Self-harm Definition, Incidence and Intervention
Authors: Kate Solomons, Julia Ndebe, Lauren Fourie, Salome Demetriou, Yumna Seedat, & Gerrit van Wyk
Self-harm Definition, Incidence and Intervention
by: Authors: Kate Solomons, Julia Ndebe, Lauren Fourie, Salome Demetriou,
Yumna Seedat, & Gerrit van Wyk
Self-harm (which can also be referred to as self-injury, self-injurious behaviour non-suicidal self-injury, or self-inflicted violence) is a controversial act which has been receiving a growing amount of attention over the past decade. The subject matter appears to have become a popular area of discussion in the field of mental health and illness. Yet it has also extended to other domains such as media, where discourse regarding the topic has been generated on a much larger scale than previously before. Granting that the action is a global phenomenon which has captured the interest of many, the problem is still faced with numerous instances of stigma, confusion and shame. It is therefore imperative to explore the many aspects to the act and to critically engage with its origins and development as well as the interventions sought to halt its destructive intention.
1. Definition, Incidence and Intervention
A common definition of self-harm is, “an individual’s deliberate and/or intentional act to cause themselves harm” (de Cates et al., 2017; Laye-Gindhu & Schonert-Reichl, 2005; Muehlenkamp, Claes, Havertape, & Plener, 2012). Yet this particular definition of this act has caused a lot of controversy over past years, as there has been a debate whether to define self-harm with or without the intent of committing suicide. This discussion is relevant as self-harming could possibly lead to deliberate or accidental suicide, making the association between the two prominent. Furthermore, it has been found that persons who perpetrate self-harm often have more than one intent; thereby defining the term more challenging (Skegg, 2005). As no single definition exists for self-harm, there has been the formulation of two distinct terms: ‘Deliberate Self-Harm (DHS)’ and ‘Non-suicidal Self-Injury (NSSI)’. DHS can be defined as the deliberate infliction of injury both with and without the intent of suicide, without causing fatality. DHS has also been classified as ‘para-suicide’ or ‘attempted suicide’. NSSI can be defined as deliberate destruction of self without the intent of suicide, that of which is not accepted by society (Muehlenkamp et al., 2012).
The classification of self-harm within the Diagnostic and Statistical Manual of Mental Disorders (DSM) has progressed over the years (Muehlenkamp & Jennifer, 2005). Previous DSM’s classified self-harm as one of the many symptoms of Borderline Personality Disorder (BPD). Self-harm was then classified in later versions of the manual as being a feature of mental illnesses such as Post-Traumatic Stress Disorder (PTSD), depression, mood disorders etc. In the fifth (and currently latest) version of the manual, self-harm was classified as a separate disorder altogether (Muehlenkamp et al., 2005). The DSM-5 defined self-harm as intentional damage to one’s body with the outcome being minor to moderate damage’ (Crowe, 2014). The DSM-5’s adoption of the NSSI definition of the term deems it to be without the intent of suicide. Comparatively, the tenth version of the International Classification of Diseases (ICD-10) classifies self-harm under the category of ‘external causes of morbidity and mortality’. It defines the term as deliberately inflicting harm to oneself through poisoning and injuries leading to attempted suicide or fatality. Conversely, ICD-10 then adopts the DHS definition of self-harm which includes suicidal intent (WHO, 2010). Furthermore, the ICD-10 classifies self-harm in relation to the methods used. The most prominent methods used for both with and without intent are cutting, burning, hanging, strangulation, banging, poisoning and the use of medication (Royal College of Psychiatrists, 2010). Areas which are common targets of self-harm are the arms, legs and chest due to its accessibility (Muehlenkamp et al., 2012).
2. Global Prevalence and Incidence
The prevalence of self-harm in the youth is on the rise, with approximately 10% of individuals reporting an incident of self-harm at least once in their lives (de Cates et al., 2017; Hawton et al., 2010). Self-harming, which is commonly known to occur in adolescence, between 14 and 24 years old, has a lifetime prevalence rate of 13% to 17% (Muehlenkamp et al., 2012; Nixon, Cloutier, & Janson, 2008). In adults, the lifetime prevalence rate is from 5.9% to 23.2% (Selby et al., 2015; Taylor et al., 2008). In addition, self-harming is predominately higher in females than in males (de Cates et al., 2017; Kirtley, Caroll, & Connor, 2016).
