Nursing
January 1, 2002

Do No Harm
By Penny Simpson Brooke

Question: I’ve recently started working in the acute psychiatric unit of a general hospital. One technique that the nurses use for suicidal patients is a no-self-harm contract. The primary nurse negotiates with the patient, then prepares a contract spelling out the nurses’ and the patient’s responsibilities in therapy. The primary goal, of course, is for him to promise not to harm himself.

I’m wondering, though, if such a contract can be considered binding, especially if the patient isn’t competent when he signs it. —J.E., N.M.

Answer: The no-self-harm contract you describe isn’t legally binding, whether the patient is competent or not. It’s a therapeutic (not a legal) tool designed to heighten his commitment not to hurt himself. Having this type of contract doesn’t change your responsibility to assess your patient’s suicide risk or absolve you from all liability if he does commit suicide.

You’re correct in assuming that a legally incompetent person lacks the ability to enter a contract, but the fact that someone’s receiving psychiatric care doesn’t mean he’s incompetent. If any patient needs to make an informed decision and you have concerns about his competency, contact his primary care provider.


The Canadian Press (CP)
January 9, 2002

St. Thomas, Ont., health officials concerned about kids’ self-mutilation game

ST. THOMAS, Ont. (CP)—Health officials are concerned that children at schools in this southwestern Ontario community are playing a game that draws blood. In some schools, students in Grades 5 through 9 are participating in “wussy tests.”

In the “wussy test” students scratch the skin off the back of their own hands until they bleed or can no longer continue.

This practice raises many concerns, including the danger of infection, peer pressure and self-esteem issues, said Carolyn Kuntz, acting administrator of the Elgin-St. Thomas Health Unit.

The health unit has produced a fact sheet on the problem after being contacted by concerned school principals, Kuntz said.

The danger of infection is present during this activity because hands come into contact with many bacteria and viruses, and are home to hundreds of microscopic germs.

Kuntz said germs enter the body through cuts and open sores to cause disease. The “wussy test” provides a route to infection.


This is Local London
January 22, 2002

Manson’s followers in self-mutilation

Catford: The bloody discovery of a gang of occult-obsessed children who had mutilated themselves in a Catford home has prompted a warning to parents from police.

The gothic kids, all devotees of rock star and self-proclaimed Satanist Marilyn Manson, were found at a house in Broadfield Road by specialist officers after a phone call from one of the missing children’s parents.

Police are calling on parents of children who show an interest in the occult to be vigilant and said the discoveries in Catford were “probably the tip of the iceberg.” Two boys aged 14, another boy aged 15 and a 14-year-old girl, all from Bromley, were discovered in the semi-detached home of an 18-year-old man, whose parents had gone on holiday. They had all been slashing their arms and wrists.

The man’s parents had padlocked all the doors in the house, except his bedroom and a couple of rooms downstairs.

Mottingham PC Jim Duncan, who specialises in the dangers of the occult, said he and his colleagues were “terrified” by the mental state of the children when they were found.

He said: “They seemed happy in their own little cocoon, it was as if we were disrupting their thoughts. When we realised what was going on and began speaking to them about God and Satan, they launched a really venomous verbal attack. The 14-year-old girl is very intelligent. She told me she would be dead by the time she was 15. It was a genuine statement on her part. She wasn’t trying to shock me.”

He added: “The kids are so far into self-harming and Marilyn Manson, that nothing else matters.”

The girl, who had been off school because of depression, had recently overdosed on Paracetamol tablets.

The youths are known to have scrawled disturbing poetry, apparently written in blood, on the walls of a car parks, stating: “I’m bleeding in mind and soul.”

PC Duncan is urging concerned parents and those worried by their involvement in the occult to call him on 07703 682820.


Gloucestershire Echo
February 6, 2002

Katie Hopes to Help Sufferers; Teenager Starts Group for Self Harm Victims

KATIE Foulser was 16 when she began slashing her arms with a kitchen knife.

Acts of burning herself and pulling her hair out followed along with taking overdoses and carving words, such as evil and hate, into her skin.

The 18-year-old, from Cheltenham, now hopes to use her traumatic experiences to help others. Katie feels the condition is not taken seriously enough and that some people treat it as a “taboo” subject.

The teenager, who has put her own problems behind her, has set up the Self Harm Alliance to help and support other sufferers.

She said her condition was triggered by a combination of things including being raped, bullied at school and her parents’ divorce.

“It began with small cuts to my arm,” she said.

“Although I didn’t know it at the time, when you cut yourself, the body releases hormones (endorphins) which help it to deal with the trauma and these give a natural high. The first time you do it you get a quick release. The more you self harm, the more you need to cut or burn to get the original buzz. Cutting is the most popular way, using anything from razors to knives or simple things like staples. It escalates on to hitting yourself, pulling hair out and even breaking bones. It’s extreme but it’s easy to explain away. Some people even swallow poisons.” Katie’s parents realised their daughter needed help and took her to a GP to get counseling and psychiatric treatment.

She was hospitalised several times and was once sectioned under The Mental Health Act.

Katie is now looking to the future and she says setting up the support group has helped her do that.

She wants to raise awareness of the condition and provide help for others.

The SHA is one of the first support groups in Britain to deal with the subject.

The condition affects mostly girls and women aged between 12 and 25. Usually they have suffered some kind of serious trauma.

The group has a team of four trustees and seven volunteers who offer support, information and advice. Most of them have either recovered from self harm or have helped a friend or family member to recover.

To continue its work, the group needs to raise more funds.

If the SHA can amass GBP 1,000 in its bank account, it can apply for charitable status. An appeal has been made for ideas on how to raise more cash.

Katie says she hopes the group will grow to a point where it can be office-based.

