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’

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

The mental health workers’ audio guide – now available

It’s been a while coming but The mental health workers’ audio guide is now available for purchase from The Care Guy shop for less than the price of a lunchtime sandwich. The first 4 of 6 parts are already available and the final two will be out soon. Scroll down to view the contents of each instalment.

You can The Guide parts 1-6 accompanying tables and references containing the contents list for all 6 parts, various diagrams and charts as well as references here……


Part one – clinical basics

What’s a mental health worker worth?

Three models of mental health and disorder

The biological (medical) model

The social model

Merging the two (stress and vulnerability)

The importance of physiology

The meaning of psychiatric diagnoses


The psychology of anxiety


The psychology of depression

Psychosis (introduction)


Delusions part 1

Delusions part 2

Thought disorders

Part 1

Part 2 – The dementias

The dementias

Types of dementia – Alzheimer’s

Types of dementia – Vascular

Types of dementia – Lewy Body

Types of dementia – Parkinson’s

Types of dementia – Korsakoff’s

Types of dementia – Fronto-temporal

Types of dementia – Mixed

Orientation and memory


The CAM scale

Working with the limbic system


Part 3 – Personality and recovery

Personality disorder

High Expressed Emotion

Sympathy is not usually helpful

More on the Stress & Vulnerability model of mental health and disorder

The invalidating environment

The Self-fulfilling prophecy

The meaning of recovery in mental health

The three types of recovery


Part 4 – In practice

Duty of care: A slug in a bottle

‘Hanged if you do, hanged if you don’t’ – a duty of care myth

There is no ‘us and them’

People are just people

Coping skills develop slowly

Lapse is different from relapse

Don’t expect your service user to perform perfectly.

The word ‘support’ is meaningless in and of itself

“It’s just behavioural” (A workers’ excuse for lazy thinking)

Challenging behaviour means….

Behaviours that harm the individual

Behaviours that harm other people

Do we need help?

Consequence, learned behaviour and the need for boundaries

Maintaining the problem

The whole team approach

Firm Boundaries

No ‘Pedestals’ and Staff Safety

Effective, Consistent Care

‘Corporate’ Identity – “You’re All The Same.”



Part 5 – risk issues


Self-harm as a response to trauma

Responding to a person who harms themselves

Individual v Organisational risk (Risk-free is impossible. Manageable risk is the way to go)

Don’t flap (more haste – less speed)

The saviour fantasy

You’re probably not an emergency service – don’t try to behave like one


Part 6 – Thinking styles

Unhelpful thinking

Ignoring the positive

Exaggerating the negative



Arbitrary inference


Selective abstraction

Global thinking

Dichotomous thinking

Magical thinking (the Wizard did it)


Socratic dialogue and ‘the razors’.

The sticks we use to beat ourselves

Who put us in charge?

Final words

Models of mental health and disorder

The world of mental health care can be confusing – especially for those new to the topic. Often the different theories and professional approaches seem to contradict each other. It’s almost as though different workers speak different languages,

That’s not quite true but they do often come from different theoretical perspectives. That’s why, for example, a social worker and a psychiatrist will give you two completely different explanations for the same person’s problems. They’ve been taught radically different ‘models’ that they use to understand mental health and disorder, its causes and its treatments.

This little table isn’t intended to cover all the different models in depth. Instead think of it as a very basic list of models that can guide you in understanding why people focus upon different things. There’s more to it, of course but it’s a start for newcomers trying to get to grips with the contradictions they come across in practice.

The Care Guy Models of mental health and disorder

Meet the overzealous Mr Selous

Andrew “the overzealous” Selous MP is Ian Duncan Smith’s Parliamentary Private Secretary (PPS). He also seems to be a bit confused. Arguably confusion is to be expected since he cherry picks his ideas of right and wrong from an ancient book with a moral compass that points straight back to the bronze age.

Yet with such a public assertion of faith you’d think he’d have read at least parts of the Bible before taking public office.