Research on the true incidence of self-harm is limited, due to the varying definitions of the act and methodologies used. Often, the most commonly cited incident rates of self-harm are from hospital admissions (Laye-Gindhu & Schonert-Reichl, 2005; O’Donnell, House, & Waterman, 2015). According to O’Donnell et al. (2015), suicide is a more reliable way of determining incident rates of self-harm – this is because over half of those who die from suicide will most likely have a history of self-harm. Every year there are approximately ten million people who deliberately self-harm, with one million who die by suicide across the world (Bilén et al., 2013). In 2017, according to the World Health Organization (WHO), suicide rates have increased by 60% in the last fifty years, and has become the third leading cause of death in individuals, from the ages of 15 to 44 years old (Bilén et al., 2013). Accordingly, by using the incident rates of suicide and hospital admissions to determine the incidence of self-harm, one finds that this is an underestimate of the actual incident rate. This is due to the fact that hospital admissions for individuals who self-harm, and for those who have committed suicide, although at high rates, exclude those who self-harm but have not been admitted to hospital or need medical attention. This suggests that the incident rate for self-harm is most likely higher than what is currently known (O’Donnell et al., 2015).
Within the United Kingdom, researchers have found that self-harm was on the rise from the 1960s to the 1970s, and increased again from the 1990s (Hawton et al., 2010; Kirtley et al., 2016; Moran et al., 2012). In Western countries, there is an estimate of 5% to 8% of adolescents who report self-harm each year (Greydanus & Shek, 2009). The reasons for the increases are unclear, however, it has been speculated that it may be due to social transmission, availability of medication, and an increase in drug and alcohol consumption, as well as greater stress, especially amongst adolescents in the UK (Hawton et al., 2010). Other risk factors that may contribute to the increasing incidence rate are suggested to be associated with child abuse or neglect, anti-social behaviours, alcohol consumption, social context (for example, poverty), low emotional control, drug use, and mental disorders, to name a few (Greydanus & Shek, 2009; Heerde et al., 2015; Huang et al., 2017; O’Donnell et al., 2015). Despite most of the research originating from Europe and North America, it has been found that self-harm is evident in all cultures and affects heterogeneous groups (Bilén et al., 2013; Borschmann et al., 2012; Forrester et al., 2017).
According to Huang et al. (2017), only three studies have investigated the incidence of self-harming. This includes one study from England with a 6-month incidence rate, a study conducted in Norway with a one-year incidence rate of 3.3% to 5.3%; and another from both Australia and the United States, with a one-year incidence rate of 3.5% (Huang et al., 2017).
In addition to this, researchers have conducted a meta-analysis on 177 research papers to investigate the incident rate of fatal and non-fatal self-harm (Carroll, Metcalfe, & Gunnell, 2014). The research papers were sourced from the United Kingdom (28.8%), Sweden (10, 2%), Norway (7.3%), Australia and New Zealand (7.9%), Asia (8,5%) as well as North and South America (5.1%) (Carroll et al., 2014). There were no papers sourced from African countries that were included in this meta-analysis. The meta-analysis found that there was a 16.3%. incident rate of repeated non-fatal self-harm in one year, 16.8% in the second year, and last 22.4% in five years. Specifically, in the European countries, a repeat of non-fatal self-harm in a year was an estimate of 17.1%; whereas in Asia there was a 10% repeat of non-fatal self-harm in a year (Carroll et al., 2014). With reference to the incidence of repeated fatal self-harm in one year, the incident rate was 1.6%, at two years it was 2.1%, increased further to 3.9% at five years, and last 4.2% at ten years (Carroll et al., 2014). Factually, both fatal and non-fatal self-harm had an increase in incident rates over ten years. It is, therefore, evident that the incidence of self-harm has increased globally over the years.