On March 1, the alliance is planning to mark national self injury day, an American idea, with conferences and presentations by professionals involved in treating self-harm patients.

To contact the alliance for advice, ring the helpline on 01242 578820. It is open Wednesday to Sunday, each week, from 7pm to 8pm. An answering machine is on at all other times. Or log on to the alliance website at www.selfharmalliance.org, or email the group on selfharmalliance@aol.com


The Times (London)
March 2, 2002

The blade became an anaesthetic, a way to take a holiday from myself

By Nick Johnstone

When I was 18 I cut my left wrist with a razor blade. This was not a suicide attempt. In fact, it was the furthest possible thing from a suicide attempt. I prefer to call it a “life attempt.” All I wanted was to feel alive again. I was drunk the night I did it. I was also at the end of my tether. It was summer, 1989. I was coming to the end of my gap year and about to begin an English degree at the University of London. I had gone to the doctor in January after fantasising about making cuts on my arm with a Stanley knife. Not that I told him that. What I did tell him was that I was having trouble sleeping, that I was crying all the time, drinking heavily and waking up shaking with dread at the thought of the day ahead. He diagnosed severe depression and anxiety and put me on anti-depressants.

Once the medication kicked in, everything was fine for a few months. Then it came back. And, as would soon become a pattern, when the depression and anxiety came back, I drank to numb the feeling of being locked out of the world and I cut. When I first cut myself that summer, I was trying to excavate the part of me that had gone missing, that was frozen beneath the depression. For the next four years, I cut myself on a regular basis, always with a razor blade. It was a coping mechanism, a survival technique. As incomprehensible as it sounds, cutting saved my life.

Today, 31 years old, a full-time writer, sober for seven years and happily married, I know that self-harm is a symptom of underlying problems that feel unmanageable. Most healthcare professionals call it “self-harm” or “self-inflicted violence.” The most frequently reported forms of self-harm are cutting (with razor blades or knives) and burning (mostly with cigarettes or lighters) although hitting (in extreme cases, breaking bones), trichotillomania (pulling out hair) and scratching (mostly the face, arms and legs) are also common.

I only ever cut and I did so with care. The planning that accompanies self-harm often baffles psychologists. I never cut unless I had the following to hand: a tube of Savlon, a box of plasters and a packet of tissues. I never wanted to do any damage to myself. This is important to understand. The ritualistic nature of self-harm is all about imposing order on a life that has spiraled out of control. When I cut I was always drunk and I always felt like I was going to explode.

During the act of cutting—and I only ever cut the insides of my arms and wrists—I experienced “dissociation,” the sensation of “leaving” reality for a moment. The blade became an anaesthetic, a way to take a holiday from myself. When blood appeared, the holiday was over. But I always felt a massive sense of relief, as though it had rained after weeks of lifeless, humid weather. Then I washed the cuts, disinfected them with Savlon and dressed them with a plaster.

Self-harm is also a very private act. I wore long sleeves until the cuts healed. I kept it secret from my family, from girlfriends, friends. I thought they would think I had gone crazy. There were times when I thought the cutting meant that I had. Not long after I went away to university I was again diagnosed with severe depression and anxiety. I was referred to a psychiatrist. At one appointment, I showed him fresh cuts. His response was to raise the dose of anti-depressants I was taking.

I’ve read stories like this on the most useful self-harm website, Secret Shame, as well as on the 100-plus web sites linked to the web ring, Bodies under Siege. However, I’ve also read accounts of people getting the help they needed after they were honest with doctors and psychiatrists. When I was 20 and up to my third diagnosis, I was referred to a wonderful therapist who worked weekly with me for the next 18 months. I never told her about the cutting. But she helped teach me new ways to express myself.

When I was 22, I graduated with a 2:1 in English. I also stopped cutting. I can’t say why for sure, but I can say that I no longer felt the need to do it. Since then, I’ve read books such as Tracy Alderman’s The Scarred Soul, Caroline Kettlewell’s memoir Skin Game and Marilee Strong’s A Bright Red Scream. I’ve learnt from organisations such as The National Self-Harm Network in London (020-7916 5472) and Bristol Crisis Service for Women (0117 925 1119) that self-harm is a typical symptom of severe depression, that it usually comes on in females between the ages of 15-19 and in males between 20-24, that as many as one in ten teenagers are estimated to self-harm and that in most cases, with professional help, it stops. I’ve also learnt that it affects a tremendous number of people across the world who needlessly suffer in silence. Some of them are my friends now. And best of all, it’s been almost ten years since I’ve used a razor blade for anything other than shaving.


San Antonio Express-News March 6, 2002

Self-injury can be sign of stress

It has been called many things—self-inflicted violence, self-injury, self-harm, self-abuse, and self-mutilation.

In basic terms, self-injury is the act of attempting to alter how someone feels emotionally by inflicting physical damage to the body. This can include cutting with knives, razors, glass, pins, or any sharp object; burning; hitting your body with an object or your fists; hitting a heavy object like a wall; picking at skin until it bleeds; biting yourself; or pulling your hair out.

Research shows that self-injury is a way of dealing with difficult feelings that build up inside. Anyone who is harming himself or herself is struggling to cope. If people do not get help when they need it, the situation will only get worse. Twenty two-year-old Andres (not his real name) is familiar with this because of his own self-abuse as a teen.

“I had a lot of problems with my dad,” he said. “We had a very abusive relationship.”

In severe cases of self-harm, medication is necessary to control the problem. In others, therapy to teach new coping mechanisms is effective.


The Associated Press State & Local Wir
March 10, 2002

‘Cutter’ goes public to help expose practice of self-injury By Martha Irvine

Long sleeves couldn’t hide the secret—not from her parents and a college roommate, who began to notice inconsistencies in the stories she made up about her scars.

