The Stoic 5.3: Anticipated misfortune

“Rehearse death. To say this is to tell a person to rehearse his freedom. A person who has learned how to die has unlearned how to be a slave.”

(Seneca)

In the previous post I suggested that there’s no point in becoming distressed today because we think something might distress us later. That just increases the misfortune. Indeed, once we realise that most of the things people worry about never actually happen it becomes clear that it’s possible to ruin the quality of an entire life with pointless and unnecessary anxiety. If we expect next Friday afternoon to be distressing that’s one thing. But let’s not destroy today as well.

In the Christian tradition this seems to be what Jesus meant when he said

“….. do not worry about tomorrow, for tomorrow will worry about itself. Each day has enough trouble of its own.”

(Matthew 6:34)

I have long believed that Jesus (or whoever wrote the Gospels after his death) must have been familiar with the earlier works of stoic philosophers, there are just too many such coincidences for it to be otherwise in my opinion.

But it’s important to be clear. Freedom from distress by avoiding the emotional content of anticipation (avoiding worry, in other words) isn’t the same as avoiding anticipation altogether. On the contrary, we must anticipate. In fact the stoics advised us to go further than most worriers do in our anticipation – but we do so without distress. We do it as an intellectual exercise. We visualise loss and misfortune and we imagine how we might cope with the worst. On the one hand his can prepare us for what tragedies may befall us. On the other it helps us to understand and appreciate what we already have.

“Take full account of what Excellencies you possess, and in gratitude remember how you would hanker after them, if you had them not.”

(Marcus Aurelius, meditations)

This is one of the ways that stoics are able to maintain emotional equilibrium when things go wrong for them. They understand that all things in life are transient and they prepare for the changes in advance – they are always prepared to ‘give back’, to ‘return’.

  1. “Never say of anything, “I have lost it”; but “I have returned it”…….

“But he who took it away is a bad man.” What difference is it to you who the giver assigns to take it back? While he gives it to you to possess, take care of it; but don’t view it as your own, just as travellers view a hotel.

  1. If you want to improve, reject such reasonings as these: “If I neglect my affairs, I’ll have no income; if I don’t correct my servant, he will be bad.” For it is better to die with hunger, exempt from grief and fear, than to live in affluence with perturbation; and it is better your servant should be bad, than you unhappy.

Begin therefore from little things. Is a little oil spilt? A little wine stolen? Say to yourself, “This is the price paid for apathy, for tranquility, and nothing is to be had for nothing.” When you call your servant, it is possible that he may not come; or, if he does, he may not do what you want. But he is by no means of such importance that it should be in his power to give you any disturbance.”

(Epictetus, The Enchiridion)

Stoics visualise the loss of the things they hold dear, They make a point of contemplating death, material losses, homelessness, hunger, injury and illness, unemployment, grief – all the unfortunate things that might happen for them. And then they imagine how they might deal with them. There are several advantages to this:

  1. Increased contentment with the things we have;
  2. Increased awareness of the things we need to od to maintain and improve our circumstances;
  3. Significant reduction in distress if the worst does happen because we’re prepared;
  4. Clear direction to deal with misfortune if it does occur;
  5. Freedom from anticipatory anxiety (worrying about what might happen).

Of course that doesn’t mean stoics need to go around reflecting upon miserable possibilities all the time. That wouldn’t do at all. But every so often, once or twice a week perhaps it’s a good idea to stop and think about what we have (health, possessions, abilities, relationships, status etc) and how it might be taken away. I promise you – make this a habit and you’ll enjoy life a great deal more. You’ll also be much more resourceful and better prepared to deal with tragedy.

Anxiety 3 stage process

In a different, less obviously philosophical context I talk to anxious, worried people about the ‘three stage plan’ for dealing with anxiety. I’ve used it for years with good effect. Once again it’s an idea stolen from the stoics. This is how I described it in one of my mental health Ebooks:

“We can also help people to plan, both should the worst happen and also how to prevent it. This becomes a fairly straightforward three-point process:

  1. What’s the worst that could happen?
  2. If it does happen how can you survive it?
  3. Now we know you can survive the worst what can you (or we) do to make sure it doesn’t happen?

Whatever else we do we must be honest, rational and realistic. Only then can we understand whether or not the anxiety, the perception of threat is justified. If it is then we can begin to work on making the situation safe with all the facts that we need. If it isn’t justified (if it’s what Freud called inappropriate anxiety) then we can have the confidence to work on activities designed to help the person to face the thing they fear.”