3. Local Prevalence and Incidence
Self-harm research within South Africa has been increasing, however suicidal behaviour is still very much underreported (Schlebusch, 2012). As stated by the South African Stress and Health Survey (SASH), the lifetime prevalence of suicidal attempts was 2.9% between the years of 2002 and 2003 (Joe, Stein, Seedat, Herman, & William, 2009). The National Injury Mortality Surveillance System (NIMSS) indicated that suicide was the fourth cause of death in South Africa. Findings have also shown that even though women have higher reports of suicide attempts, men have the highest suicide rate within the country (Burrows, Vaez, & Laflamme, 2007) Studies have also revealed that there has been an increase in suicidal behaviour in the South African adolescent group (Donson, 2009). Possible factors contributing towards this increase in self-harm may be due to the idea that adolescents and young adults are perceived to be the most susceptible age groups within the country. For example, in the Durban Para-Suicide Study (DPS) young adults were the highest risk group followed by adolescents with regards to suicidal behaviour (Suffla & van Niekerk, 2004).
One of the main reasons for self-harm in a South African context stems from family and interpersonal conflicts. Adolescents who experience change within the family structure due to divorce or separation, violence within the home, and who have a predisposition to psychopathology are more at risk to self-harm. Similarly, adolescents who have trouble coping with personal struggles such as the loss of support, low self-esteem or academic problems tend to be more likely to self-harm (Kinyanda, Hjelmelana, & Musisi, 2005). Individuals who have poor problem-solving skills are also more susceptible to these problems, as they use self-harm as a coping mechanism (Suffla et al., 2004). This is apparent in a research study conducted in three hospitals in Kampala, Uganda where people under the age of 25 years old reported self-harming due to interpersonal and familial problems (Kinyanda et al., 2005).
Additionally, stress is an additional reason for adolescents to practice self-harm. These stressors are continuous and act as triggers to already predisposed individuals. One such trigger is acculturation, in which people take on practices and value systems of a different culture. Young adults coming from traditional backgrounds find it particularly challenging as they must adapt to the outside influences of westernised culture (Schlebusch, Vawda, & Bosch, 2003). Another stress trigger is the high crime and violence rates in South Africa (Suffla et al., 2004). The result of these triggers is often continuous trauma, which leads to self-harm. The SASH study indicates that 75% of South Africans experience a traumatic event in their lifetime, making this trigger an unfortunate reality for a large part of the population (Joe et al., 2008).
The last most prominent reason for self-harming in South Africa is the alarming HIV/AIDS crisis, where there is an estimate of 5.7 million people who have been afflicted with the disease. There are a multitude of factors which can contribute to this, with such factors being the initial diagnosis, a lack of social support, depression and anxiety related to the ‘AIDS phobia’, and suicidal tendency to avoid apparent disability or rejection. Individuals with HIV/AIDS are 36 times more likely to display suicidal behaviour. A study conducted in a general state hospital in Durban, with recently diagnosed patients, found that all patients who were interviewed had attempted suicide due to the internalisation of the disease, because they had perceived themselves as ‘spoilt’ and wanted to have control over how they died (Schlebusch & Vawda, 2010).
Self-harm serves a different purpose or function for each individual and with little doubt, is a high-risk action. It is one which has the potential to cause great injury to those who partake in it. It therefore comes into question as to why individuals would prefer to engage in this particular behaviour rather than healthier alternatives. It is critical to understand the effectiveness of this act; to comprehend its meaning and purpose. This can be done by examining the different theoretical frameworks where the aims are to investigate the critical underpinnings of this mutative act. There is a myriad of theories which seek to explain this, but this paper will focus on those which appear to be more relevant, as well as have a larger amount of empirical research to validate their claims.
