This essay will discuss the complex issue that is self harm in society today; although word count will restrict many of the areas this essay will try and achieve an overall balance. The essay will look at the psychological causes and treatments available to service users via the National Health Service. It will be necessary throughout the essay to compare the issues surrounding self harm with that of parasuicide and suicide itself. Consideration will also be given to the views and perspectives of the service user with regard to the service they receive and where appropriate this essay will refer to practice experience to provide depth and insight into aspects of the discussion. Reference will also be made to the links with self harm in the animal kingdom. This brief discussion with animal self harm will be an attempt to show dual causation in humans and animals. Highly concise introduction, well done.
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In order to better understand self harm this issue must be clearly defined as to avoid inaccurate and misleading terminology as self-harm covers a wide range of behaviours some of which are directly related to suicide and some are not. Self harm (SH) or deliberate self harm (DSH) including self injury (SI) and self poisoning (SP) is defined as the intentional direct injury of body tissue without suicidal intent (Laye-Gindhu, A 2005., Klonsky, E.D 2007., Muehlenkamp, J.J 2005). Self harm is listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-1V-TR) (1994) as a symptom of borderline personality disorder. However, patients with other diagnosis may also self harm including those with depression, and anxiety disorders, substance abuse, eating disorders post-traumatic stress disorders, schizophrenia and several personality disorders. Self harm is also apparent in high-functioning individuals who have no underlying clinical diagnosis. (Klonsky, E.D 2007). Guidelines for the treatment of self harm are not specified from NICE.
What is self harm, self harm is deliberate damage of the body that is intentionally not life threatening, often repetitive in nature and usually considered socially unacceptable, 80% of self harm involves stabbing or cutting the skin with a sharp object (Greydanus, & Shek, 2009). It is generally agreed that someone does not intend to die as a result of his or her self harm. However, many acts of self harm are not directly connected to suicidal intent they may be an attempt to communicate with others to influence or to secure help or care from others or a way of obtaining relief from it difficult and otherwise overwhelming situation or emotional state (Hjelmeland et al., 2002). Walsh and Rosen (1998) in discussing the difference between self mutilation and parasuicide have noted; “In the case of ingesting pills or poison, the harm caused is uncertain, unpredictable, and basically invisible. In the case of self lacerations, the degree of self harm is clear, unambiguous, predictable as to course, and highly visible” (Walsh, B.W., Rosen, P.M 1988). However someone who self harms is 50-100 times more likely to attempt suicide than someone who does not (Martinson, D. 1998).There are many reasons why people self harm, in a survey conducted of young people aged 16 through to 25 the most common reason was “to find relief from a terrible situation” (Samaritans 2001).Self harm is often associated with a history of trauma and abuse including emotional abuse, sexual abuse, drug dependence eating disorders or mental traits such as low self-esteem or perfectionism. (Swales, M. 2008)
Emotionally invalidating environments where parents punish children for expressing sadness or hurt can contribute to a difficulty experiencing emotions and increased rates of self harm (Martinson, D. 2002). Abuse during childhood is accepted as the primary social factor as is bereavement, and troubled parental or partner relationships. Factors such as war, poverty, and unemployment may also contribute. In addition some individuals with pervasive developmental disabilities such as autism engage in self harm, although whether this is a form of self stimulation or for the purpose of harming oneself is a matter of debate (Edelson, 2004)
It is noted that Service users who self harm give broadly three reasons for their behaviour these are, controlling mood, regulating moods in terms of how a person is able to cope with emotions and feelings especially feelings which are particularly unsettling unpleasant or intense. Communication, some people use self harm as a way of expressing themselves if those expressions are directed at others this can be seen by some as attention seeking and manipulation. Understand in what an act of self harm is trying to communicate can be crucial to dealing with it in an effective and constructive way. Control/punishment, people who self harm have often experienced traumatic experiences in their lives including emotional physical or sexual abuse. (Martinson, D. 1998). Self harm can be a form of trauma re-enactment or way of bargaining or engaging in magical thinking “if I hurt myself I will prevent the thing I fear protect the person I care about”. A common belief regarding self harm is that it is an attention seeking behaviour however in most cases this is inaccurate. Many self- harmers are very self-conscious of their wounds and scars and feel guilty about their behaviour leading them to go to great lengths to conceal their behaviours from others (Mental Health Foundation 2006).
People diagnosed as having certain types of medical disorder are much more likely to self harm in one survey of a sample of the British population people with current symptoms of mental disorder up to 20 times more likely to report having harm themselves in the past (Meltzer et al., 2002).People diagnosed as having schizophrenia are most at risk and about one-half of this group will have harmed themselves at some time. When assessed the majority of individuals engaging in self harm will be diagnosed with depression although two thirds will no longer fit the criteria after a year. This explains why nearly half of those who present to an emergency department meet criteria for having a personality disorder (Haw et al., 2001). However, there are problems with doing this because some people who self harm consider the term personality disorder to be offensive and to create a stereotype that can lead to damaging stigmatization by social care workers (Babiker & Arnold, 1997., Pembroke, 1994). About one in six people who attend an emergency departments following self harm will harm themselves again in the following year (Owen et al., 2002).