(Stuart Sorensen – Mental health and social care p.20)

When we take gratitude, negative visualisation and awareness of the eternal now (see yesterday’s post) together we have a powerful blueprint for dealing with anxiety and enhancing enjoyment of life as a whole. But don’t just take my word for it. Give it a go and see what happens.

The Stoic 5.1: Taking responsibility

The following is an edited version of a handout I wrote over fifteen years ago when I was still a ward based staff nurse.  It was  written for people experiencing mental health problems such as anxiety or depression. I reproduce it here in edited form because the notion of accepting personal responsibility for our thoughts, feelings and behaviours often seems alien to modern readers and yet it is vital to the task of maintaining happiness. 

The next few blog posts will consider specific thinking techniques intended to help us deal with particular types of challenge and misfortune. They all involve taking responsibility for our own thoughts, our feelings, our actions and our attitudes. So I decided to resurrect this long-lost handout as a sort of prelude. The language is modern but the principles could have been lifted straight out of the ancient writings of Epictetus and Seneca. In fact they were.

Philosophers collage 1Many people think about life as something that just happens to them instead of something that they can control themselves. They drift through life reacting to the actions of others instead of taking steps on their own behalf. Such people are like rudderless boats, completely at the mercy of the tides to take them wherever they will. They don’t know where they are going and they usually end up where they don’t want to be.

In the case of a boat on the sea, sooner or later the currents will run it aground or break it upon the rocks. Most people would agree that it would be much better if someone steered the boat past the danger and out into clear waters instead. People are just the same. If we don’t take control of the direction our lives will take we leave ourselves to the mercy of others, often with disastrous consequences.

Of course most people understand this idea, at least intellectually or as it applies to other people. It’s applying the same principle to our own lives that many of us find difficult.

The problem is that it often feels easier to leave all the decisions to someone or something else. They imagine that if they can make another person responsible for their situation or their circumstances then somehow they can be happy without having to make any effort. Unfortunately it doesn’t really work that way. We can give other people authority over us if we wish but we can never make them responsible for us, our actions or our happiness. These things can only ever be our own responsibility.

Of course this just sounds like so much ‘psychobabble’ and many people will have heard it all before – or maybe not quite all of it. Counsellors have a habit of talking about responsibility, encouraging clients to become more and more responsible, often without really explaining why. Not surprisingly, without proper explanation the message often fails to get through.

Why be responsible?

Actually there isn’t any choice. We are all responsible already for everything we do. When we try to give responsibility away all we actually do is surrender control. We still remain responsible (and accountable) for our actions, behaviours and our emotions. Yes, that’s right – even our moods.

If we give up control when we could work to keep it ourselves we are responsible for the decision to do so. We are responsible for our choice to abdicate responsibility. It’s just like a drunk driver claiming he wasn’t responsible for a fatal car accident because he was drunk. The law would (and does) argue that he was responsible before he started drinking and chose to give up that responsibility to alcohol. He remains responsible and accountable.

This is more than just a philosophical musing – it’s reality. So if we really are responsible for what we do – and by extension most of what happens to us – it makes sense to remain in control of our lives as well. After all, if we’re accountable for the choices we make in our lives then they may as well be our own choices instead of those inflicted upon us by someone else.

One major problem is that people can only realistically make choices if they believe that they have some control over their situation. The first step in accepting responsibility is to acknowledge our ability to choose. At the start of this handout we talked briefly about people who think of life as a series of  things that happen to them. These people believe they have no choices and so are unable to accept responsibility for their lives – at least until they change their way of thinking.

Of course this is easier said than done. If we accept that we have choices and responsibility now then we must also accept that we had choices and responsibility in the past. This leads some people to feel extremely guilty about the way they’ve behaved before. If they allowed their lives to become traumatic by inaction, possibly with unpleasant consequences for others as well as themselves, it may seem easier to go on believing that they had no option, no control and so no responsibility. This way of thinking is often no more than a convenient lie we tell ourselves to avoid guilt.

Another way to think about past mistakes is to acknowledge them for what they are. We are all born with no idea about life or the way to keep ourselves happy. As we get older we learn from experiences and change our strategies for living. Part of this experience is that we make inevitable mistakes. This is not only our right it’s unavoidable. It’s part of being human.

Responsibility

Whenever you are faced with a problem, be it emotional or practical, take a deep breath, focus your thoughts and remind yourself that you are responsible. Then ask yourself what you intend to do about it. This may involve something designed to change the situation itself or simply to alter the way you feel about it. Remember that there are always options and choosing to give up your own choices usually isn’t the best course of action

You may need to learn new skills. Many people find that assertiveness training is of enormous benefit in helping them to regain control of their lives. So is emotional management training of one kind or another.