Now Elizabeth Franas is going public with her problem and even gearing her studies at Central Michigan University to prepare for research that could eventually help her and others.

Franas is a “cutter,” a commonly used term for the estimated hundreds of thousands of people who injure themselves regularly—and deeply enough to draw blood—in times of stress, anxiety and depression. Some have called the practice the anorexia of a new generation, particularly for girls who seem to have a hard time expressing anger and frustration.

“We don’t know how to verbalize our pain, so we write it on our bodies,” says Franas, who’ll be 20 next month and is finishing her sophomore year. “I bleed it out instead of talking it out.” She’s used everything from broken glass and staples to her own fingernails to draw blood on her arm, belly and hip—inexplicably, all on her left side.

Even now, Franas occasionally gives in to the urge to cut herself with razor blades, thought to be the most common way cutters and other self-injurers hurt themselves. For some, the alarming trend also includes biting, burning and even self-strangulation (generally without the intention of suicide).

It is a quiet and often shame-filled obsession.

“You think you’re the only one. You feel like you’re absolutely crazy,” says Franas, who has also been diagnosed with an eating disorder and obsessive-compulsive disorder, both common diagnoses among self-injurers.

A trip to the hospital for stitches—one of three since she’s been at college—revealed her secret to her roommate and a dorm adviser. Their support prompted her to slowly start sharing it with others. And she found she was far from alone.

“Literally every person I talked to knew someone like me,” she says.

Steven Levenkron, a New York psychotherapist who treats cutters, says that’s not surprising. He used to believe that one out of every 250 people was a self-injurer.

“But in interviewing school guidance counselors, they literally laugh at me,” says Levenkron, author of several books on cutting, anorexia, and obsessive-compulsive disorder. “They’re saying one out of 50, and one out of 100.”

Levenkron says therapy and prescription drugs, including antidepressants, have helped his patients subdue urges to hurt themselves. About 80 percent of his patients are girls and young women. And though the source of their anger has many sources, he says as many as 70 percent have been molested.

Despite successes, he and others note that help for self-injurers can be difficult to find, or at the very least expensive, in a profession that is grappling with its own misconceptions of the disorder.

Levenkron says some therapists are afraid cutters will kill themselves. “But this is not a suicide attempt. They all assume they will live to cut again,” he says, noting that the cuts are generally less than an inch long.

Support groups for cutters have formed at some schools, including Central Michigan and Bryn Mawr College. But they are still the exception, partly because shame keeps some students from coming forward.

“It’s still so underground,” says Franas, who began speaking at public forums on the issue last year.

A psychology major, she’s also taking upper-level courses in neuroscience and is among the youngest students helping with Parkinson’s and Huntington’s disease research at the university’s Brain Research Laboratory. It’s all part of her plan to eventually do research on self-injuring.

She’s also writing a memoir for her senior honors project, which she’ll complete in two years. “I’ve learned that I can get my emotions out with a pen,” says Franas, who’s gone from cutting one to three times a day to once “every couple months.”

Her parents, who live about two hours south, in suburban Detroit, are both pleased with her progress and astounded by her decision to go public.

“I said, ‘It’s going to be like coming out of the closet for a gay person back in the old days,”‘ her father, Ben Franas, says. “But she said, ‘I’m ready to do this, Dad.”‘

This from the daughter they dragged from therapist to therapist after her mom first saw deep scratches on her shoulder in late 1999, as Franas was getting out of the shower.

“The first time they found out, my dad cried,” says Franas, who was a high school senior at the time.

Then came the question that was tough to answer.

“Why do you do this?” asked her parents, who had never heard of cutting.

She was, after all, a good student and an accomplished gymnast with a dream of competing at the college level.

But her parents had been consumed by the emotional troubles of their older daughter, Tara, and didn’t realize that their youngest had developed an eating disorder. Tara eventually worked things out, after an ordeal of her own: She told her parents she’d been raped but was too scared to reveal it to them for more than a year.

The family turmoil took its toll on the younger Franas, leaving her feeling ignored.

“My sister was running the family,” says Franas, whose eating disorder began to sap her strength and ability to train for six hours a day. “It wasn’t her fault, but there wasn’t much left for me.”

Then Franas’ much-loved gymnastics coach decided to return to Russia.

“That was the beginning of the downfall for Elizabeth,” her dad says.

Unable to hold herself together to train, the self-described “adrenaline junkie” quit the sport—and with that, lost her stress outlet, and her dream.

“I was like an animal in a caged box that’s trying to get out,” she says. “That’s pretty much what it felt like.”

The feeling led her to repeatedly dig her fingernails into her arm. Six months later, she started cutting and ended up spending the rest of her senior year studying at home.

“A lot of friends gave up on me really quickly,” she says, recalling one boyfriend who told her to quit to prove her love.

“As if it was about him,” she says, rolling her eyes.

As rough as it got, Franas stuck with plans to go to college—a move her parents nervously supported.

“At home, my identity was gymnastics,” says Franas, whose bedroom in her parents’ house is still filled with medals and trophies. “Here, I could start again.”

She has since found a therapist she likes and, last year, made the decision to take medication. Through it all, she says family and a few core friends have stuck with her.

“I’ve tested their support, pushed them away,” she says. “But they say, ‘I’m going to be there for you, like it or not.”‘

She’s also slowly letting go of the gymnast image.

“I’m a writer. I’m a good student. I’m a good friend,” she says. “I’m slowly learning to take that in.”

And maybe she’ll be a researcher who’s able to help those like her.

“I may not cut every day, but that urge will always be there,” she says. “I know I’m going to be dealing with this for the rest of my life.”