The affect regulation model appears to be a popular explanation as to why self-harm may occur. The concept of affect regulation refers to a person’s ability to adjust, modify or to extend their emotional disposition (Klonsky, 2007). To elaborate, an individual who is experiencing unpleasant emotions may choose to partake in an enjoyable activity, for example, talking to friends, where they are then able to change their negative temperament into a positive feeling. One could even argue that affect regulation could be viewed as an emotional form of homeostasis – which refers to an organism’s ability to maintain stability and constancy within their biological functioning and to adapt accordingly to various situations. It has been suggested that an individual who participates in self-harm may have great difficulty in articulating and expressing their emotions in a healthy manner – particularly sadness, anger, pain and anxiety (Klonsky, 2007; Suyemoto, 1998). The negative emotions may be experienced as too overwhelming and uncontainable. As a result, self-harm may be viewed as a solution – albeit, not a beneficial one – to these intense feelings. Through the act of mutilation, one is somewhat able to assert control over the immense distress they are experiencing, and hurting oneself ironically becomes a form of self-soothing (Laye-Gindhu1, & Schonert-Reich, 2004; Suyemoto, 1998). As to why this occurs, it is believed that such individuals are biologically dispositioned to emotional instability, which then may be greatly exacerbated by being raised within an environment has constantly invalidated and dismissed their calls for help and attention (Klonsky, 2007). As a result, the person may then develop poor coping mechanisms when dealing with emotional distress.
Self-harm may also be the result of what is known as experiential avoidance. This is when an individual attempts to evade distressing emotions, memories, feelings, as well as physical sensations as to avoid discomfort in their lives (Chapman, Gratz, & Brown, 2006). Intuitively, this appears to be a good response – humans are drawn to situations, objects and groups which provide comfort, enjoyment and safety. This would then ensure their survival (if one is looking at this from an evolutionary perspective) but also allows the individual to maintain a happy and relaxed mindset. Realistically, however, not all situations one is faced with will be pleasant – especially in modern society where individuals are challenged with numerous circumstances at varying degrees of pleasure and discontentment. Individuals who exhibit high levels of experiential avoidance will therefore display a persistent unwillingness to tolerate any form of such unwanted emotional responses or undesirable situations (Chapman et al., 2006). A person may then engage in high-intensity actions such as self-harm, for example, to withdraw from such negative feelings. This model further divides itself into two hypotheses: the distraction hypothesis and the opioid hypothesis. The distraction hypothesis believes that the physical sensation of the deliberate harm to the body can override the emotional discomfort that one is experiencing (Chapman et al., 2006). On the other hand, the opioid hypothesis (also known as the biological theory) refers to the release of endogenous opioids – commonly referred to as endorphins – which when one is injured, creates analgesia that reduces the feeling of pain (Chapman et al., 2006; Nock, 2009; Rayner & Warner, 2003). Consequently, if one were to self-harm, this could trigger the release of said chemicals and induce what could be called a “euphoric high”. This ironically subverts the harmful action into an act which produces pleasure; a sense of false wellbeing (Chapman et al., 2006; Nock, 2009; Rayner & Warner, 2003).
Psychoanalysts view the action of self-mutilation as a damaging act towards the self. Yet one cannot physically destroy one’s internal states and therefore one may respond to this need for destruction by externally harming their physical form (Yakeley & James, 2018). Theorists argue that the development of the self begins through the internalisation of important attachments which begin in infancy. The attachments themselves are instigated when the infant forms a bond with their primary caregiver – the guardian who ensures their utmost safety and wellbeing (Yakeley & James, 2018). This protective and loving figure in most cases appears to be the mother. The infant’s welfare, as well as their growth into what is ideally a healthy, sociable and considerate adult, is believed to be reliant on this vital dyad (Yakeley & James, 2018). The dyadic approach ensures that the id (the primitive component of the psyche which relies on instant gratification of pleasurable experiences) is satisfied, whilst the ego (which ensures that the id’s desires are eventually expressed in an acceptable and socially appropriate manner) is being developed. However, this process may be hindered if the caregiver, in this instance, is abusive, neglectful, or absent – the id is then negatively affected, and a fragile ego may occur as a consequence. As a result, if a person were to become distressed, they rely on primitive defence mechanisms of the id, such as hurting oneself to immediately attain relief, rather than utilise the ego and determine a healthy outlet for their emotions (Yakeley & James, 2018).