Stop waiting for other people to solve your problems for you. In most cases they can’t – not entirely. Other people may be able to change your immediate situation but they probably can’t prevent difficulties from arising again. Then you’ll find yourself in the same old position of needing to find someone willing to come and pick up the pieces again. The problem of dependence hasn’t altered.

Taking time to learn the skills you need to solve your own problems usually works much better in the long run.

You are responsible.

What are you going to do about it?

The Stoic 4.2: Stoic joy

In the last post I made the point that stoics are more likely to experience pleasure than non-stoics. Having stuck my neck out with that statement I think it’s only fair that I explain. There are two basic parts to this explanation. Both are related to what we know about human misery from modern therapy. They’re also related to what the ancients knew because the same insights prevail in both Stoic philosophy and modern therapy. The two basic ideas are…

  1. We need no excuse to be happy.
  2. Happiness is undermined when the world doesn’t meet our expectations.

It’s truly remarkable how many people in today’s world seem to think that they need a reason to be happy. They have no problem feeling good when good things happen. But until some positive cause for celebration comes along, or perhaps some agreeable event such as a night out or a family holiday, they retreat into a sort of emotional neutrality. The situation has become so bad that naturally cheerful people, whilst popular because of their positive impact upon others, are seen as an unusual ‘breath of fresh air’. It may surprise you to know that some of those ‘naturally cheerful’ people just might be stoics.

“For what prevents us from saying that the happy life is to have a mind that is free, lofty, fearless and steadfast – a mind that is placed beyond the reach of fear, beyond the reach of desire, that counts virtue the only good, baseness the only evil, and all else but a worthless mass of things, which come and go without increasing or diminishing the highest good, and neither subtract any part from the happy life nor add any part to it? A man thus grounded must, whether he wills or not, necessarily be attended by constant cheerfulness and a joy that is deep and issues from deep within, since he finds delight in his own resources, and desires no joys greater than his inner joys.”

Seneca, The Stoic Philosophy of Seneca: Essays and Letters

Interestingly, many people who think they need a reason to be happy have no difficulty at all feeling miserable, bored, dissatisfied or otherwise discontented. It’s as though their default setting is misery – the way they feel UNLESS something happens to boost their mood. And they call stoics miserable!

One of Stoicism’s greatest benefits is the realisation that happiness, even joy is always within our reach. We don’t need to wait for the world to deal us a happy hand. We can be content, happy, even ecstatic irrespective of events. But first we need to understand what is truly ours to control. This leads us to the second of today’s principles. The one about expectation.

Take a moment to reflect upon the things that you get angry or upset about. Without exception they are the things that you judge either as wrong, unfair or contrary to expectation. It’s the unexpected that upsets us most. So – stoics work hard to change their expectations.

The first task here is to understand what is ours to control and what is not. In The Enchiridion, a short guide to Stoicism, Epictetus begins….

Enchiridion“Some things are in our control and others are not. Things in our control are opinion, pursuit, desire, aversion, and, in a word, whatever are our own actions. Things not in our control are body, property, reputation, command, and, in one word, whatever are not our own actions.”

Concentrate only upon what you can control. Take charge of your thoughts, your feelings and your behaviours – in reality that is all you are able to control. That being so it’s both foolish and unreasonable to try to take charge of those things that are not yours to command. It’s an attempt to do the impossible. That’s why control freaks are so unhappy so much of the time. They’ve set themselves up for perpetual failure and distress

Once we accept that the world doesn’t do our bidding, that other people have their own choices to make and that we are not in charge of their decisions and behaviours we can be honest about what to expect.

As Marcus Aurelius put it in ‘Meditations’…

“Today I will meet with opposition, ingratitude, arrogance, betrayal, anger and self-love – and they are all caused by ignorance of the offenders, their inability to distinguish good from evil.”

We all understand that the world is full of misfortune, unfairness and injustice. We know that others will treat us badly and that ‘into each life a little rain must fall’. Indeed – the wise man expects that misfortune and unfairness will befall him and those he cares for from time to time.

As we become used to this fact of life we can begin to accept these things without surprise and concentrate upon our responses to them (the things we can control). The alternative is to waste our energies worrying about the actions of others. Actions which are theirs to manage, not ours. After all, the more energy we waste trying to control the external world (which is impossible) the less energy we retain to choose our own reactions. And it’s the way we react that determines our mood.

