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Midlen
the main difficulties working psychologically with people who…
the main difficulties working psychologically with people who self-harm or who are suicidal, with reference to best practice and research in counselling and forensic psychology.
What thoughts and feelings could be brought up in you when working with clients who self-harm?
Expain as per below info:
definition of self harm and suicide, and fact/ figures
so whats is best practice
what research tells us
Logan(2013)argues that paper exercise approach taken to risk assessment
death in custody
Logan 2013- each person needs to be assessed as a unique individual
study of self harm prevalence by Hawton et al. 2014
A simple definition provided by the NHS describes self-harm as any ‘intentional damage or injury that we cause to ourselves. It is usually a way of coping with or expressing overwhelming emotional distress’ (NHS Choices, 2017a).
Self-harm, very complex behaviour that can hold a number of different meanings- James and Samuels, 2018
Most common reason for self harm is to manage emotions
Best practice -needs to be seen as coping strategy with personal meaning not seen as mental illness ( James and Saumuels, 2018)
All Logan , 2013- sudden changes in circumstances can be a trigger
much suicidal behavior is driven by anger as much as despair- by Pilgrim, 2023
the most high risk clients are dual diagnosed with severe mental problems and substance use disorder – by Logan, 2013
Self harm is linked to problematic anger management and impulse control by james and Samuels , 2018
The World Health Organisation (WHO, 2016) defines suicide as, ‘the act of deliberately killing oneself’, while De Leo et al. (2006, p. 12) offer a definition as ‘an act with fatal outcome, which the deceased, knowing or expecting a potentially fatal outcome, has initiated and carried out with a purpose of bringing about wanted changes’.
Reeves (2013) offers a summary of the key aspects of self-harm/injury that capture a broader array of behaviours. Self-harm/injury can:
be directed against the body (e.g. cutting, burning), which might be termed as self-injury
include behaviours without immediate impact, such as eating disorders, risky sexual behaviour
be planned and form part of a habitual pattern, or may be unplanned and spontaneous
be about coping, living, surviving and self-worth
have a relationship with suicide potential, particularly in the context of other risk factors.
Cohen (1985), have argued that medical interventions can lead to the very real risk of unintended consequences occurring, such as increased stigmatisation and unnecessary compulsion/treatment under mental health legislation
Lorentzon (2005) point out that conversely the act of suicide can also be conceived as an act of taking control amid a life that is experienced as out of control.
Indeed, scholars such as Thomas Szasz (see, for example, Szasz, 1997) have opened rich debates on the territorial parameters of psychiatric and medical power, while at the same time actively working as a psychiatrist.
In the UK, suicide was decriminalised in the 1961 Suicide Act and while there is not a general duty to report concerns of potential suicide,
2005 Mental Capacity Act in England and Wales and the 2000 Adults with Incapacity Act in Scotland) concerning capacity that informs practitioner decisions concerning risk. These Acts are based on the principle that adults have the right to self-determination, including the right to die through suicide, if they have the capacity to do so. However, practitioners can act to protect the well-being of the client if a contract with a client is established at the outset of therapy, which limits confidentiality with regards to the risk of suicide
Bond and Mitchels (2014) offer some helpful guidance (see Information box 18.1).
However, it must be noted that NICE state the following regarding the scales involved in such risk assessment: ‘The sensitivity and specificity of these scales are, at best, modest’ (NICE, 2011, p. 29).
Below are some of the factors we identified:
Gender: male
Age: 53 and so in the age group where suicide is most prevalent
Loss of employment
Loss of relationship
Loss of home
Limited social support
Increasing use of alcohol to cope
Expressed suicidal thoughts.
in addition to following ethical guidance of respective professional associations, practitioners can also work to a number of principles to help ensure they remain in therapeutic connection with their clients (Reeves, 2015):
Therapists must be qualified (or in advanced training) and drawing on a core theoretical model (or an integration of models) to support their practice.
Regular supervision must be in place, meeting at least the minimal requirements of supervision set by their professional body.
Therapists must work within the context of a clear ethical framework.
Therapy must be carefully contracted, including clearly setting the boundaries around time, availability between sessions and the limits of confidentiality, in this context, as defined by risk.
Therapists must be reflective practitioners in relation to risk, with a willingness to identify personal and professional areas for development and to seek resources to support that development, as appropriate.
Therapists must be able to engage with a dialogue around risk and be aware of any existing policies or procedures (where they exist), and work accordingly.
Therapists need to be aware of issues that relate to suicide and self-harm/injury, including definitions, aetiology and key research findings informing practice.
Therapists must be willing to communicate clearly with clients about suicidal ideation and self-harm/injury.
While therapists need to be carefully attentive to risk, they need to ensure they do not become risk-driven, missing important therapeutic possibilities or losing therapeutic contact with clients.
Therapists must not judge, but instead be empathic, compassionate and understanding, and willing to be congruent in line with the teaching of their core theoretical model(s).
Therapists must be willing to name risk as it presents, and to work proactively and collaboratively with clients to engage with the risk in a way that is respectful of the client’s well-being and autonomy, where possible.
A challenge to common understandings and professional expertise of suicide is the case of the suicide-terrorist (see Weatherston & Moran, 2003).
Causal relationships between the presence of mental health problems and criminality are difficult to demonstrate and cultural narratives that depict individuals with mental health problems as violent and high risk are hugely damaging, especially when those with mental health problems are more likely to be victims of crime rather than perpetrators (Peay, 2011).
Schouten (2010) poses an important question which highlights some complexities of the area when asking whether cases should be categorised as ‘terrorist acts’ or ‘acts of violence related to mental health problems/mental illness?’. Topics such as the question of whether ideology does in fact interact with suicidal ideation (that is already held by the individual), resulting in an act of murder-suicide, has been well developed by Lankford (2011, 2012). ‘Psychiatrising’ terrorism is not an easy task but studies have been conducted with pre-emptively arrested suicide-terrorists and organisers (see Merari et al., 2009).
Lankford (2011) draws attention to issues of intent, questioning whether a suicide-terrorist is actually suicidal, or is instead motivated by martyrdom, and highlighting how difficult it is to reach a conclusion either way. Indeed, cultural narratives and popular representations may lead to a common view of suicide-terrorism as an act underpinned by politically, culturally or religiously motivated goals. To identify all murder-suicide actors in this way, as Lankford (2011) suggests, would be misleading, and in fact it may well be plausible to suggest individual motivations (which may be suicidal) can be overlooked.
Disclosure of self-harm or thoughts of suicide can induce fear and anxiety in a therapist which can affect how they deal with such disclosures (Reeves, 2015). For this reason, as part of their training and ongoing practice, therapists are required by their professional registration to have regular supervision to enable them to be aware of and reflect on any assumptions that underlie their responses to these and other disclosures in therapy.