A hypothesis which can be linked from the psychoanalytic model is that of the self-punishment model. It aids individuals in dealing with internal feelings of guilt by using their body to punish themselves. In cases of childhood abuse by a parental figure, the individual internalises the parent’s behaviour and blames themselves for the abuse. Yakeley and James (2018) state that angry and aggressive feelings towards the abuser are experienced as unacceptable and creates a psychic dilemma where the child simultaneously perceives and confuses the good object with the bad behaviour. They further explained that the ensuing unbearable confusion, rage and horror are internalised as parts of the bad self, so that harming their own body may be seen as punishment for any gratification that may have been experienced, and to assuage an unconscious sense of guilt. This particular framework suggests that the harmful behaviour can be perceived as a form of self-directed abuse (Klonsky, 2007; Nock, 2009). This explanation suggests that self-harm has strong associations to child abuse as well as continuous parental criticism within their early childhood environment. An individual within these circumstances is often told to repress their emotions, and any expression of such may be met with intense antagonism (Klonsky, 2007; Nock, 2009). This can instigate a defence mechanism termed “introjection”, in which a person internalises the thoughts, beliefs and emotions of others, and is unable to separate their self from such ideas. In this scenario, the self-harming individual has internalised ideas of worthlessness – they believe that they are insignificant and deserving of the maltreatment and fury which is projected onto them. Instead of recognising and processing their anger and sadness, they may resort to punishing themselves in an attempt to validate the emotions which were belittled by others (Klonsky, 2007; Nock, 2009).
Yakeley and James (2018) saw self-harm as a ‘breach of the body’, adding that “the body boundary connects the external with the internal, the mind and the body, and the self and others.” (p. 39). This simply means that individuals who self-harm use their bodies as communication tools to show or share what they are feeling inside, thus creating a connection between the external and internal, or the body and mind. They further explained that cutting is viewed as an unconscious behaviour which represents cutting out negative thoughts and feelings (represented by the opening of the skin and the blood) that they experience internally and releasing them outwardly (Yakeley & James, 2018).
Another theory suggests that one engages in self-harm to communicate pain and distress – this is known as the social-signalling hypothesis. A psychiatrist once stated that a patient mutilated their skin as a method of garnering attention – calling it a “bright, red scream” (Nock, 2009). There are several ideas as to why mutilation may serve as means to display anguish and to ask for support. Firstly, the individual may find great difficulty in verbalising their emotions – the words that they would use to express their emotions may not do justice to state how overwhelming their circumstances may be (Nock, 2009; Skegg, 2005; Hawton & James, 2005). Or, as previously mentioned, they have been raised in an environment which has punished them for merely expressing their wants and needs, and thus they may be fearful to speak openly about their struggles (Nock, 2009; Skegg, 2005; Hawton, & James, 2005). This non-verbal communication of one’s emotions is supported by Adshead (2016) who emphasised how individuals used their bodies to communicate their internal thoughts and feelings, which they could not express in words. Motz (2009) proposed that self-harm is seen as an attempt to preserve their life instead of ending it. It helps individuals to release negative thoughts and feelings and providing them with calm after the act of cutting. Yakeley and James (2018) also added that “self-injury is understood as a morbid form of self-help, temporarily alleviating distressing symptoms, and attempting to heal, to attain some measure of spirituality and to establish a sense of personal order.”
According to Rayner and Warner (2003) individuals who self-harm uses this strategy to mask their internal negative thoughts and feelings with the external pain they have inflicted onto them. Thus, it contains both intra-personal and inter-personal meaning. It allows them to use the body to escape such internal negative thoughts. Self-harm can also be viewed as a way to communicate one’s internal negative thoughts and feelings using one’s body. Yakeley and James (2018) further stated that “anxiety-provoking experiences of the infant’s body cannot be represented in the mind but are instead enacted and communicated via the body”. Accordingly, individuals may want to visually see and describe what they feel inside by cutting the body in various ways.
Often the first form of treatment for an individual who self-harms is hospitalisation (Muehlenkamp, 2006; Skegg, 2005). However, despite providing the patient with temporary care, this does not prove to be effective for long-term recovery (Muehlenkamp, 2006). Possible factors contributing towards this low recovery rate may be because some individuals are not admitted for inpatient treatment, as they may not show signs of suicide, and/or may have financial constraints. This could prevent the individual from receiving the necessary care needed (Muehlenkamp, 2006; Skegg, 2005).