South China Morning Post
March 24, 2002

Counselor uses memories of self-mutilation to help others
By Ella Lee

A young woman who used to harm herself when upset over poor relations with friends has now become a counselor for a youth hotline and helps people her own age who are suicidal.

Vickie Chan Wai-hay, a third-year student of psychology and counseling at Shue Yan College, used to inflict injuries on herself to gain attention.

“When I was a Form Three student, my classmates rejected me. I felt so depressed. I slashed my hands with a cutter several times,” she said. Her behaviour is not unique. Self-inflicted injuries have become a disturbing trend among some young people. “I wanted to draw attention by hurting myself. I wanted my friends who saw my injuries to care about me. But I was wrong. My friends talked to me again not because they liked me, just because they were scared.”

Ms Chan, 21, said she recovered through the care and support of her parents and a guidance teacher and now has a positive outlook on life.

As well as her studies, she also performs voluntary work as a counselor for the Youth Line, run by the Hong Kong Federation of Youth Groups. She wants to be a professional counselor after graduating to help people who have had similar experiences.

Ms Chan says she has received calls from people who say they want to die.

“I encourage them to think more about the good side of life, their families and people who care about them,” she said. “Young people in this generation are even more fragile than my generation. They do not treasure life. They think about suicide whenever they cannot solve a problem.”

Shirley Kwong, a schoolmate of Ms Chan and another volunteer for the hotline, also thinks today’s teenagers are vulnerable. “It’s probably because they have a good standard of living and have no experience of difficulty or trauma in life,” she said.

She said children as young as seven or eight had called in for emotional support.

“A Primary One student called and said he was so lonely because his parents are always out working,” she said.

Andy Ho Wing-cheong, supervisor of Youth Line, said calls to the hotline had increased since last Sunday’s tragedy. Social workers had been particularly disturbed by the casual way some callers talked about suicide.

“Some teenagers called and said they were unhappy about the incident, but some said the pictures of the three dead bodies showed they died with no pain. They thought suicide was not a big deal—that is very worrying.”


The Practitioner
March 26, 2002

Reducing repeated deliberate self-harm

* What is the relationship between deliberate self-harm and suicide?
* What are the likely motivators to self-harm?
* How can the GP help to prevent further attempts at self-harm?

Repetition of deliberate self-harm appears to be on the increase: in women it is the most common cause of acute admission to hospital, and in men it is second only to admissions for ischaemic heart disease

Julia MA Sinclair MRCPsych, Specialist Registrar in Psychiatry, Oxford Mental Healthcare Trust, Warneford Hospital, Oxford

Keith Hawton DSc, FRCPsych, Professor of Psychiatry, Director, Centre for Suicide Research, and Consultant Psychiatrist, Oxford Mental Healthcare Trust, Warneford Hospital, Oxford

Deliberate self-harm (DSH) is extremely common in the UK, particularly in young people—so common in fact that prevention of suicidal behaviour is a government health priority.1

There are over 170,000 presentations for DSH per year to general hospitals, and recent evidence suggests that repetition of DSH is an increasing problem. It is the most common cause for women of acute admission to hospital, and in men it is second only to admissions for ischaemic heart disease. However, these figures represent only part of the picture as many acts of DSH do not result in admission to hospital and are dealt with in primary care, if they are disclosed at all. A GP with a list of 2500 patients is likely to have five to eight patients a year present to specialist services following an episode of DSH, and GPs themselves may manage many more who admit to a recent episode of DSH as part of their overall presentation.

The term deliberate self-harm is used to describe an act of intentional self-poisoning or self-injury, without reference to whether or not death was the intended outcome, which is often far from clear. It describes a spectrum of behaviours from impulsive superficial self- cutting, which rarely presents to medical attention, through to premeditated and carefully planned suicide attempts, which, for some reason, did not result in death.

While in these extreme examples it may be easy to differentiate intent, most cases are less clear-cut and presentations require a careful risk assessment.

Over 90 per cent of presentations to hospitals following an episode of DSH involve self-poisoning, and the choice of substance taken appears to be related to its availability and perceived toxicity.

A thorough assessment of the patient is necessary to elucidate the factors precipitating the overdose, ongoing suicidal intent and the risk of repetition in similar circumstances in the future.

It is also important to screen for an underlying psychiatric or substance misuse disorder, which may be amenable to treatment.

* Epidemiology. Deliberate self-harm was recognised as an increasing problem during the 1960s and early 70s. Since 1976 the Oxford Monitoring System for attempted suicide has collected data on all presentations following an act of DSH to the general hospital in Oxford.

In the early 1990s there was a sharp rise in presentations following DSH for both men and women in all age groups except the over-55s. In the past few years this trend has started to decline in men, especially the 15-34 age group, but in women the rates have remained relatively stable.2

* Relationship of DSH to suicide. There is a significant association between episodes of DSH and suicide. Some 20-25 per cent of suicide victims presented with an episode of DSH in the year prior to their death, and up to 50 per cent of those who ultimately commit suicide have a life-time history of DSH.

Conversely one per cent of DSH patients die within the year by suicide. This risk is highest in those with multiple episodes of DSH.

As DSH is a very frequent occurrence and suicide a relatively rare event, it is difficult to predict those patients within the DSH population who will ultimately kill themselves; however, there are certain factors that suggest higher suicidal intent is involved in an act of deliberate self-harm. These should alert the assessor to an increased possibility that a further attempt is both likely and may prove fatal. However, even accurate recognition of high-risk patients is not a sensitive predictor of eventual suicide.

