Self-Harm in Young People: A Therapeutic Assessment Manual

Dennis Ougrin, Tobias Zundel, Audrey V Ng

• Publisher: CRC Press
• Year: 2009
• ISBN:
  9781444164305
• Edition: 1
• Topic: Medicine
• Subtopic: Pediatric Medicine

Self-harm is a distressing and all too common presentation to emergency departments, and yet there is no clear understanding of what it represents, and success rates of interventions to prevent future episodes are enormously variable.Therapeutic Assessment for self-harm is a pragmatic model, developed by the authors of this book and forming an orga

CHAPTER 1

DEFINING SELF-HARM

Dennis Ougrin

Tobias Zundel

Introduction

Readers might be surprised to find a whole chapter dedicated to the definition of self-harm at the very beginning of this book. It may be even more surprising to know that in many ways this chapter is not comprehensive and certain aspects of the discussion around defining self-harm will be developed further in subsequent chapters. The authors’ decision to write this chapter was based on the assumption that without a clear definition it is impossible to interpret any literature on self-harm, including this book. ‘What do the authors mean when they say self-harm?’ should probably be the first question readers ask themselves when reading any material on the subject.

It may be that the readers of this book have already crystallised their own definitions of self-harm. We suspect, however, that for many this is not the case. While it is not suggested that readers necessarily accept the definition presented here, for operational purposes it is important to bear it in mind while reading the rest of this book.

The historical divide in defining self-harm

Self-harm as a form of human behaviour has attracted considerable research attention in the last 20 years,¹ but it has existed for millennia, perhaps for as long as humans existed, in different cultures and in different geographical areas.² It was described variably in the Bible as a sign of madness, a deed of the devil or a way to salvation (Mark 9: 47–8, Kings 18: 28, Mark 5: 5, Matthew 6: 22–3).³ Differences in the underlying motivation and intent were at the heart of the understanding of self-harm. It will not surprise readers that, as with many other ancient debates, this one has not been resolved to date. The history of modern self-harm definitions is also fraught with disputes. These still revolve primarily around its meaning.

One of the first attempts to introduce sub-categorisation to suicide-related behaviour dates back to 1938, when Meninger⁴ attempted to sub-categorise self-mutilative behaviour. In 1964 Stengel⁵ proposed that people who committed suicide and suicide attempters represented two distinct populations. However, according to Stengel, strictly speaking, a ‘true’ suicide attempt should refer only to those who failed to die after having tried to kill themselves. Many authorities disagreed with this nomenclature, especially feminist writers who suggested the more inclusive term of ‘suicidal behaviour’.^6,7 A driver for this change was a suggestion that men were perceived more competent in completing suicide whereas women were seen as failing.

Kreitman’s seminal work on parasuicide⁸ was designed to produce a broad category of suicide-related behaviours and has been widely used in Europe^9–11 and in the USA¹² until recently. Many contemporary definitions of suicidal behaviour are based on this concept.

The American perspective, epitomised by the early work of Beck and colleagues,^13,14 placed classification of intent at the foundation of suicidal behaviour classification and argued that suicidal behaviour should be defined, researched and treated differently depending on the presence or the absence of the intent to die.

For the last 50 years the field of self-harm has been divided between those experts who consider self-harm to be a broad continuum of self-injurious behaviours, irrespective of intent, and those who argue in favour of firm categorisation of self-harm into that with and without suicidal intent.

In the remainder of this chapter the authors will focus on these two conceptual nomenclatures broadly representing American and European/Australasian approaches, which will somewhat arbitrarily be called the Beck–O’Carroll–Silverman nomenclature and the Kreitman–Hawton–De Leo nomenclature.

Nomenclature and classification of self-harm

Although the terms ‘nomenclature’ and ‘classification’ have some overlap, they are distinct. Nomenclature seeks to define the basic concepts and is concerned with terminology and definitions, whereas classification seeks to comprehensibly describe the phenomena. A classification system is impossible without clear nomenclature. Nomenclature of self-harm is confusing and many authorities use self-harm terminology to denote different concepts. The field is probably still at the point of developing nomenclature rather than classification.¹⁵ Some of the difficulties with establishing self-harm nomenclature are considered below.

The basis of self-harm nomenclature: looking for objective measures

All self-harm nomenclatures are based on the following four concepts: intent, method, outcome and lethality.

Outcome of self-harm is probably the most objective and non-controversial domain. Method of self-harm is somewhat more difficult to establish with confidence as it is largely based on self-reporting. Method and outcome are closely linked and it might be possible to verify both with an examination and/or investigations. Epidemiological studies rely primarily on subjective self-report when establishing the method of self-harm.^16,17

Lethality can be misleading as an indicator of the severity of self-harm. This is primarily due to a variable gap between objective and subjective lethality.