“If you are distressed by anything external, the pain is not due to the thing itself, but to your estimate of it; and this you have the power to revoke at any moment.” Marcus Aurelius, Meditations

So the first thing is to accept what we cannot control and expect the full range of possibilities, good and bad, constructive and destructive because that’s what the world does. I recently had a conversation with a colleague at work. He was angry because of an incident of child neglect involving someone on his caseload. Whilst I fully understand the reasons for his anger I don’t think that it was at all necessary.

He knows the world contains child neglecters, just as he knows that the world contains rain. When it rains we put on coats. When people neglect children we protect the youngsters. Both these situations are expected in life and both require a response. Neither are made any easier to deal with by becoming angry. Actually I can’t think of a single situation that was improved by my becoming upset.

Meditations extract

So – Stoics manage their expectations. We accept that we cannot control anything beyond ourselves, we maintain an awareness that the world provides a range of experiences, not all of which are pleasant, and we focus upon responding well rather than upon lamenting that which we could not avoid in any case. And when we respond well we can take joy from that. However negative the situation itself may be, a job well done on our part is a cause for celebration. It’s even possible to delight in misfortune – or at least to delight in the fact that we didn’t allow the  misfortune to perturb us.  After all, how else will we get the chance to practice our stoic resolve except in response to misfortune?

When we put all this together we have a recipe for ‘Stoic joy’ that really does work…

  1. Allow happiness as the default.
  2. Be joyful for no particular reason. It’s enough that we are alive and able to be joyful.
  3. Focus only upon that which we can control.
  4. Expect the world to throw us the odd ‘curve ball’.
  5. In difficult times concentrate upon responding – not upon lamenting.

SH 4: Responding to people who harm themselves

Welcome to this mini blog series on self-harm. It’s by no means intended to cover all aspects of self-harm and the support that can be offered to those who use this particular coping strategy rather than any other. It is intended to dispel just a few of the more common myths surrounding people who self-harm and to provide some very basic pointers for those who work with them.

The mini-series covers:

  1. Socially acceptable self-harm
  2. Clinically significant self-harm
  3. Self-harm as a response to trauma
  4. Responding to people who harm themselves

Responding to people who harm themselves

Working with people who hurt themselves can be a confusing and bewildering experience. It is often extremely frustrating and distressing for the staff who may well be at a loss to understand why their resident keeps on injuring themselves. Traditional views about ‘manipulation’ or a ‘cry for help’ may bring some limited sense of explanation but they do little or nothing to help prevent future self-harm. This article explores some alternative notions about self-harm and examines ways that workers can make a difference in a genuinely difficult situation.

First of all bear in mind that you are not alone. No single person can do everything. Whilst self-harm does not necessarily lead to suicide these things do happen and it’s always a good idea to liaise with other, specialist professionals. A decent GP, Psychiatrist or community psychiatric nurse will be worth their weight in gold. It is important that you and the resident, together with input from other professionals, perform a thorough risk assessment. Agree how to manage future problems and when to seek outside or emergency help.

All that aside though, there is much that workers can do on their own.

A resident’s ability to manage is greatly enhanced by good support from their surroundings and social group. In supported housing this means that the staff can influence significantly the resident’s coping skills.

Back in the 1950s George Brown began studying the effects of families and social groups on coping and mental health. This research led to the concept of ‘High Expressed Emotion’. A few decades later in the USA Marsha Linehan came up with the concept of the ‘Invalidating Environment’. Both these concepts outline the ways in which certain types of interaction increase stress, reduce coping and lead to the conditions which encourage psychological and behavioural problems including self-harm.

These include:

High Expressed Emotion

  • Aggression and hostility
  • Criticism
  • Emotional over-involvement

The Invalidating Environment

  • Erratic, inappropriate responses from significant others to the individual’s thoughts, beliefs and emotions.
  • Oversimplifying the ease with which problems can be solved.
  • Blaming the individual for not solving difficulties with ease.
  • A chronic and classical ‘double bind’ scenario in which the individual cannot ‘win’ whatever he or she does.

It clearly would be inappropriate for all workers to undertake full-scale psychotherapy. However, attention to the concepts of expressed emotion and the invalidating environment is appropriate for us all to take on board and can make a huge difference. Remember that befriending is an extremely effective method of supporting people, with or without external therapy.

I hope that by now as we reach the end of this series it is clear that self -harm is likely to represent a coping strategy. For many people it is the only effective strategy they know. Often in training sessions I use the analogy of a small child in a sweet shop. They can have anything they want but there’s a problem. The lights are turned off and all they have is a small ‘pen’ torch – the kind with a very narrow beam that only illuminates a small are of the shop.

