidified and whilst self-harmers may at times talk about suicidal intention the action of harm is not necessarily an expression of suicidal intent.
Most commonly, deliberate self harm amongst younger patients takes the form of cutting which may be carried out on discreet parts of the body (i.e. upper thighs), or may be more visible (i.e. the forearms).
Older patients, often with a stronger history of mental illness may present themselves regularly to Accident and Emergency departments with cutting, ingestion of dangerous substances and objects and self inflicted injury. This category of patients are often regular attenders who periodically inflate claims of actual self harm in order to create drama around them and create doubt in their care givers. An example of this would be the patient who attends the department frequently with claims of overdose, and then arrives claiming to have swallowed razor blades when they have done no such thing.
Adolescent self harmers rarely present themselves to A&E as their intention is not to garner attention from medical professionals but rather to relieve stress and emotional tension. Medical help is usually only sought when injury is greater than intended or parental intervention occurs.
It is not uncommon for self-harmers to share techniques, stories, acting out, cries for help and photos of injury on social network sites. This behaviour can further alarm and confuse already distraught parents who may have exhausted the available verbal repertoire and attempts at intervention without success.
As a clinician who has worked extensively with this client group in a variety of settings (psychiatry, A&E, private practice) I have the following observations to offer:
- patients who deliberately self harm tend to feel emotions more strongly than other people in the same age group.
- self harmers feel a lot of mixed emotions and are confused by their emotions. "Talking about it" is rarely beneficial and often serves to confuse the patient even more.
- self harm is actually the patients' solution to their problem and as far as they are concerned, it is not the actual problem. But because the cutting (or whatever) is the most visible aspect of the psycho-pathology, it is this that garners the most attention from others.
- self harm actually brings pleasure because it brings the patients relief. As such, sharing the photos on the internet like trophies also brings relief as it offers pleasure.
- "I don't know" and "fuck you" are the most common answers to the question, "Why do you do this?" Trying to understand why the patient cuts is a waste of time and does little to help create therapeutic change.
- most self harmers are cynical of therapy for good reason - most therapists are appalling and most 'therapy' is mostly inept, naive and patronising.
- family dynamics around self harmers may be turbulant and high levels of expressed emotions may occur... as with all families. On the surface this can appear to be causal in self harm, but it probably isn't. It is far too easy to blame everyone else for our emotions, and difficult to take responsibility ourselves. This is an aspect of life rarely grasped too well by DSH patients.
- pathologising self-harmers by diagnosing fictitious disorders such as "borderline personality disorder" and prescribing medication is rarely productive. Often such an activity is actually counter-productive with the self-harmer now using their diagnosis as further manipulation against those around them.
- self harmers tend to be very adept at pointing out faults in everyone else's behavours except their own as a method of ducking from their own responsibilities inside relationships.
- deliberate self harm and the psychological and emotional states that accompany it are very seductive and in a strange way are appealing to this client group. As a result, it appears that these clients actually enjoy their behaviours and emotional states that are clearly destructive to any outside observer. This is "the romance of self destruction" which has taken numerous different forms over millenia.
- deliberate self harm has a significant identity aspect to it. Given the advent of modern mass communications, there is an interactivity that is available to adolescent sub-cultures that was not present 25 years ago. As a result, self harm tends to follow trends, it has its own language, idioms and phrases as well as conceptualisations and philosophies that may be inaccessible to those outside of this group. Those outside of this subcultural group who fail to use the right language of the culture may be accused of not understanding anything.
- whilst some self harmers have traumatic incidents in their background (rape, sexual abuse/assault), not all self harmers have any history of note when it comes to looking for incidents of causation. Some are just very upset by life itself, others are just confused by their intense and often irrational emotions.
- because of the high intensity by which this patient group experience their emotions, they tend to be prone to gross exagerration and impulsive lies. However this behaviour is usually emotionally reactive (and thus later regretted) rather than as an act of intended deception.
- deliberate self harm patients tend to be highly reactive to their emotions and thus say and do things that carry social and emotional consequence. This in turn leads to rumination, regret and self recrimination, self loathing and so on, thus perpetuating the cycle of strong negative emotions.
- self harmers tend to cut themselves off from normal social interactions and in turn seek out others who "understand." These "understanders" are often people who themselves carry serious emotive psychopathology (i.e. cutters, drug users, low self esteem, sexually vulnerable individuals) and as a result are often caught up in destructive and complex social relationships.
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