Intent is the most controversial dimension of the four and the least amenable to objective evaluation. In essence, authorities are split on the role of intent in self-harm nomenclature. Both European and American nomenclatures use the concept of intent, but in different ways. Whereas the Beck–O’Carroll–Silverman nomenclature uses intent to differentiate between suicidal and non-suicidal self-harm, the Kreitman–Hawton–De Leo approach argues that intent cannot be used as a reliable differentiator and all non-fatal self-harm may or may not be underpinned by suicidal intent. A further disagreement exists about the taxonomy of suicidal thinking. American nomenclatures usually include suicidal thinking in the spectrum of ‘suicidality’. European nomenclatures consider behaviour separately from thoughts.

What is intent?

According to the Merriam Webster dictionary, intent (intention) can be defined as the determination to act in a certain way.¹⁸ It refers to the aim of an action, although the action itself is not required.¹⁹ Motivation (motives, reasons) is a driving force underpinning intent; for example, a wish to escape, desire to obtain relief, to end suffering, etc.²⁰ Motivation and intent are sometimes confused in the literature²¹ and it is intent rather than motivation that is used as a basis for self-harm nomenclature.

Intent: explicit versus implicit

Like lethality, intent can be thought about as subjective and objective,¹⁴ although this distinction is not made universally. A rather controversial approach to intent was formalised in O’Carroll’s nomenclature, dichotomising ‘zero’ versus ‘non-zero’ intent.²² Posner et al.²³ followed this logic, recognising further that ‘non-zero’ intent could be substantiated by either an explicit subjective report or inferred from the subject’s behaviour. Rudd²⁴ further argues that the assessment of objective evidence of intent is more important than the subjective report. Brent et al.²⁵ see suicidal intent as consisting of four orthogonal factors:

• belief about intent

• preparation before attempt

• prevention of discovery

• communication.

These four factors vary in the degree to which they can be assessed objectively.

Finally, while recognising the importance of intent, other authors argue that the distinction between subjective and objective intent may be hard to interpret.²⁶

Intent: importance

Although there is disagreement among researchers about the role of suicidal intent in the definition of self-harm, most authorities have come to the conclusion that it is an important aspect of risk assessment.^10,27,28 Subjects with a combination of suicidal and non-suicidal self-harm may score higher on several measures of psychopathology and risk-taking behaviour.²⁹

Intent: measurement reliability

Beck and colleagues^13,14,30 argue that measuring suicidal intent is essential for both clinical and research reasons and can be done reliably. In recent reports, Beck’s group have moved to a more dialectical view of suicidal intent, balancing the wish to live and the wish to die and replicating the previous work of Kovacs and Beck.^31,32

The authors who consider intent hard to measure reliably, do so on the basis of the following arguments: that intent is frequently assessed incorrectly and/or is subject to recall bias; that many subjects are unclear about their intent; that suicidal and non-suicidal intent may coexist and both suicidal and non-suicidal behaviour frequently occur within the same individual.

Freeman et al.³³ showed that a vast majority of so-called suicide attempts are in fact episodes of self-injury without suicidal intent. The authors proposed to eliminate the term suicide attempt and replace it with the term self-harm irrespective of intent. A similar question was raised by Meehan et al.,³⁴ who found that for every 10 reported suicide attempts only one required hospitalisation. This, the authors concluded, suggests that the term is overused and an independent verification is needed for an accurate classification of suicide attempts.

Subjects often present a variety of reasons for self-harm and frequently different reasons coexist.^9,35 Common overlapping reasons for self-harm include the following: to die, to escape from unbearable circumstances, to influence others and to feel better.

Finally, in the studies of non-suicidal self-harmers a significant proportion of subjects report suicidal as well as non-suicidal self-harm.^36,37

Intent: assessment

Bearing in mind the theoretical differences outlined above, it should be no surprise that measuring inten...

Table of contents

• Cover
• Title Page
• Copyright
• Contents
• Foreword
• Preface
• Acknowledgements
• Chapter 1: Defining Self-Harm
• Chapter 2: Prevalence and Natural History of Self-Harm
• Chapter 3: The Genetics of Suicidal Behaviour
• Chapter 4: The Neurobiology of Self-Harm
• Chapter 5: Psychosocial and Psychiatric Factors Relating to Adolescent Suicidality and Self-Harm
• Chapter 6: Effective Interventions
• Chapter 7: Engagement
• Chapter 8: Hopes and Expectations From Self-Harm Assessments: Adolescents’ Versus Clinicians’ Views
• Chapter 9: Testing Therapeutic Assessment in Real Life
• Chapter 10: Therapeutic Assessment Overview
• Chapter 11: History Taking
• Chapter 12: Developing Understanding
• Chapter 13: Instilling Hope
• Chapter 14: Assessing and Enhancing Motivation
• Chapter 15: Using a Future-Oriented Reflexive Approach
• Chapter 16: Problem-Solving Techniques
• Chapter 17: Using Systemic and Narrative Approaches to Create Exits
• Chapter 18: Using Cognitive–Behavioural Therapy Techniques
• Chapter 19: Using Interpersonal Psychotherapy Techniques
• Chapter 20: Mentalisation-Based Interventions
• Chapter 21: Emotional Regulation and Distress Tolerance Psychological First AID