Research suggests that the act of self-harm may be related to the function known as affect regulation, where several sources of literature have proposed various group interventions that focus on emotion dysregulation and avoidance as forms of treatment (Muehlenkamp, 2006; Gratz & Gunderson, 2006). Yet, such interventions may differ according to one’s developmental stage. With child and adolescent age groups, such interventions may target the functionality of emotions. In contrast, interventions structured for adults may focus on learning how to regulate and reduce the negative emotions that they are experiencing (Gratz & Gunderson, 2006). the interventions targeted at children follow methods similar to behavioural approaches such as Cognitive Behavioral Therapy (CBT). These approaches encourage the child or adolescent to view both positive and negative emotions as being valuable in their life and growth (Gratz & Gunderson, 2006; Muehlenkamp, 2006). The child interventions usually consist of four aspects. The first phase of the intervention focuses on the awareness, understanding and acceptance of one’s emotions, whilst the second phase encourages the individual to develop the ability to proceed with behavior goals and to not act on impulsive behavior (e.g. cutting,), as a means to cope, when experiencing negative emotions (Gratz & Gunderson, 2006). The third phase provides the individual with a skill-set of coping mechanisms so that he/she will be able to regulate the intensity of their emotions, when strategizing or considering solutions to a problem; rather than avoiding their feelings altogether. Last, the fourth phase, focuses on assisting the individual to learn to understand and accept negative emotions as necessary and meaningful, in his/her situation (Gratz & Gunderson, 2006).
Affect regulation may also be achieved through more structured therapeutic treatments such as CBT. In CBT, emphasis is placed on how an individual’s emotional, cognitive and behavioral factors influence the reoccurring act of self-harm (Ougrin, Tranah, Leigh, Taylor, & Asarnow, 2012). The intervention targets dysfunctional cognitions, the inability to regulate emotions, as well as poor problem-solving abilities with the aim to reform the maladaptive thoughts and feelings that the individual may have (Gratz & Gunderson, 2006; Ougrin et al., 2012). For example, individuals who self-harm often report feeling unlovable, perceive that he/she is a burden to family or friends, and exhibit poor distress tolerance. (Slee, Garnefski, van der Leeden, Arensman, & Spinhoven, 2008). Therefore, the approach undertaken by this behavioral discipline is to help improve the individual’s self-image. Essentially, the primary goal of CBT is to reach a mental state of learned hopefulness, and consciousness of one’s negative thoughts, in which one is able to identify and problem solve. However, it must be noted that in order for CBT to be effective, it is crucial for the individual to attend all sessions involving the therapeutic practice – the success rate of their recovery is highly dependent on this (Muehlenkamp, 2006; Slee et. al., 2008).
Problem-solving therapy (PST) is another therapeutic approach for self-harm. The framework targets dysfunctional coping behaviours which have been employed by the individual as a way to regulate their emotions (Muehlenkamp, 2006). It proposes that the individual may have cognitive or behavioral difficulties with regards to their problem-solving skills, especially in situations of distress. Thus, the goal of PST is to have the individual work towards being able to identify their current problems as well as the possibilities and options to resolve the problems in their life, in an efficient manner (Muehlenkamp, 2006). In order for the individual to reach this stage, they are taught how to identify a problem and to set a goal, whereby they learn how to brainstorm and assess various solutions. For example, an individual may set up a short-term goal and devise the possible ways to reach it. While doing this, they account for possible setbacks, and think of ways to overcome them. (Muehlenkamp, 2006). As a result, the individual is encouraged to implement and evaluate the likelihood of success of one of their hypothesized solutions for the possible setbacks. Through this process, the intervention aims at developing and refining an individual’s coping mechanisms and problem-solving skills in everyday life. However, research suggests that the effectiveness of PST for self-harm is mixed. (Muehlenkamp, 2006).