* Substances used in self-poisoning. The frequency with which a prescribed medication is taken in overdose appears to reflect its relative availability and perception of its toxicity. Over the past 20 years there has been a decline in the use of benzodiazepines and other hypnotics for self-poisoning. This mirrors the reduction in the prescribing of these substances in general practice.

* Antidepressant drugs. In Oxford there has been an increase in the use of antidepressants taken in non-fatal self-poisoning, which also reflects their increased use in general practice for the treatment of depression.

Recent trends in the substances used for self-poisoning also show an increase in selective serotonin reuptake inhibitors (SSRIs) and decrease in tricyclics.2

In a study of the fatal toxicities of antidepressant drugs between 1987-92 the data on the number of antidepressant prescriptions for general medical practices within the NHS for England, Wales and Scotland was compared against the number of deaths due to acute poisoning by a single antidepressant.3 From this, the number of deaths per million prescriptions was calculated. The results showed that 81.6 per cent (1310/1606) of deaths from antidepressant overdose were with two drugs: amitriptyline and dothiepin.

The number of deaths per million SSRI prescriptions was found to be 2.02 whereas the overall rate for tricyclic drugs was 34.14.

The selective serotonin reuptake inhibitors (SSRIs) are now more frequently prescribed in general practice, and therefore more accessible for use in self-poisoning, but they are less dangerous in overdose and more likely than the TCAs to be prescribed in therapeutic doses for the treatment of depression and anxiety disorders.

* Paracetamol. Until recently there had been a rapid rise in the use of paracetamol in DSH in line with increasing sales. At its peak, paracetamol poisoning was responsible for almost half of all cases of liver failure in the UK.

However, a prospective study of the effects of limiting paracetamol and salicylate pack sizes showed that following legislation in 1998, the rate of non-fatal self-poisoning with paracetamol was reduced by 11 per cent and the annual number of fatal poisonings by 21 per cent.4 The general effect of the legislation has been to limit the quantity of paracetamol in households and thus its availability for impulsive acts of self-poisoning.

* Repetition of DSH is also recognised as an increasing problem, and one that has implications for finding effective prevention and clinical management strategies.

There is evidence from the Oxford Monitoring System that repetition becomes more likely with increasing acts of DSH.2 Of those patients assessed in 1999 with no previous history of DSH, only ten per cent repeated self-harm within the following year, compared with 32.4 per cent of those who already had a history of prior DSH.

…any patient with ongoing suicidal thoughts, especially if they already have a history of DSH, should be considered at risk of further self-harm.

Management

At present there is limited evidence for the effectiveness of either pharmacological or psychological interventions.12 However, low-dose flupenthixol has been found effective in reducing the repetition of DSH in those with a history of multiple episodes, and a brief psychological intervention aimed at identifying and helping to resolve interpersonal difficulties may be of value.14

* Assessment. Some 90 per cent of episodes of DSH presenting to hospitals involve self-poisoning, often associated with alcohol intoxication at the time of the act. As a general rule the medical severity of the overdose is not necessarily related to suicidal intent, except in those cases where the act has been premeditated and the patient has hoarded tablets as part of their preparation, or the patient has clear knowledge of the dangers involved.

Self-injury is most likely to present as superficial cutting to the wrist and forearms and is associated with low suicidal intent. Violent forms of self-injury such as stabbing or gun shot wounds are less common in survivors of DSH, and are more suggestive of serious suicidal intent.

Severe and unusual forms of self-laceration (mutilation of eyes, genitals and so on) are often associated with severe mental illness and should raise the suspicion of an underlying psychosis.

* Intention. Although about one-third of those who harm themselves claim an intention to die at the time of the act, other factors in the history and circumstances around the time of DSH would suggest that serious suicidal intent is far less common than stated.

DSH is a highly impulsive act, commonly occurring at a time of tension and when disinhibited by alcohol. Consequently, the degree of planning may be as little as a few minutes and the availability of a particular substance or method the main factor in the choice of its use.

The motivation to self-harm is often complex; it may be seen as a temporary escape from an intolerable situation or escape from psychic or physical pain; it may be a way of communicating distress or anger to family members or professionals involved in their care; and it can be a way to try to influence the behaviour of others.

It is an important part of the assessment to understand the chain of events, both distal and proximal that culminated in DSH, and elucidate the likely motivation, intention and severity of the act, and the probability of its re-occurrence.

* Past history. There is an association between childhood sexual abuse and DSH. Patients have often had a disrupted early childhood and have poor problem-solving skills. Consequently they may find it difficult to think of alternative solutions in a difficult situation, and helping them to do so may form an effective part of their initial management.

* Screening for psychiatric disorders. Over 90 per cent of patients will fulfill the criteria for an ICD-10 psychiatric disorder at the time of DSH. In a recent study of 150 representative DSH patients assessed following an episode of DSH, 72 per cent had a depressive disorder, 26.7 per cent harmful use of alcohol or alcohol dependency, 8.7 per cent another substance misuse disorder and 45.9 per cent comorbid disorders.5

The identification of treatable underlying psychiatric conditions should always be a main focus of assessment.

* History from relevant others. The value of a collaborative history, wherever possible, in the assessment and management of patients cannot be overstated. Important details of history, symptomatology and motivation not volunteered by the patient may be vital for an accurate risk-assessment to be made.

The support of family members and close friends is often also integral to the management plan.

* Recognition and treatment of underlying psychiatric conditions. Depression is the most common disorder in deliberate self-harm patients, and the mortality rate from suicide in patients with major depression has been calculated to be 20 times the expected rate.6 A study in Finland7 found that over 60 per cent of DSH patients reached the DSM-III-R diagnostic criteria for depression, and that only a minority were receiving therapeutic doses of antidepressants at presentation.