Whatever they can see in the torchlight they can have but it’s a very limited choice because most of the sweets on display are in darkness. They’re effectively invisible. Clearly the child will choose from very limited options – not because the other sweets aren’t available but because he doesn’t know about them.

In one sense this is what it’s like for people with limited coping skills. The other coping strategies are available to them but they don’t know about them or they don’t believe that they will work. The coping strategies are the sweets in the shop in other words and your job is to turn the lights on.

Don’t waste time attacking the only coping strategy the service-user knows. That is unlikely to succeed and, quite frankly you wouldn’t want it to. If you remove the only coping skill a person has then they may see no alternative but suicide. It is no coincidence that service-users who harm themselves are around 50 times more likely than the general population to kill themselves.

“About 3 in 100 people who self-harm over 15 years will actually kill themselves. This is more than 50 times the rate for people who don’t self-harm. The risk increases with age, and is much greater for men.”

Royal College of Psychiatrists leaflet: ‘Self Harm’

www.rcpsych.ac.uk

Instead acknowledge the benefits of self-harm as discussed earlier and then work on discovering and experimenting with other, less injurious methods of dealing with stress. It may well be that to begin with this will amount to nothing more than some slightly less injurious methods of self harming but this is a step in the right direction. Build upon what you can and remember that Rome wasn’t built in a day.

Overt criticism of the service-user is likely to create a barrier

between you that may never come down again.

The chart below outlines some of the things support workers can do to support people who self-harm and suggests responses to likely situations.

SH Do and Dont

You can download a PDF version of the whole four post series here Self Harm mini series by The Care Guy

SH 3: Self-harm as a response to trauma

Welcome to this mini blog series on self-harm. It’s by no means intended to cover all aspects of self-harm and the support that can be offered to those who use this particular coping strategy rather than any other. It is intended to dispel just a few of the more common myths surrounding people who self-harm and to provide some very basic pointers for those who work with them.

The mini-series covers:

  1. Socially acceptable self-harm
  2. Clinically significant self-harm
  3. Self-harm as a response to trauma
  4. Responding to people who harm themselves

Self-harm as a response to trauma

Before we go any further let’s acknowledge the thing we’ve been neglecting throughout this series. Some people harm themselves to get a response from others. However they are not the majority. In fact, most people who harm themselves for the benefit of others or to get a reaction of some kind tend not to repeat the experience very often – or their self-harm is very superficial. If you want attention there are many less harmful behaviours that will achieve the same result without the pain. Shouting and stamping your feet or undressing in public for example. There are many ways to get a response without resorting to overdosing or extinguishing cigarettes on your skin.

Contrary to popular belief, self-harm is not usually an attempt to manipulate others. Nor is it usually a ‘cry for help’. Most people are quite able to ask for help without self-harming and the secrecy that often accompanies self-harm demonstrates that something else is going on.

Many people, particularly many of those diagnosed with Post-Traumatic Stress Disorder or Borderline Personality Disorder experience emotions in a particular way. When under pressure they may find it impossible to make sense of what they feel. It’s as though they experience all emotions at the same time but no single emotion in particular. This, understandably enough, is difficult to bear.

One way to ‘reset’ the emotional balance is through physical pain. Self-harm prompts the brain to produce endorphins, a kind of natural opiate, which overcomes the motional turmoil and allows the person to feel better. So when a distressed person self-harms it’s entirely possible that they’re feeling stressed and overwhelmed. It doesn’t matter how stressful others believe their situation to be. Different people have different coping abilities and what may be no problem at all for one person might well overwhelm another.

The key to understanding this process is by looking a little (and only a little) at the body’s response to trauma. The endorphins mentioned above are very similair in effect to opiates such as heroin although the effect may be milder. The result is a state of euphoria (a pleasant, almost dreamy state) that overturns the dysthymia. That’s why in an earlier post I (very briefly) likened the effects of self -harm to the effects of illicit drug use and why it may not be quite so valid to think of addiction and self harm as very different processes.

Incidentally the same endorphins are produced when the body is subject to other types of stressors such as over exertion and this explains why some people become psychologically addicted to exercise. It’s not the purpose of this series to explore eating disorders in any detail but it is significant that the exercise regimes that people diagnosed with anorexia nervosa often employ carry the same endorphin-related response. There is also a very real statistical correlation between the diagnoses of Borderline Personality Disorder and Anorexia with many people receiving both diagnoses at the same time. Of course there’s a ‘chicken and egg’ argument here as there is with all the personality disorder diagnoses but it’s interesting none the less.

