A Therapeutic Approach to Self-Harm and Suicide

by Joan Freeman

In recent years, there has been a significant increase in media coverage concerning suicide. Special emphasis in particular has been placed on young men between the ages of 15 and 24 years who take their lives. However, in recent weeks there has been an alarming increase of suicides involving young girls. While there has been much speculation as to the cause or even the catalyst that would have brought about their deaths, the method of death should also be taken into consideration. Studies have shown that in fact the group with the highest rate of deliberate self-harm (DSH) is young women in the 15 to 19 years age group. Furthermore, in all age groups, females are more likely to self-harm than males (Nordentoft et al.: 1993 & Hawton K.: 1992). Heretofore, it has been shown that men are more likely to use fatal methods such as ingesting solvents, pesticides, hanging or throwing themselves in front of moving objects, whereas overdoses and drowning was used more often by women. (Michel K: 2000).

So, does this recent upsurge in female suicides suggest that young girls are now using more violent and fatal methods? It would appear so. The rate of suicide in Ireland is estimated at 196 per 100,000 populations. And approximately 11,000 cases of Para suicide are recorded in Irish hospitals annually (NSRF 2002). However, these figures must be viewed with a certain amount of scepticism. The data is based upon hospital presentations only and does not take into consideration the people who may present themselves to their GP nor does it include the people who self-treat or recover at home. After being bombarded with so much statistics and research evidence, it is time to look beyond these figures and scrape away the myths from the facts concerning suicide and of equal importance, to look at the critical difference between  suicide and self-harm.

Popular Myths Concerning Suicide

– Most suicides occur with no warning

In many cases, people will indicate their intentions either through physical signs (such as purchasing a rope, storing tablets, tidying up their affairs: writing a will etc., or giving away their belongings). Or by making direct statements (such as “I don’t see the point of going on, I wish I was dead, I won’t be here this time next year”)

– Talking about suicide might encourage it

Talking about suicide reduces risk, it does not create it or ‘put the thought into the person’s mind’. Showing concern and talking about suicide in an open manner can provide a wonderful sense of relief – because suicidal ideation is such a frightening sensation.

– We only need to pay attention to youth suicide

All ages are at risk. In some areas, (in particular rural areas) suicide is at a higher rate with people who are in there 40’s and is prevalent amongst the elderly. Many older people who die by suicide are in poor physical health and find it difficult to cope with increasing dependency and a decrease in mobility.

– The seriousness of the intent depends on the lethality of the method

The choice of methods is largely due to the availability of items such as tablets or ropes and what might be more comfortable for them. Sometimes methods are used for personal reasons (punishment style).

– Suicidal people want to die

Most people who take their lives are ambivalent about dying right up to the point of the act. Their aim is to stop consciousness and death is the permanent solution. People want to be helped so that suicide is not an option.

Some Possible Explanations for Suicide

• Rational:  To escape unendurable psychological pain

• Reaction: In particular to loss, also there is an element of impulsivity. This impulsiveness can be exacerbated with alcohol and drugs because of their dis-inhibiting properties.

• Other possible contributing risk factors: – Sexual orientation, marital status, and first generation of immigrants.

When we look at the act of suicide, it needs to be placed at one end of the spectrum. It is the final act of a variety of harming behaviours harboring the ultimate degree of suicidal intent. Terms such as deliberate self-harm, Para-suicide, suicide attempt are used to describe varying degrees of suicidal intent. However, one type of self-harm is at the opposite end of the spectrum that should not be viewed as a suicide attempt and that is self-injury.

What is Self-injury?

We all self-harm. Activities such as smoking, overeating or drinking, driving too fast, working too hard, – are all forms of self-harm (Mind 2003). However, self-injury (in Ireland known as self-harm) is a behaviour, which involves the causation of injuries or pain to a person’s body. The method probably most used is cutting. However, people also take tablets (with the intent that the analgesic properties will remove inner pain), burn parts of their body, punch or hit their bodies against objects, pull out hair or skin picking. Whatever end of the spectrum a person finds himself or herself, all have one common denominator – the experience of intense emotional distress. The main difference between deliberate self-harm and self-injury is that one has a desire to die and the other has a desire to live. Self-injury is a very private and personal way of expressing overwhelming emotions. It is a secret behaviour that usually does not require any medical intervention and its occurrence is far more common than realized. (Spandler H. :1996). Self-injury is now acknowledged as a coping strategy that allows a person to continue to live.

