Understanding the nature and extent of a young person’s self-injury
When discussing a history of self-injury with a young person it is important not to ‘assess for assessment’s sake’. However, at times it may be useful to look in detail at the self-injuring behaviour with the young person in order to develop a support plan. Questions to consider in the process may include:
What is the process of self-injury?
- The time between trigger, thought of self-injury & self-injuring eg: seconds, minutes, hours
- Does the person try other coping strategies prior to self-injuring
- Is the process the same every time? (has the process of self-injury changed)
- Environment eg: alone, group, home, school, bathroom
- Is there a relationship between their self-injuring & Alcohol & Other Drug use?
- In relation to specific AOD types
- how do they feel?
- what do they do?
If the person is unable to self-injure
- how do they feel?
- what do they do?
Using this information to inform the development of a support plan will allow a more detailed and personalised response for each young person.
Understand the function and meaning of self-injury
When a positive connection has been made with the young person who self-injures (and, where appropriate, those involved in their care) it is possible to work on understanding the function of their self-injury and the meaning that it holds for them. It is also essential to investigate with the young person the impact that self-injury has in a range of areas, such as their relationships, connection to activites, and self-concept.
Knowing the function and impact of self-injury, enables a practitioner and a young person to develop relevant, context sensitive, strategies for reducing harm and finding viable alternatives where self-injury is an identified risk (see Aspect 4).
The ‘Look Beyond the Scars’ (2002) research conducted in the United Kingdom provides a unique insight into what people who self injure identify as reasons for the behaviour. They include:
- The influence of past life events (trauma & abuse)
- Stress resulting from current events
- A release mechanism (coping with emotions)
- Relief - a brief escape
- Creating a visual sign / communication (of distress)
- For the good feelings it brings
- Taking back control
- A habit or addiction
- A self-harming environment
Self -injury and emotional dysregulation
Self-injury can be an indication of emotion dysregulation. While self injury fulfills the function of providing relief from the distress associated with overwhelming emotions it does not assisting the young person to develop any sustainable emotion regulation skills. The following is an example of how this occurs in practice. A person is experiencing a level of emotional or psychological distress. This may be flashbacks to trauma (associated with PTSD), overwhelming anger, grief, loneliness or frustration, or a state of ‘numbness’, emptiness or tension often linked to dissociation. They perceive this state to be intolerable and take action to find relief. This is when they self-injure, which can provide that release or relief from the seemingly intolerable state. However, while the symptoms may be relieved somewhat, they will return, and the stigmatisation and shame associated with self-injury may increase the level of distress.
Sometimes a young person who self-injures will be negatively labeled as an ‘attention-seeker’. Many young people who self injure go to great lengths to hide the behavior from others. Some young people might self injure to communicate that are very distressed and needing support and attention. It may be that the young person lacks the interpersonal skills to ask for help so they ‘act it out’ by self-injuring. It is also possible that self-injury is a learned behavior that has been inadvertently reinforced over time by caregivers who ignored or dismissed the young person unless they were sick or injured.
It may be helpful to conduct a structured ‘Functional Analysis’ of a young person’s self-injury with them. The ‘Self-injury Functional Analysis Questionnaire' can be completed with the young person or used as a guide for early and subsequent conversations about self-injury. The tool might also be useful for care planning and for the young person to reflect on in later conversations.
The following are examples of some of the questions included in the Functional Analysis:
- What is normally happening immediately prior to self-injury? (Conflict/Anxiety/School etc)
- What are you usually thinking about right before you self-injure?
- What are you usually physically feeling right before you self-injure?
- What are you usually feeling emotionally right before you self-injure?
- What is the method of self-injury? (eg. cutting, burning etc.)
- What are some of the positive feelings you have while you self-injure?
- What are some of the negative feelings you have while you self-injure?
- What effect does your self-injury have on: family, friendships, self-esteem etc.
For young people who find it difficult to describe their feelings and experiences in words, consider using more creative approaches, for example, a self-injury comic strip which could provide valuable insights into the ‘before’ and ‘after’ states of the young person.
G2ii. Chain analysis
An alternative form of behavioural analysis used in Dialectical Behaviour Therapy (DBT) is a chain analysis. Like a functional analysis, a chain analysis involves defining a problem and gathering evidence to determine what is causing it, what is preventing its resolution, and what tools might be available for solving it. Chain analysis can help the practitioner and client gain a perspective on several factors that may be working in specific contexts to maintain problem behaviours, or prevent the use of skill-based strategies.
Chain analysis conducted with the young person helps describe their self-injury precisely in behavioural terms. The chain-analysis itself is an exhaustive blow-by-blow description of the chain of events that commonly lead up to and follow the young person’s self-injury (i.e. antecedents and consequences).