For the last 25 years it has been NHS policy that everybody who attends hospital after an episode of self harm should receive a psychological assessment (Department of Health and Social Security, 1984).While psychological assessment includes several components, the most important are the assessment of needs in the assessment of risks. The assessment of needs is to each item to identify those personal (psychological) and environmental (social) factors that might explain an act of self harm; this assessment should lead to a formulation, based upon which a management plan can be developed. Despite the importance of comprehensive assessment following an act of self harm many service users “fall through the net”. In many hospitals, more than half of the attendees are discharge from the emergency department without specialist assessment (Termansen & Bywater, 1975; Thomas et al., 1996; Kapur et al., 1998). Patients who leave hospital direct from an emergency department and especially those who leave without a psychological assessment are less likely to have been offered to follow- up (Owens et al., 1991; Suokas & Lonnquist, 1991; Gunnell et al., 1996; Kapur et al., 1998). In addition, those who do receive the psychological assessment (rather than the needs or risk assessment specifically) may be less likely to repeat an act of self- harm (Hickey et al., 2001; Kapur et al., 2002). These figures suggest that the service user is being set up to fail or more directly not being correctly diagnosed and treated properly.
Service user’s experiences and attitudes to the services they receive can vary but most feel like the following quotation “Got no help at all. All they wanted to do is pick on me like I was a naughty little girl, and it made me very angry, and I couldn’t open all for how they treated me. I just dreaded going to see them (Harris, 200). Not only do these kinds of attitudes make users experiences of services unpleasant, but they can also increase service user’s echoes of distress. Not only are service users critical of emergency department staff, but patients admitted to hospital following self poisoning also feel isolated, ignored and inhibited by staff (Dunleavey 1992) a fast tracking of service users through the system should be considered to minimize harm resulting from their injury and to minimize distress. Service users also point out the importance of being listened to by staff even when the interaction is brief or only a single occasion (Arnold 1995). A safe environment and being listened to it especially important since service users may reveal information about their injuries that makes them feel vulnerable, fearing negative repercussions. As a result of poor stuff attitudes towards people who self harm, service users feel that they are frequently treated differently compared with service users who have not self harmed.
“I was told off by nurses and the doctors; I just felt small. They do treat self harmers different to accident people. We are classed as suicides. The hospital staff just look at you as though you’re wasting time. That’s how I felt. (Harris. 2000).
Some self harmers, however, use the practice of self harm in a ritualistic way. This type of self harm has been practiced by different cultures for centuries, for example the Maya priesthood performed auto- sacrifice by cutting and piercing their bodies in order to draw blood (Gualberto, A. 1991). It is also practiced by the sadhu Hindu ascetic, in Catholic mortification of the flesh, in ancient Canaanite mourning rituals as described in the Ras Shamra tablets and in the Shi’ite annual ritual of self-flagellation, using chains and swords, that takes place during Ashura where there Shi’ites sect mourne the martyrdom of Imam Hussein (Reference).
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Another little known fact is that the animal world is prone to self harming and there is some correlation between animals and human beings on this issue. Self -mutilation in non-human mammals is well-established, although not a widely known phenomenon and its study under zoo or a laboratory conditions could lead to a better understanding of self harm in human patients (Jones, I.H., Barraclough, B.M. 2007). Zoo or laboratory rearing and isolation are important factors leading to increased susceptibility to self harm in higher mammals. Lower mammals are also known to mutilate themselves under laboratory conditions after administration of drugs (Jones, I.H., Barraclough, B.M 2007). In dogs, canine obsessive compulsory disorder can lead to self inflicted injuries, for example canine lick. Captive birds are sometimes known to engage in feather plucking causing damage to feathers or even the mutilation of skin or muscle tissue (20..?..) A good example of feather plucking in birds would be battery hens that are kept in cages with no access to movement or sunlight. Useful analogies!
Many people who engage in self harm do so not that they intend to take their life or that they are seeking attention. People who self harm do so because they are looking for some form of relief from their situation. As a coping mechanism, self harm works for the person doing it. (Reference needed on coping mechanisms) Many self harmers who seek help in the form of medical attention face an uphill struggle in the face of adversity, negativity and disbelief from the service that is in situ to help them. Negative attitudes from medical staff and social care workers affect the self harmer and they feel increasingly isolated. Within the medical profession comes a coldness not afforded to accident and ill people, along with a lack of understanding and a lack of training. Communication with the service user as well as empowerment would enable service users to have a greater say in their treatment and rehabilitation and this would go a long way in addressing this problem. Service users know why they self harm but feel they are not being listened to. Until this issue is addressed the problem will go largely unchanged. (Need references for stigma and self harm treatment in A & E)
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