If we think of some of the main emotions that face us on a daily basis such as sadness or anger and if we ask ourselves ‘How do we express this emotion’? For many of us, we can express it quite freely- such as if we are sad, we can cry or if we are angry – we can shout or swear! However, for many people, for whatever reason, the expression of certain emotions is not allowed. These reasons could be for example, if a parent has a terminal illness – the young person is not allowed to show sadness, or maybe a person comes from a home where anger is not allowed to be expressed. That anger – or what ever emotion – is then swallowed, it remains internalized. This would obviously culminate in unbearable tension. This tension whether it is anxiety, grief, or anger must be released in some way – and for some cutting allows this release. For others, it allows them to put their pain ‘outside’ where it is easier to cope with. Whilst other people use self-injury as a form of self-punishment, usually because of feelings of shame or guilt. All sorts of people self-injure and although this behaviour is more common in young girls and women, it is also becoming increasingly common in adolescent boys

The problems with using self-injuring as a coping strategy are numerous. Although people who self-injure may not have suicidal ideation or intent, studies have shown that, there is a risk of accidental death (Mind 2003). Research has also shown that there is a strong link between self-injuring behaviour and later suicide (Owens et al.: 2002).

It is recognized that many people wish to stop injuring themselves but find it difficult – this would suggest that this coping strategy might have compulsive or addictive properties to the behaviour (Kinmond K.: 2001). Obviously, besides the physical damage to a persons’ body, self-injury could be viewed as a violation to self that must have a serious psychological impact on the person’s self-esteem. As mentioned before, suicide and self-injury is an expression of intensive emotional distress – so from a therapeutic perspective, how can we help people in crisis?

Pieta House  c.p.s.o.s. (Centre for the Prevention of Self-harm Or Suicide)

Pieta House was established in January of this year ‘to provide a holistic solution to the ever increasing problems of hopelessness and despair’. It is at present a privately funded charity that provides a one to one service for people in crisis. A cohort of accredited therapists work in a non-clinical setting that targets specifically people who have already attempted to take their lives and people who self-injure. Although working with opposite ends of the spectrum, our therapeutic approach is somewhat similar to both groups. In both cases, people from these groups are highly emotionally aroused. The first group (people who attempt to take their lives) is overwhelmed with emotions due to a series of previous life events, such as loss and other major happenings. They feel that their pain is unendurable and that their only option is to end their pain through death. The second group are also overwhelmed by strong emotions but injuring themselves is their way of ending their pain – albeit –temporarily. It is their way of staying alive. It is a coping mechanism that enables them to survive. In essence, both groups need to learn how to cope with strong emotions and to make some cognitive changes.

We at Pieta House offer a unique therapeutic approach that establishes a rapport with the client that will develop trust and motivation. This is achieved through therapist consistency and by seeing the client daily – in particular during the first week. Therapy will not dwell on past negative events but will be solution focused and using an approach that is strength based. This time intensive therapy over four to six weeks is in essesence, the equivalent to approximately 6 months therapy. (The Ashleigh Model ä).

Our service also reaches out to the families who have a distressed member and we also teach them coping skills and offer much needed support during this crisis. We involve a key member of the family (one who has been selected by the client) who will reflect and support the work that is being done at the center, thus ensuring a ‘continuity of care’.

At present, we are open five days a week – 9am to 5pm. However, within the next few weeks we propose to open from 10am to 10pm for six days a week. This can only be achieved through the support and effort from local volunteers, whom we also hope to train and educate in suicide intervention and prevention. This service is in response to a gap within services and is to compliment and act as a support to psychiatric services and A & E Departments.  It also needs to be noted that because we focus on only two target groups, we can offer a personalised service that is enveloping, supportive, and warm. Care, concern, and compassion are the foundation stones of our therapy and of our organization.

Joan Freeman had her own clinical practice in Leixlip for ten years and is also a Research Psychologist. She is the founder of Pieta House where she is now works as CEO.
Pieta House can be contacted at 6010000 or 6302222″

References:

Hawton, K. ‘Suicide and attempted suicide’ in Paykel and Churchill (eds) Handbook of Affective Disorders, Livingstone 1992

Kimmond,  K. (2001) ‘Why would I want to kill myself?  Self-harm as an Adaptive Response: Young Women’s views’ in International Journal of Mental Health Promotion, 3 (2), 37-44

Michel, K. (2000) ‘Methods used for Para suicide: results of the WHO/EURO Multi centre Study on Para suicide’, Soc. Psychiatry Psychiatric Epidemiol 35, 156-63

Mind ‘Understanding self-harm’ Information booklet, 2003 (revised), www.mind.org.uk

National Suicide Research Foundation, ‘National Parasuicide Registry Ireland Annual Report 2002’, NSRF, Cork, Ireland (www.nsrf.org)

Nordentoft M. et al., (1993) ‘High mortality by natural and unnatural causes: a year follow up study of patients admitted to a poisoning treatment center after suicide attempts’in British Medical Journal, 306, 1637-41

Owens, D., Horrocks, J. and House, A. (2002) ‘Fatal and non-fatal repetition of self-harm: Systematic Review’ in British Journal of Psychiatry.

Spandler, H. (1996) ‘Who’s hurting who? Young people, self-harm and suicide’, 42^nd Street, Manchester.