Thursday, May 17, 2012

Self Harm Research Paper

Self Harm Research Paper

Hereby it is proposed to establish a support group for young females who self harm. While self-mutilating behavior is most prevalent among adolescents, young females are also at risk. Furthermore, underage patients are usually cared for by their parents or legal guardians, while young females have to deal with their problems on their own. In a month-long therapy course of four sessions, patients will learn to manage feelings of guilt and rage, build self-esteem, and develop positive affirmations.

Purpose of the group
1. To alleviate and help patients learn to control negative feeling which lead to self-mutilating behaviors. These feelings fall within two broad categories, namely guilt and rage. 
2. To develop healthy self-image among patients and to give them positive affirmations. Self-mutilating behaviors are usually caused by deeper psychological problems; furthermore, patients who self harm are at risk of developing other disorders, like eating disorders.

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Target Population 
In terms of gender, the group will be limited to female participants. Issues discussed within the group might be too personal and sensitive to be talked about in the presence of people of a different gender. For example, self-mutilation can sometimes be the result of sexual trauma: Stone (1987) writes that a number of patients who self harm have experienced sadistic sexual abuse from an older person during their childhood. They use self-mutilation to relieve their guilt from having “inappropriate” sexual thoughts and to punish not only themselves but also, symbolically, the original perpetrator.

As for age, females from the age of eighteen to the age of twenty six will be targeted. At the age of eighteen, people acquire full legal rights and are released from parental custody. Challenges of adulthood might be overwhelming at first, therefore young females are especially at risk of developing behaviors that might cause them to inflict harm upon themselves. While self-injury tendencies are most common among adolescents (Pattison, & Kahan, 1983), behaviors can persists if not treated in a timely and effective manner or even develop during adulthood. Therefore, young women can engage in such dangerous behaviors as well.

The group would welcome people with different diagnoses and problems. As Winchel and Stanley (1991) observe, the four categories of patients which are most likely to develop self-injurious behaviors are: 1) individuals with character disorders (primarily borderline personality disorder); 2) mentally retarded; 3) psychotic patients, and 4) prison populations. Not all of the aforementioned categories would be included in the group; please see the following section for a more detailed explanation of inclusion and exclusion criteria. Patients from the first category are most likely to comprise the majority in the group, therefore a closer look at this category is required. In a particularly relevant study of the prevalence of self-injurious behavior in a non-clinical population, Klonsky, Oltmanns and Turkheimer (2003) discovered that persons who engaged in such behavior had borderline, schizotypal, dependent, and avoidant personality disorder symptoms and reported more symptoms of anxiety and depression. Generally speaking, target population would include patients who engage in self-mutilation with these or similar problems. However, other problems like substance abuse, posttraumatic stress disorder, and intermittent explosive disorder (Zlotnick, Mattia & Zimmerman, 1999) can also lead to self-harm.

Selection of participants 
Inclusion criteria 
Persons of the age and gender specified above that engage in behaviors that can be classified “as the commission of deliberate harm to one’s own body. The injury is done to oneself, without the aid of another person, and the injury is severe enough for tissue damage (such as scarring) to result. Acts that are committed with conscious suicidal intent or are associated with sexual arousal are excluded” (Winchel & Stanley, 1991, p. 306). The reason why persons with suicidal thoughts should be excluded is because self-mutilation is fundamentally different from the desire to kill oneself and therefore requires a different treatment approach.

Exclusion criteria 
Patients with mental retardation, psychosis, schizophrenia or another condition which requires hospital treatment; prison populations; persons failing to meet the profile described in the “Target Population” section.

How will the participants be acquired? 
Acquisition of participants should happen through a combination of all available methods, such as referrals from hospitals, community health centers, private health practitioners or citizens (like a concerned friend or spouse). Also, patients should be encouraged to join therapy by themselves. Therefore, the strategy for publicizing the group should be three-pronged and include actions aimed at raising awareness among general public, among at-risk population, and among health care practitioners.

The group program
The program would consist of four sessions: two of them will be aimed at eliminating or teaching how to manage negative emotions, while two others would assist patients in developing a sense of dignity and control of their own life.

Description of overall program: 
Aims Session One:
Dealing with Guilt Self-mutilating behavior is most frequently associated with guilt, especially among female adolescent or young women (Rodham, Hawton & Evans, 2004). As a consequence, teaching patients to acknowledge guilt and deal with it in a constructive manner should be one of the main goals of the therapy.

Session Two:
Managing Anger and Anxiety Winchel and Stanley (1991) established the “presence of a group of patients, most of whom are young and female, with a high rate of self-injurious acts associated with poor tolerance of anxiety and anger” (p. 308). Thus, another aim of the group therapy would be to educate patients in the management of their anxiety and rage.

Session Three:
Empowerment Self-mutilation can sometimes be a sign of the patient’s craving for control over her own body and, symbolically, over her life. For them, cutting or burning themselves produces a feeling of empowerment thy need to counter the feeling of helplessness (Leibenluft, Gardner & Cowdry, 1987). Patients should be shown other avenues to empowerment, such as education, satisfying career, or fulfilling relationships.

Session Four:
Building Self-Esteem Podvoll (1969) notes that patients that engage in self-injurious behavior are so insecure they do not dare express their anger to the outward world; by redirecting aggression toward oneself, their rage and explosiveness appear to be fixed on a seemingly indestructible object, their own body. Thus, patients have to develop a sufficient degree of self-esteem to be able to engage in constructive conflict with others. Higher self-esteem would also serve to counter or prevent disorders which often go hand in hand with self-mutilation in young females, such as eating disorders (Yaryura-Tobias & Neziroglu, 1978; Favazza & DeRosear, 1989). Thus, developing a healthy body image would be another goal of the therapy. Higher self-esteem might potentially lead to a more active lifestyle, which would in turn eliminate root causes of other problems causing or accompanied the tendency to self harm, such as substance abuse or depression.

