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Working with individuals who self-harm T he approach of the Crisis Recovery Unit

Working with individuals who self-harm T he approach of the Crisis Recovery Unit. SCOTTISH Personality Disorder Network. Outline. Setting the scene The unit ~ where we started Dilemmas How to work with the work The unit ~ where we are now Repetition and reparation.

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Working with individuals who self-harm T he approach of the Crisis Recovery Unit

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  1. Working with individuals who self-harmThe approach of the Crisis Recovery Unit SCOTTISH Personality Disorder Network

  2. Outline • Setting the scene • The unit ~ where we started • Dilemmas • How to work with the work • The unit ~ where we are now • Repetition and reparation

  3. Self-harm - an act of religious devotion

  4. Self-harm: a form of protest Shias stage anti-US protest Protests against the US presence in Iraq have been staged by Shias in the city of Karbala at the climax of a pilgrimage that has attracted one million people. Groups of marchers chanted slogans against a US-imposed government calling for unity among Shias. Many hit their backs with flails or cut their heads with swords in ritual self-flagellation.

  5. Self-harm: a way of restoring health!

  6. Definitions “ …. an individual intentionally damaging a part of his or her own body, apparently without a conscious intent to die” Feldman, 1988

  7. Definitions “…intentional self-poisoning or injury, irrespective of the apparent purpose of the act” • NICE Guidelines, 2004

  8. Definitions “…a deliberate act to damage yourself, without intending to die. This varies according to the situation the individual carrying out the act & is a means of getting away from intolerable thoughts or feelings” HOTUSH

  9. The Unit ~ Where We Started

  10. “The sufferer who frustrates a keen therapist, by failing to improve is always in danger of meeting primitive human behaviour disguised as treatment” Main,T. 1957

  11. Inclusive definition • Self-harm as a symptom

  12. Self-harm & suicide • Not about wanting to die • Self-harm and suicide lie on a continuum Socially acceptable self-harm Suicide self-harm

  13. Underlying principles • Retention of Responsibility • Short Term Risk Taking

  14. Dilemmas Anxiety

  15. Dilemmas Anxiety “Unless anxieties can be identified, addressed & contained within the system it is likely that the system itself will produce defences that actively hinder rather than help therapeutic intervention”Menzies Lyth, 1970

  16. Dilemmas Polarity of thinking and catastrophysing

  17. Dilemmas Specialness

  18. Dilemmas Specialness “These patients have the capacity to gain a unique position in the lives of their treaters, characterised by an intense, although mutually ambivalent, attachment on the part of the treater & the patient” Gabbard, G.1986

  19. Dilemmas Seeking of ideal attachments

  20. Dilemmas Insatiability and inability to get things right

  21. Dilemmas Insatiability “leading people on & then letting them use us, we get people to dislike us by doing things to making them angry. Some of exhaust people with our intense relationships” “I don’t think you’ll ever get it right – it changes for me each time”HOTUSH

  22. Dilemmas Abuser-abused

  23. Dilemmas Abused/abuser “they experience a sense of power through being in control of the shapes & forms their bodies assume, as a result of the physical injuries & abuse they inflict upon themselves” Welldon 1988

  24. Dilemmas Abused/abuser “self-abusing & mutilating attacks in such patients may serve the double purpose of producing further additive, perverse excitement & also of a punishing attack on the ‘bad’ internal organs which have become contaminated by the identification with the excited, intrusive organs of the abuser” Milton 1994

  25. Dilemmas Abused/abuser “the patient is at times in her current life the abuser, & then at times the abused. In fact the two are inextricable, as masochism involves the accompanying projection of sadism, forcing the other to be the helpless witness of suffering in which they are supposed to be implicated” Milton 1994

  26. Dilemmas Difficulty in thinking & feeling

  27. Dilemmas Behaviour Practitioners impelled: “towards action rather than towards contemplation” Heimann, 1950

  28. Dilemmas Breaking of boundaries

  29. Dilemmas Projection/countertransference

  30. Dilemmas Countertransference “The psychiatrist cannot avoid hating them & fearing them, & the better he knows this the less will hate and fear be the motives determining what he does to his patients” Winnicott, 1947

  31. Dilemmas Countertransference “Though it is acknowledged that at times countertransference hate may be justified, the more justifiable it seems, the more likely the therapist is to act it out in a non-therapeutic fashion” Progers 1991

  32. Dilemmas Breaking of boundaries

  33. Dilemmas Boundaries • The Professional Boundary • Treatment Boundary • Self Disclosure Boundary • Safety Boundary • Boundaries and Individuality

  34. Dilemmas Boundaries "The skin ego is the interface between psyche and body, self and others" Anzieu 1989

  35. How to work with the work • Protocols • Mutli-disciplinary working • Staff support/supervision • Relationship with the institution • Risk Assessment • Understanding who owns the problem • Communication • Boundaries

  36. The Service 3 components • In-patient unit (Crisis Recovery Unit) • Self-harm Outpatient Service (SHOP) • A national training programme

  37. The Unit

  38. Referral criteria • Over 18 years • Non-psychotic • Not dependent on alcohol or substances • No significant learning difficulties • Not homeless

  39. Why referred • Exhausted local services • Enmeshed teams • Loss of professional boundaries • High levels of anxiety • Desperation

  40. At assessment • “Psychologically minded” • Contemplating change • A degree of adult functioning

  41. Post assessment • Provisos • Reporting • Outreach • Voluntary admission

  42. Admission • Timed admission • Work not care • Responsibility • Relationships • Tolerance of self-harm • Work on internal damage not SH management

  43. Admission • Community • Repetition then change • Conflict • Group • Individual • Creative therapies • Practice at home

  44. Admission • Family therapy • All part of day are work • Finishing relationships • Post discharge group • Responsibility for handover to local workers

  45. The programme • Community group • Coping skills • Projective art • Creative writing • Movement group • CRU group • Weekend planning

  46. The programme • HOTUSH • Negotiation • Planned meetings • Safety planning • Evening activity • Evaluation • Occupational therapy

  47. Ground rules • No use of alcohol or illicit drugs • No violence towards others • No assisting others in their SH • Deliberate damage to property paid for • Consideration for others • Keep to provisos

  48. Boundaries for self-harm • Report SH 2 hours (sooner if severe) • Accept treatment • Complete an incident form • Consider handing in implements • Dispose of sharps correctly • Clean up blood spillages

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