In a similar study in the United Kingdom, 86 DSH patients who met the criteria for ICD-10 major depression at initial presentation and who were followed up 12-20 months later,8 29 patients (36.3 per cent) remained in contact with secondary psychiatric services and 12 (15 per cent) continued to be treated for mental-health problems by their GP.

A quarter of those receiving no treatment still reached the criteria for a depressive episode. Of the 27 patients (31.4 per cent) who reported a further episode of DSH during the follow-up period, more met the criteria for a depressive episode at the time of follow-up (42.4 per cent versus 20.0 per cent).

Adequate treatment with therapeutic doses of antidepressants in patients with major depression may reduce the likelihood of repetition of DSH and prevent suicide.9

* Recurrent brief depression. RBD appears to be a common condition, with one-year prevalence rates of between four and eight per cent.10 It is characterised by brief but severe depressive episodes, lasting less than two weeks, recurring at least monthly over one year and associated with significant social and occupational impairment.

As yet there is no established treatment for RBD. Most patients seem to recognise the intermittent nature of their disorder, but some present to doctors while acutely depressed, demanding treatment.

It is probably misguided to attempt to manage acute episodes of RBD with antidepressants, as the episode will usually have resolved before the medication has time to be effective. It may be helpful to advise patients to limit their alcohol consumption, and to avoid prescribing benzodiazepines in view of the reported tendency of these drugs to cause disinhibition.

* Substance misuse Some 20 per cent of those who are alcohol-dependant engage in acts of DSH, and eight per cent ultimately kill themselves. Screening of all patients for alcohol misuse should therefore be an essential part of any assessment.

Brief psycho-educational interventions in primary care have been shown to be effective in reducing harmful use of alcohol, thereby also relieving associated depressive symptoms, and the likelihood of impulsive acts of DSH.

* Other psychiatric disorders In the United Kingdom Study of DSH referred to above,5 personality disorders were identified in 45.9 per cent of 111 patients followed up 12-20 months after an episode of DSH, and only two of these did not also have an Axis 1 (psychiatric) disorder at initial presentation.

The risk of suicide in those with co-morbid psychiatric and personality disorders has been found to be increased six-fold compared with the risk in individuals with psychiatric disorder alone.11

Although rare, psychotic disorders may present with an episode of DSH. Any bizarre or violent acts of self-mutilation should particularly raise the suspicion of an underlying psychotic process.

* Psychosocial interventions. A systematic review of the efficacy of psychological and pharmacological treatments in preventing repetition of DSH found little convincing evidence for the efficacy of most treatments.12 The only psychological treatment for which a significant reduction in rates of further self-harm were seen was dialectical behaviour therapy in women with borderline personality disorder and a history of multiple episodes of DSH.

Low-dose neuroleptics were also associated with a reduction in repetition of DSH in similar patients. Recent evidence suggests that a brief psychological intervention may reduce risk of repetition,13 and significant benefits of similar therapy for depression, hopelessness and problem-solving have been shown in a meta-analysis of studies.14

Table 1 Risk of suicide after deliberate self-harm.

* Act of DSH planned long in advance.
* Suicide note written.
* Actions in anticipation of death (writing will, sorting personal effects).
* Alone at time of DSH.
* Attempts to avoid discovery.
* Did not seek help following the act.
* Stated wish to die.
* Thought act would prove fatal.
* Sorry/angry that act failed.
* Ongoing suicidal intent.

Table 2 The base rate problem in predicting suicide.

* If the risk of suicide in year after DSH is 1%, then 1000 attempters will give rise to 10 suicides.
* Assuming that prediction of suicide is 80% accurate, then:

Correct prediction = 8/10 suicides
Incorrect prediction = 2/10 suicides
Plus 192 false-positive predictions of suicide

Table 3 Characteristics associated with an increased risk of further deliberate self-harm.

* Previous deliberate self-harm.
* Alcohol misuse.
* Illicit substance misuse.
* Unemployment.
* History of violence.
* Forensic history.
* Personality disorder.
* Age 25-54.
* Social class V.
* Previous psychiatric treatment.
* Unrelieved distress.

References

1. National Service Framework for Mental Health, DOH. London 2000.
2. Hawton K, Hall S et al. Deliberate Self-Harm in Oxford 2000. Annual Report 2000.
3. Henry JA, Alexander CA, Sener EK. Relative mortality from overdose of antidepressants. BMJ 1995;310:221-4.
4. Hawton K, Townsend E, et al. Effects of legislation restricting pack sizes of paracetamol and salicylate on self-poisoning in the United Kingdom: before and after study. BMJ 2001;322:1-7.
5. Haw C, Hawton K, et al. Psychiatric and personality disorders in deliberate self-harm patients. Brit J Psychiatry 2001;178:48-54.
6. Harris C, Barraclough B. Suicide as an outcome for mental disorders. Br J Psychiatry 1997;170:205-28.
7. Suominen K, Henriksson M, et al. Mental disorders and comorbidity in attempted suicide. Acta Psychiatr Scand 1996;94:234-40.
8. Haw C, Houston K, et al. Deliberate self-harm patients with depressive disorders: treatment and outcome. J Affective Disord (in press).
9. Isacsson G. Suicide prevention—a medical breakthrough? Acta Psychiatr Scand 2000;102:113-7. 10. Angst J. The epidemiology of dysthymia. Perspect Depr 1995;3:1-5.
11. Foster T, et al. Risk factors for suicide independent of DSM-III-R Axis I disorder. Case-control psychological autopsy study in Northern Ireland. Br J Psychiatry 1999;175:175-9.
12. Hawton K, Arensman E, et al. Deliberate self-harm: systematic review of efficacy of psychosocial and pharmacological treatments in preventing repetition. BMJ 1998;317:441-7.
13. Guthrie E, Kapur N, et al. Randomised controlled trial of brief psychological intervention after deliberate self-poisoning. BMJ 2001;323:1-5.
14. Townsend E, Hawton K, et al. The efficacy of problem-solving treatments after deliberate self-harm: meta-analysis of randomised controlled trials with respect to depression, hopelessness and improvement in problems. Psychol Med 2001;31:979-88.