Group facilitators 
The group should be run by an experienced mental health practitioner, with a co-facilitator. Co-facilitator comes in handy when a patient fails to develop an effective therapeutic relationship with the mental health practitioner for the reason of personal idiosyncrasies. Co-facilitator does not need to be a qualified mental health professional; a nurse would be the most appropriate candidate. One guest speaker should be invited: rather than having an authority figure speak (e.g. an anger management guru), it is better to involve a patient who has successfully dealt with her self-mutilation problem. Group participants might have an aversion to authority after having dealt with psychiatrists or maybe even police officers as a result of their self-mutilation experience.

Time frame of group program
Sessions should last for two hours and take place every week. Consequently, the entire course of therapy would last for a month. One month is a sufficient amount of time for patients to initiate a positive personality change; a longer course might result in a high drop-out rate. Compliance might be an important obstacle to the success of group therapy, since it is reported that between a quarter and a half of patients who self harm do not attend out-patient appointments even though they had committed to doing so when seen during their in-patient stay (Morgan et al., 1976). Therefore, a relative short duration of the course should be seen as an advantage. Drop-out is a very negative phenomenon in terms of group dynamics and should be avoided at all cost.

Meeting once a week would give patients time to work on issues on their own. Furthermore, patients should be given homework they should commit to doing, presenting the results during the following session.

Tentative plan of each session 
Group therapy has been shown to be an effective way to enhance affect-management skills among female patient suffering from post-traumatic stress disorder and dissociation. The profile of women with these symptoms is very similar to those who engage in self-mutilating behaviors, therefore it is appropriate to borrow certain methodological tools from such therapy. In general, each session will be structured similarly and include a “review of the previous week’s homework, a psychoeducational presentation, followed by skill building, application of skills, and assignment of homework” (Zlotnick et al., 1997, p. 431). In the first session, patients should be encouraged to introduce themselves and share their experiences. The facilitator will then talk the issue of guilt through, perhaps by discussing an example of a person who had done something wrong, suffered from an excruciating feeling of guilt, and was able to move on as time went by. This will give patients a positive example to look up to; furthermore, comparing their experience of guilt caused by something illusory and insignificant (which it is in most cases) with what the discussed person had to go through will assist them in letting go of their negative emotions.

The second session devoted to controlling rage should enhance patients’ skills in such fields as “identification of emotions, crisis planning, anger management, and techniques for distraction, self-soothing, distress tolerance, and relaxation” (Zlotnick et al., 1997, p. 431).

As it has been outlined above, the first two sessions should aim at helping patients overcome and learn to control negative emotions. Winchel and Stanley (1991) note that in the case with self-injurious patients, the “havoc they wreak on their bodies may be seen as directed toward internalized representations of others or as attempts to undo guilt. Episodes of self-injury may often be temporally linked to crises in relationships with significant others” (p. 309).

Thus, the last two sessions should equip patients with skills necessary to reestablish meaningful contact with others and build a sense of self-worth. Such an approach might seem rather unconventional: usually therapy focuses solely on the removal of causes of a particular disorder. However, having patients move on with their lives and develop fulfilling relationships is the best safeguard against relapse. Research indicates that problem solving therapy has a potential for reducing recurrence of self-harm in patients (Hawton et al. 1998).

This approach, in essence, is a combination of behavioral techniques and features of cognitive therapy. Changing dysfunctional attitudes speeds up recovery and contributes to the stability of treatment results. Cognitive therapy, in itself, rest upon the basic rationale that a person’s emotional responses and behavior are to a great extent determined by the way that individual perceives the world. Person’s cognitions stem from attitudes and stereotypes developed from previous encounters with particular phenomena. In other words, this type of therapy focuses on changing peoples’ perceptions and attitudes instead of attempting to alter the surrounding conditions.

The group will have the following benefits for the participants:

it will assist them in overcoming feelings of guilt and rage; it will teach them how to acknowledge and manage their emotions; it will give them confidence and willingness to engage in meaningful activities and personal development; it will provide human contact and motivate them to develop relationships with others.

Given the short duration of the course, evaluation of each session might be unnecessary. Instead, an effective evaluation technique of the entire course should be developed. First of all, a self-report will be filled in by patients following the completion of the therapy. Patients will be asked to evaluate their emotional state (e.g. feeling more or less depresses, guilty, angry etc.) and acquisition of new skills (e.g. interpersonal skills, self-motivation, long-term planning etc.). However, given the inherent subjectivity of self-reporting mechanisms, follow-up evaluation is necessary. Readmission rates for self-mutilation among group members will be checked every two months. Another follow-up measure might be implemented: devising “a way of offering contact and support which would be available at any time of day or night and which could be used at the earliest possible moment should difficulties recur” (Morgan, Jones & Owen, 1993) to patients with a history of self-harm has been proven effective.

Ethical issues
Ethical issues are very likely to arise given the profile of patients. Self-mutilating behavior can sometimes be caused by antisocial personality disorder (Zlotnick, Mattia & Zimmerman, 1999), therefore some group members might express disregard for others. This might be very dangerous, since patients with a history of self-injury have heightened sensitivity to interpersonal rejection (Klonsky, Oltmanns & Turkheimer, 2003). In case such a situation arises, the co-facilitator should talk to the offender in private and try to resolve the conflict. Furthermore, having participants themselves establish group rules at the beginning of the process is a must.
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