Many people who self-harm do so during a state of dissociation. This isn’t so surprising given what we know about dissociation already and the link to overwhelming emotional trauma. The adult who learned to dissociate from trauma as a child will do so when stressed. They dissociate away from the dysthymia but they still need to ‘reset the balance’ as we outlined earlier. So dissociation and self-harm often go hand in hand.

This provides a stereotypical pattern (although not everyone follows it) that goes something like this:

  1. Distress
  2. Dissociation
  3. Self-Harm
  4. Euphoria

I know of several people who cannot remember the act of self-harm at all. This is because they have dissociated away from the trauma before they harm themselves. Only when the ensuing euphoria wears off do they notice the self-inflicted wounds and realise what they have done. This is why the NICE guidelines make the distinction that not all self-harm is deliberate. It is difficult to say that an act is purposeful when the individual is in a dissociative state at the time.

In Dialectic Behaviour Therapy one of the key skills is ‘mindfulness’. This is a technique specifically taught to help people to ‘remain present’ and not dissociate away from their situation. It’s a simple technique in theory involving people taking note of the minute details of their surroundings and consciously cataloguing them in their minds. I describe it as simple in theory because in practice it takes a fair amount of training to develop the skill – the pull to dissociate is so strong. The point here is that more often than not self-harm is a response to trauma and stress. It’s ironic then that the judgemental attitudes of some care workers actually recreate the emotional turmoil (that the service-user has just dealt with) by reacting in overly hostile or critical ways to the only coping strategy the self-harmer knows.

Extreme criticism simply recreates the invalidating environment

that may well have caused the problem in the first place.

There is a more appropriate and more helpful way to respond to people who self harm and that will be the focus of the next post.

You can download a PDF version of the whole four post series here Self Harm mini series by The Care Guy

SH 2: Clinically significant Self Harm

Welcome to this mini blog series on self-harm. It’s by no means intended to cover all aspects of self-harm and the support that can be offered to those who use this particular coping strategy rather than any other. It is intended to dispel just a few of the more common myths surrounding people who self-harm and to provide some very basic pointers for those who work with them.

The mini-series covers:

  1. Socially acceptable self-harm
  2. Clinically significant self-harm
  3. Self-harm as a response to trauma
  4. Responding to people who harm themselves

Clinically significant Self Harm

As we have seen some forms of self-harm are more socially acceptable than others. The specific delineation between ‘acceptable’ and ‘unacceptable’ changes as society evolves. A topical example of the way that society’s tolerances change relates to smoking. Twenty years ago this form of self-harm was completely acceptable. Today society has a rather uneasy relationship with the habit. It may be that in just a few more decades it will be just as socially unacceptable as opium use is today – a state of affairs that would have been very hard for our Victorian forebears to understand.

For today though Self Harm is generally considered to mean physical injury or ingestion of substances, prescribed or otherwise, that harm the person.

According to the National Institute for Clinical Excellence (NICE)(2004) self-harm means:

“self-poisoning or self-injury, irrespective of the apparent purpose of the act”.

http://www.nice.org.uk/nicemedia/live/10946/29424/29424.pdf

The words ‘irrespective of the apparent purpose of the act’ seem reasonable in that the body doesn’t know how many tablets are supposed to be harmful and so whatever the reason for taking 20 sleeping tablets, even if you just want a good night’s sleep, the harm is real and should be taken seriously by clinicians.

Unfortunately the NICE guidelines go on to confuse the issue and the document appears to contradict itself a few sentences later:

“The guideline focuses on those acts of self-harm that are an expression of personal distress and where the person directly intends to injure him/herself. It is important also to acknowledge that for some people, especially those who have been abused as children, acts of self-harm occur seemingly out of the person’s control or even awareness, during ‘trance-like’, or dissociative, states. It therefore uses the term ‘self-harm’ rather than ‘self harm’.”

http://www.nice.org.uk/nicemedia/live/10946/29424/29424.pdf

This seems to be an attempt to get past the problems with definition, acceptability and unacceptability we outlined earlier. The statement is contradictory because society’s attitude is contradictory and the closer we look at self-harm the more we see the double standard.

Still, at least the guidelines do acknowledge that self harm is often a response to distress

The most common reasons given were ‘to get relief from a terrible state of mind’ followed by ‘to die’, although there were differences between those cutting themselves and those taking overdoses. About half the young people decided to harm themselves in the hour before doing so, and many did not attend hospital or tell anyone else. Just over half those who had harmed themselves during the previous year reported more than one episode over their lifetime.”