His confusion over dyed in the wool biblical issues like gay rights seems very odd. He voted strongly against equal rights for gay people and yet vaccilated about gay marriage. Could it be that his 20th century conscience has been pricked a little despite the ‘ancient wisdom’ of a small group of desert nomads?
Andrew Selous MP social issues voting record
Unfortunately he has had no such fit of conscience in relation to homelessness. This is odd in itself considering that his entry for the SW Bedfordshire Conservative Home website reports a keen interest in homelessness and participation in sponsored sleepouts for homelessness charities.

He supports local homeless charities by taking part in annual sponsored sleep-outs.”

Perhaps though his interest is more about keeping homeless numbers up than about helping the homeless themselves. Perhaps his annual sleep out is no more than a form of penance intended to assuage the wrath of God in payment for his other homelessness related activities.
Andrew Selous MP voting record
As if his voting record wasn’t enough to demonstrate his abusive, pathological need to increase poverty and homelessness he recently attacked that other bastion of his Christian faith, the Trussell Trust. And yet even here he seems confused. Speaking about his local foodbank he said:

“I have been a supporter of Foodbank for many years. Working in addition to the welfare system, Foodbanks have been proven to help turn people’s lives around which is why I think so highly of them”

Andrew Selous, Local Constituency MP

And then he goes and does this:
Andrew Selous MP
It seems that the Right Hon. Andrew Selous MP is fine with his own receipt of taxpayer funded nourishment but not too keen on charitable organisations that provide sustenance to people who really are in need. Especially when those organisations, such as The Trussell Trust have the audacity (some might say ‘sense of fairness and social justice’) to question why so many UK citizens are so desperately hungry in the first place.

Apparently asking questions about hunger and trying to do something to change the situation is ‘too political’. I’d have thought that for someone with such a publically professed Christian faith he’d have heard about ‘the sermon on the mount’ and ‘the beatitudes’ with its list of ‘blessed’ individuals. But let me remind the good Mr. Selous of another familiar bible quote:

“Whatsoever you do unto the least of my brethren, do you also unto me.”
Matthew 25:45

It’s going to take more than the occasional night out of doors to make up for this catalogue of oppression Mr. Selous. Not least because, as the good book says….

You shall know them by their deeds.

Care to share magazine issue 7

Just a reminder. Care to share magazine issue 7 is out today as a series of blog posts or downloadable PDF.

Get your free copy here.


Mental Health and Social Care

Don’t forget about my other book – also available from The Care Guy website.

MH and SC simple lessons meme

This easy to follow book has been written with social care support workers in mind. It’s jargon free and packed with reflection points, tips and exercises to guide you through the social care process from basic principles to support planning and relapse profiling. What’s more – it only costs a tenner. You can download a sampler here.

The author, Stuart Sorensen has many years experience of working in mental health and social care. Drawing on past experience of ‘real world’ care services he boils down the complicated theory of mental health care into the fundamental principles of best practice. The result is an easy to follow book that explains what mental disorder is, what recovery really means and what social care staff can do to help

Behaviours that challenge

It’s taken me a while to finish this but my new book ‘Behaviours that challenge’ is now on sale on The Care Guy website. Only a tenner plus P&P.

Go on, you know you want to


Often the advice given to social care workers about behaviours that challenge makes their problems worse instead of better. This easy to follow workbook is full of no nonsense tips, techniques and ideas for dealing with the behaviours YOU face at work (and at home).


Introductory questionnaire
What is Challenging Behaviour?
Legal principles
Theories of behaviour and interaction
Different types of Challenging Behaviours
Its only behavioural
Philosophy and challenging behaviour (rights, paternalism and intervention – people are just people)
Assertiveness – as opposed to aggression, passivity and passive-aggression
Assessing behaviour – ABC, the Pleasure Principle, lessons from research
Basic behavioural management – classical and operant conditioning, reinforcement, gradual progression
Boundaries and the escalation or recession of inappropriate behaviours
The importance of the whole team approach
The problem with punishment
Answers to safeguarding quiz


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