Dialectical behavior therapy (DBT) is a popular remedial framework when treating self-harm and other disorders (for example, borderline personality disorder). This form of therapy is multifaceted as it incorporates numerous theoretical frameworks such as Zen Buddhism, cognitive behavioral interventions as well as problem solving skills (Gratz & Gunderson, 2006; Linehan, 1993a; Muehlenkamp, 2006;). The primary focus of DBT is placed on having the client simultaneously reach a state of awareness, while accepting him/herself as well as their reality (Linehan, 1993a; Muehlenkamp, 2006). Through the promotion of actions such as mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness, the individual learns to develop coping mechanisms as well as the ability to self-validate their own emotions and thoughts. Similarly to PST, DBT aims at lessening the behavior of self-harm, by encouraging and developing different coping skills, identifying motivational obstacles in treatment, and enhancing skill generalization; beyond the therapist’s presence (Gratz & Gunderson, 2006; Linehan, 1993a; Muehlenkamp, 2006). Studies comparing DBT to non-behaviorally orientated treatment or interventions, for example interpersonal therapy (IPT), suggest that DBT has a higher and more effective rate to reduce self-harm (Muehlenkamp, 2006; Ougrin, Tranah, Stahl, Moran, & Asarnow, 2015).
In order to successfully reach recovery in DBT, one has to undergo a hierarchical process within a specific number of sessions. This includes individual therapy, group skills training, phone coaching and supervision from the counselor, so that he/she can remain motivated when working with difficult cases (Gratz & Gunderson, 2006; Linehan, 1993a; Muehlenkamp, 2006;). DBT begins with pre-treatment, which is aimed at familiarising the client with the therapy, whereby the client will sign an agreement to commit to the therapy. The initial stage targets the behavior of self-harm in which the client is required to maintain therapy compliance (Muehlenkamp, 2006). Throughout the therapeutic process, the client begins to work towards controlling self-destructive behaviours. Resources and skills learnt include, but are not limited to, validating the client’s experiences, learning new problem-solving skills, behavioral analyses of the client’s self-inflicted injuries, practicing mindfulness, emotional regulation and contingency management strategies (Muehlenkamp, 2006). Thereafter, the framework aids the individual in processing and making sense of traumatic incidents (past and present) in a healthy manner. Last, the treatment aims at achieving a holistic and balanced set of actions, by developing and upholding the individual’s self-respect, together with the skills learned in previous sessions (Muehlenkamp, 2006).
Other studies have shown that interventions that incorporate a more psychoanalytic approach, such as Mentalization-Based Therapy, are seen as more effective in reducing self-harm, compared to family work, social support and/or supportive therapy (Rossouw & Fonagy, 2012). MBT focuses on the ability to understand one’s actions through their thoughts and emotions (Rossouw & Fonagy, 2012). The aim of this is for the individual to gain mastery over self-control, and agency to reduce the likelihood of impulsive behavior. It has been suggested that compromised mentalisation may lead to an increase in negative thoughts or beliefs and an urgent need to be distracted; which may also lead to depression (Rossouw & Fonagy, 2012). More so, the individual may be at risk to self-harm if there is a deficit in the mentalisation of social experiences; thereby, impulsive behaviours (unhealthy coping strategies) are then triggered (Rossouw & Fonagy, 2012).
Research suggests that interventions in relation to self-harm should encourage help-seeking behaviour and interaction between the individual and practitioners (Hawton et. al., 2012; Muehlenkamp, 2006). For example, studies recommend CBT, in this regard, as it primarily focuses on the individual’ inability to problem solve and aims to increase self-esteem, with the likelihood of repetitive self-harming decreasing (Hawton et. al., 2012; Muehlenkamp, 2006; Slee et. al., 2008). However, there is still a need for innovative interventions and strategies, which are particularly important when considering the risk factors of self-harm such as the social environment and/or risk of suicide (Hawton et. al., 2012). Furthermore, psychosocial support is also assumed to influence health outcomes – research investigating the causes and influencing factors of self-harm have shown that poor social support is often understood as a contributing factor to the increase in self-harm (Hawton et. al., 2012; Skegg, 2005; Slee et. al., 2008). Additionally, research supports the claim that social support from family, friends and clinicians, may lower the risk of self-harm (Skegg, 2005).