Journal of Child Psychology and Psychiatry

Volume 49 Issue 6, Pages 667 – 677

Published Online: 10 Mar 2008

Journal compilation © 2008 ACAMH

Some people who self-harm will describe the urge, the impulse to harm themselves as though it was an addiction. I don’t want to get too deeply into a discussion of addiction as a reason for self-harm here because that will only cloud an already confused issue of definition. All I will say is that there is an assumption that addiction to a chemical is treated differently from self-harm even though in many cases the actual chemical effect of causing physical trauma is directly comparable to the effects of illicit substance use.

It has been said that the main problem associated with Self-harm is not the physical damage itself so much as the stigma that surrounds it. Personally I don’t think that this is true – at least not in every case but there is certainly a major issue with stigma and the attitudes of some workers toward people who harm themselves.

Much of the stigma comes from the many myths and misconceptions that abound among professionals and the public alike about the reasons behind Self Harm. I remember as a student nurse in the early 1990s being fed these same myths by nursing and medical staff. The failure to see past our own perceived importance as professional ‘experts’ was rife and it led to some extremely damaging and cruel approaches to people who harm themselves. Let’s look at some of the more common misconceptions.

Perhaps one of the most common myths is to do with the notion of the ‘cry for help’. The idea is that by cutting or otherwise injuring themselves clients are trying to get some sort of assistance from services. If this is true then as professionals working in the field we need to ask ourselves some very difficult questions such as……

  • Do these people really not know how to ask for help?
  • If not – why not?
  • What sort of help can I offer them that is worth self-mutilation in order to achieve it?
  • Am I really that special?
  • How good am I at noticing people’s distress if they need to resort to self-harm to get my attention?
  • What’s wrong with our access policies?
  • How good are my listening skills?
  • How ‘accessible’ am I if people can’t just talk to me and ask for what they want?
  • What does this say about me as a professional and as a person?

Another myth is that self harm is an attempt to manipulate or emotionally blackmail professionals.

  • Do we really believe ourselves to be so important that people will mutilate themselves just to influence our thoughts, feelings and behaviours?
  • Is self-harm really all about us as professionals or is it more to do with the personal needs of the client?

Then there is the good old ‘attention seeking’ myth. It doesn’t take a genius to work out how inaccurate such an assumption is likely to be when we understand that the vast majority of self-harm is done secretly and in private.

“Since many acts of self-harm do not come to the attention of healthcare services, hospital attendance rates do not reflect the true scale of the problem.”

Self Harm

The British Psychological Society

& The Royal College of Psychiatrists, 2004

What we do know is that the incidence of clinically significant Self Harm is rising in UK.

“Although the prevalence statistics are not as reliable as one would like, there is no disputing the fact that self-harm has increased markedly in the UK in recent years. Indeed the rate of self-harm in the UK is amongst the highest in Europe”

The Psychologist

Vol.18 – Part 7 – July 2005

Although there is an undoubted ‘crossover’ population of people with a diagnosis of Emotionally Unstable Personality Disorder (especially EUPD: ‘Borderline type) who also engage in Self Harm, we also know that it is unhelpful to assume the diagnosis. It is even more unhelpful to focus upon diagnosis rather than the actual, lived problems that the human being before us is experiencing. Problems exist irrespective of diagnostic labels and psychiatric classifications.

“Certain psychological characteristics are more common among the group of people who self-harm, including impulsivity, poor problem-solving and hopelessness. Also, people who self-harm more often have interpersonal difficulties. It is possible to apply diagnostic criteria to these characteristics. This explains why nearly one-half of those who present to an emergency department meet criteria for having a personality disorder. However, there are problems with doing this because:

  • There is an unhelpful circularity in that self-harm is considered to be one of the defining features of both borderline and histrionic personality disorder.
  • The diagnostic label tends to divert attention from helping the person to overcome their problems and can even lead to the person being denied help (National Institute for Mental Health in England, 2003).
  • Some people who self-harm consider the term personality disorder to be offensive and to create a stereotype that can lead to damaging stigmatisation by care workers.”

Self Harm

The British Psychological Society

& The Royal College of Psychiatrists, 2004

Ironically it seems that this trend of increasing self-harm might actually be the result of society’s angst over the issue. One interesting theory about the rise of self-harm, particularly among the young is that by raising awareness and normalising the behaviour well-meaning campaigns are creating an environment that encourages it:

“In my view, as long as self-injury is discussed as a common and legitimate expression of distress amongst students and young people, and as long as the behaviour is normalised and publicised through awareness initiatives, people will increasingly turn to this very behaviour as a way of communicating and relieving their discomfort. We must therefore seek to question the necessity for, and challenge the usefulness of, such campaigns, and ultimately ask

‘Is awareness making us ill?’ ”

Crowley R.