Clinical focus.

* The term deliberate self-harm is used to describe an act of intentional self-poisoning or self-injury, without reference to whether or not death was the intended outcome, which is often far from clear.
* A thorough assessment of the patient is necessary to elucidate the factors precipitating the overdose, ongoing suicidal intent and the risk of repetition in similar circumstances in the future.
* Some 20-25 per cent of suicide victims presented with an episode of DSH in the year prior to their death, and up to 50 per cent of those who ultimately commit suicide have a life-time history of DSH. Conversely one per cent of DSH patients die within the year by suicide. This risk is highest in those with multiple episodes of DSH.
* There is limited evidence for the effectiveness of either pharmacological or psychological interventions. However, low-dose flupenthixol has been found effective in reducing the repetition of DSH in those with a history of multiple episodes.
* DSH is a highly impulsive act, commonly occurring at a time of tension and when disinhibited by alcohol. Consequently, the degree of planning may be as little as a few minutes and the availability of a particular substance or method the main factor in the choice of its use.
* As many as 20 per cent of those who are alcohol dependant engage in acts of DSH, and eight per cent will ultimately kill themselves. Screening of all patients for alcohol misuse should therefore be an essential part of any assessment.


The Advocate (Baton Rouge, LA)
April 3, 2002

Seek new attitude about old scars
By Lucie Walters

Question: I used to self-harm when I was 15. I was depressed because of bullying, sexual abuse, exam pressure, national athletics pressure, etc. Anyway, I stopped after I realized that I was scarring myself. I am now left with about three major scars and 20 very small white ones on my upper thighs. I absolutely despise these marks. After recovering from depression, sorting out my life and staying in school with good grades, I feel like that part of my life is over and behind me. The problem is I have these constant reminders that are stopping me from putting it to rest. Also, I cannot go swimming, change in public or wear a bikini (no vacations or holidays). I hate myself so much for being so idiotic and ruining any chance of a happy future. I decided to go for a consultation with a surgeon. Apart from it being one of the most degrading and humiliating moments of my life, he broke the bad news that there was nothing that could be done for the small ones, but he was willing to reduce the large ones. The cost was too expensive, so that is out of the question. Anyway, I have decided I want to do it myself. I know this sounds bad, but I have been taught how to suture and know the Web site where I can obtain the required materials. I am not stupid, and I figure since I made the cuts in the first place, it is not really that different. The only problem is I am not aware of the drug laws for getting anesthetics over the Internet. There is nowhere else for me to turn on this. I cannot live with these scars as they are. If I make them worse, then they’ll still just never be shown. Basically I’ve nothing to lose. You may not approve of what I want to do, but please, for my safety, is there anything I should be aware of? Know I am trying to be as careful as possible. Maybe it would be better if I opened the wounds and went to an ER?

I’m a bit scared, but this is my only option. –No Choice

Answer: Congratulations on your recovery efforts. I am totally against your plan. Why not start saving for the surgery? Could you focus on the rest of your body that is free of scars? Can you consider those scars as positive reminders of what you have endured and overcome?

Your self-cutting was a survival attempt during a time of tremendous pain and pressure. It’s all you knew to do, so they are also scars of self-love.

As you can read, I eliminated the Web address, and I have no knowledge of those laws.

Every cut will leave another scar and another chance of infection. Rather than cut yourself, which could worsen the scars, maybe you could forgive yourself. Try to get some understanding of how many people live with scars of all kinds, in all kinds of places. Some are from multiple burns, mastectomies, suicide attempts, open-heart surgery, amputations, car accidents, emergency surgery, to name a few.

Most people will not know (or care) about the origins of your scars. The average person has none of the knowledge you do about this. I know that scars lighten over the years and become much less noticeable.

I believe that your cuts were accidents in a way. If anyone asks you about them, explain that you were in an accident, then change the subject.

Your regret is what is making you so self-conscious. If these three bad scars had happened because of a car accident, I doubt you would be so determined. I don’t know if you are seeing a therapist or ever have, but doing so would help you connect with gratitude that you survived and are no longer cutting.


Los Angeles Times
April 6, 2002

‘Cutters’ Learn How to Heal Their Scars
By Bob Pool

The teenager tugs at the sleeves of her oversized sweatshirt and pulls them over her hands. She wants to make certain that the scars on her arms do not show.

“You don’t want people to know,” said 14-year-old Danielle Opremcak. “People who cut themselves feel really guilty and ashamed afterward. You’re not proud of it.” Danielle knows. For three years, she has repeatedly sliced her arms and legs with razor blades and pieces of glass.

The ritual of self-injury began as an attempt to gain the attention of her parents, Danielle said. Later it became an addiction. Now, however, she is sitting in the dimly lighted office of a therapist, learning all over again how to live.

She doesn’t realize it, but she is a pioneer in a crash-course effort to help teens overcome a habit that for decades has puzzled parents and experts alike.

Danielle is participating in the nation’s first residential self-injury treatment program—a year-and-a-half-old effort to assist emotionally disturbed youngsters at the Vista del Mar children’s home in West Los Angeles.

Physically injuring oneself is emotionally satisfying to some youngsters—most often girls—who say they feel cleansed and in control when they cut their skin and bleed. Many liken the euphoria they feel to that created by drugs.