Further, the individual may use the behavior of self-harm to express distressing emotions, or as a plea for help (Mikolajczak et al., 2009). In comparison, Skegg (2005) suggests that the act of self-harm may be perceived as a “cry of pain” rather than a “cry for help”. Therefore, it may prove to be valuable if family members and friends are able to identify the signs leading up to self-harm. For example, a medium to develop social support can be done through Gatekeeper training which consists of a prevention guideline. This provides the individual’s family and friends with the knowledge to identify signs of self-harm behavior (Hawton et. al., 2012). Developing this awareness may prove to be useful in recognizing feelings of loneliness and helplessness in an individual who may self-harm. The influence of support and involvement of others plays an important role in breaking habitual patterns of this harmful act and may prevent relapse (Slee et al., 2008). Interventions focusing on social support may prove to be useful, as social support may make one feel accepted, loved and cared for, seen and heard; as well as feel valued to be part of a group (Kim et al., 2008). Research suggests that social support lowers psychological distress such as anxiety or depression during stressful periods (Kim et al., 2008). More so, social support interventions can be seen as a coping strategy, which may be helpful for individuals who self-harm, as they are known to be prone to experience anxiety and/or depression (Hawton et al., 2012; Kim et al., 2008)
Furthermore, such social interventions are similar to CBT as both promote help seeking behavior and provide the individual with the skill-set to improve their self-esteem and resilience (Hawton et al., 2012). For instance, population-based measures such as educational initiatives, for individuals who self-harm, are targeted at the issues around the social transmission of self-harm (Uchino, 2009). Additionally, support groups give individuals a space to discuss various issues and to receive support from others who share similar experiences or difficulties (Kim et al., 2008). Research proposes that social support interventions are influential and effective, which may assist individuals to cope and adjust to difficult and stressful life events (where the social support acts as a buffer). However, the manner in which social support or social support interventions may be carried out, may differ due to cultural backgrounds (Kim et al., 2008).
Research proposes that cultural meaning of social support may influence an individual’s willingness to accept social support or interventions during a stressful life event (Taylor, Welch, Kim, & Sherman, 2007). In a study conducted in 2007, Asian and Asian American participants (students) showed less willingness to ask or accept social support compared to European American participants (Taylor et al., 2007). This particular study suggests such a response to other’s help may be influenced by relational concerns (Taylor et al., 2007). For example, in a collectivistic culture, the individual who self-harms may not draw on social support as he/she may view the behavior of self-harming as disrupting group harmony. They may also fear that the behavior may negatively affect the relationship, or increase poor evaluation and/or judgment by others (Taylor et al., 2007). Thus, the personal need of an individual is understood as secondary to the social group’s norms and group dynamic. Further, it is suggested that within a collectivistic culture, the individual expects the social group to recognise that he or she needs guidance rather than having to ask for ‘help’ or support (Kim et al., 2008; Taylor et al., 2007).
In contrast, individualistic cultures do not view their personal problems as a burden to the social network. For instance, studies suggest that European Americans are more open to accepting social support, to cope with life stressors, compared to Asians and Asian Americans (collectivistic cultures) (Kim et al., 2008; Taylor et al., 2007). This suggests that social support interventions may be more beneficial to such cultures. However, more research needs to be conducted to support this notion as there is very little empirical research to validate this hypothesis. More so, there is a lack of research done on social interventions targeting different social and cultural perspectives (Kim et al., 2008; Taylor et al., 2007). It may be valuable for future research to consider ways to encourage collectivist cultures to be open-minded about social support interventions. Based on the abovementioned interventions, whether a therapeutic model or social support, all focus on the importance of recognizing emotions, and finding adaptive ways in dealing with emotions.
7. Concluding Remarks
There is little doubt that the act of self-harm is gradually increasing and that its destructive effects have left a blood-stained smear on many countries across the globe. Whether it be in South Africa, the United Kingdom or elsewhere in the world, it appears that its influence and incidence is non-discriminatory. In addition to this, there seems to be numerous factors which have contributed to its growth, whether it be due to mental illness, poor social support, emotional dysregulation or trauma. However, this is not to state that those who self-harm should be without hope for a better future – as previously mentioned above, there are several forms of treatment and interventions which have been designed to help said individuals as much as possible. However, it is key for one to access this vital aid as soon as possible, otherwise they may succumb to the destructive consequences of the act – those which would even be fatal.
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