The Psychologist

Volume 20 – Part 5

May 2007

Whether we agree with Crowley (above) or not it is clear that talking about self-harm doesn’t really change anything. If we accept that the task of mental health and social care workers is to encourage the development of new coping strategies then endless discussion about existing strategies serves no practical purpose. We need to focus upon finding alternatives, upon exploring the new, not upon revisiting the old.

You can download a PDF version of the whole four post series here Self Harm mini series by The Care Guy

SH1: Socially acceptable self-harm

Welcome to this mini blog series on self-harm. It’s by no means intended to cover all aspects of self-harm and the support that can be offered to those who use this particular coping strategy rather than any other. It is intended to dispel just a few of the more common myths surrounding people who self-harm and to provide some very basic pointers for those who work with them.

The mini-series covers:

  1. Socially acceptable self-harm
  2. Clinically significant self-harm
  3. Self-harm as a response to trauma
  4. Responding to people who harm themselves

SH1: Socially acceptable self-harm

Look at the list of activities below. Give yourself one point for each behaviour you indulge in. Give yourself an additional point for each behaviour you indulge in when you’re stressed or under pressure:

acceptable SH chart

There’s no scoring matrix to match your score against and there are no deep psychological insights into your temperament and personality to follow. I simply want to make the point that these are all coping skills and they all have a couple of things in common:

  • They all are designed to make us feel better;
  • They all create their own problems and are in some way harmful to us.

Many of us respond to stress by doing things that damage us in the long term (or even the short term) but that briefly allow us to feel better or to forget our troubles for a while. Psychologists call these activities ‘safety behaviours’. They give the illusion of safety or security but tend to make things worse in the long term. They are a remarkably common aspect of human coping.

When we look at the more extreme forms of these self-damaging behaviours such as violence or over indulgence in intoxicating substances such as alcohol it is easy to see the folly. Yet these behaviours are just the extreme end of a continuum, a ‘sliding scale’ if you will of self injury with a cream cake at one end and a razor blade at the other.

Self-harm then is widespread throughout Western society as a coping strategy – a response to stress. Why then are some forms of self-injury, heavy drinking for example more acceptable than others such as self-mutilation?

Actually they’re not necessarily. For example in the ‘EMO’ culture among young people (I still want to call them ‘Goths’) self-harm through cutting for example is much more acceptable than aggression and violence.

“About 1 in 10 young people will self-harm at some point, but it can occur at any age. It is more common in young women than men. Gay and bisexual people seem to be more likely to self-harm.

Sometimes groups of young people self-harm together – having a friend who self-harms may increase your chances of doing it as well. Self-harm is more common in some subcultures – ‘goths’ seem to be particularly vulnerable.”

Royal College of Psychiatrists leaflet: ‘Self Harm’

www.rcpsych.ac.uk

However in the West Cumbrian, working culture of the 1970s in which I grew up the reverse was true. As a young man I would never have dreamed of taking a razor blade to my arm but I’d think nothing of settling my problems with my fists. I’m happy to say that I’ve since changed my attitude to violence but the point still stands. Every culture and sub-culture has its own acceptable forms of self-harm in response to stress although some of them are more ‘diagnosable’ than others.

Some groups actually use self-harm, and the scars associated with it as a kind of ‘badge of honour’. It’s as though self-harm has become the ‘price of admission’ and social acceptance just as the ability to hold your own in a fight or to drink more than the next man defines group identity in other circles. In the EMO culture I mentioned above self-inflicted wounds and scars can be thought of as evidence of emotional sensitivity and in that sense they are just as valid as the intricate scarification and body modification found in some isolated Amazonian tribes – not to mention the West coast of the United States.

However there are two significant problems with this rather liberal understanding of self-harm:

  • Like most mental health classifications self -harm can legitimately be considered from a wider cultural context and the majority of people in Western culture consider it to be inappropriate, at least in the more clinically defined versions of self harm;
  • Self-harm creates genuine injury and as such it is reasonable for clinicians and others to consider it a problem.

However the fact that you or I might consider self-harm to be a problem does not automatically mean that our service-users will agree. Any intervention that does not acknowledge the sub-cultural acceptability and even benefits of self-harm is likely to fail.

You can download a PDF version of the whole four post series here Self Harm mini series by The Care Guy

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