The self-injurer is often left feeling worthless and ashamed when that feeling wears off, however. So the cutter repeatedly reaches for a knife or shard of glass. Short-term psychological counseling for adolescent “cutters” has been offered for years at psychiatric hospitals and clinics.

But treatment has not been available at children’s homes that cater over a period of months to troubled youngsters sent by court order—or by frantic parents who no longer can handle their teenagers.

“In the past, we’ve thought these kids were self-destructive, suicidal. As soon as a kid experienced self-mutilation, we would hospitalize them. It would be interpreted as a suicide attempt,” said Gerald Zaslaw, president of Vista del Mar Child and Family Services.

Behavior Not Suicidal or to Get Attention

But that was before studies in the late 1990s suggested that adolescents who cut themselves are not trying to kill themselves. Instead, experts concluded, cutters are teens caught up in a habit that to them is alternately a crutch and a curse.

“I’ve been seeing these self-injuring kids for 30 years,” Zaslaw said. “It wasn’t until 18 months ago that someone sat me down and identified to me this is a specific type of behavior that needs specific treatment. It’s not suicidal, it’s not an attention-getting gesture.”

Vista del Mar residential counselor Andrew Levander agrees. He has spent 4_ years working with the home’s 30 teenage girls. The private, nonprofit center, with 114 beds, also serves troubled boys elsewhere on its 17-acre campus.

Counselor Gets New Insights

“Before, the first thing I’d think when I saw a girl cut herself was that it was a suicide gesture or it was poor impulse control or attention-seeking,” Levander said. “The girls would tell me, ‘You have it wrong: I’m not trying to kill myself. It’s what I do to stay alive.’ They’d say it angrily. I felt completely ineffective.”

Vista del Mar administrators launched their treatment program by dispatching Levander to Chicago to study a self-injury treatment regimen devised by experts at a psychiatric hospital. Back in West Los Angeles, he organized a program designed to teach alternatives to cutting for the teenage girls.

The 45-hour curriculum treats self-injurers with respect as they are encouraged to replace their impulse to harm themselves with better ways of feeling they are in control. Levander has a list of 58 alternatives, ranging from listening to music to planting flowers.

At the same time, the teens are taught to recognize the roots of their obsession. Typically, previous sexual or physical abuse or continuing parental or school problems have led to a loss of self-esteem that is to blame. Experts believe the habit is reinforced by the euphoric effects of endorphins released in the brain as a reaction to the injury.

Twenty-seven girls have participated so far in the program, which is voluntary for Vista del Mar residents. Mandatory treatment would not work, Levander and other experts said.

Danielle, an Agoura Hills resident who has lived at Vista del Mar for six months, is one of five girls now taking part. With permission from her mother, she freely discussed how she was introduced to cutting.

“I was 11 and in the hospital for depression when I saw my roommate do it,” she said. “My parents had divorced, we had moved away from my dad and I was failing at school. My roommate in the hospital cut herself. I thought I’d see if it worked with me.

“In the beginning, I wanted mom or dad’s attention. I wanted to talk about why I was doing cutting. But nobody caught me doing it until weeks afterward. After a while, I was doing it as an everyday thing. I’d have sharp things in my backpack in school and go to the restroom and do it.”

Low-Key Approach is Nonjudgmental

Danielle said Levander’s low-key, nonjudgmental approach to dealing with self-injuries keeps her coming to hour-long therapy sessions on Mondays, Wednesdays and Fridays.

“Years from now, I really don’t want to be a 20-year-old going into the bathroom and cutting myself,” she said.

Another participant, Jamie Valade, 16, also began cutting herself at age 11. She said she tried it after seeing it depicted in a movie.

Depressed Over Sexual Abuse

Jamie said she was depressed, in part, because of past incidents involving sexual abuse by nonfamily members. Soon, she was regularly slicing her arms and legs with razor blades, glass, and knives.

“I was mad at myself. I blamed myself—I was punishing myself,” she said. “I’d feel better for about 15 minutes afterward. I probably went 50 times to the hospital. The guy at the emergency room knew my name. He’d ask, ‘Is there anything we can do? No? OK, goodbye.’”

San Dimas resident Rikki Valade said it was heart-wrenching to see her daughter harm herself. “Her therapist said to be supportive and not make a big deal out of it. It was very frustrating watching her do it,” said Valade, who placed her daughter at Vista del Mar in part because of the self-injury therapy program.

Plans to Expand Program for Boys

Vista del Mar officials say they hope to expand the program to boys’ units. Although most self-injurers are girls, some experts feel that up to 40% of those who harm themselves are boys.

Operators of other children’s residential homes, meantime, are closely watching the West Los Angeles project. Six months ago, Levander presented a paper outlining the program at an Atlanta conference for professional therapists. He made a similar presentation to California therapists last month in San Rafael.

So far, operators of nearly 300 residential treatment centers across the country have contacted Vista del Mar officials seeking more information. They, too, may have mistakenly been labeling self-injurers as suicidal and shipping them off to hospitals.

“We’re thinking,” Zaslaw said, “that there are a lot of kids all over the country who are being treated for something they don’t have.”


Scottish Daily Record
May 15, 2002

Katie Foulser; How Misery Made Me Slash Happy

IN the teen soap Hollyoaks, Lisa’s family and friends struggle to understand why she cuts herself. Actress Gemma Atkinson, who plays the troubled teenager, says she feels alone and ignored.

Here, one young woman explains how slashing her wrists gave her a sense of relief and how she eventually overcame her addiction to self-mutilation.

KATIE’S STORY

I WAS 16 when I began harming myself. I’d bottled up lots of things—I was bullied quite a lot at school, then my parents got divorced. I moved away from home to take up a job at a riding school, but I didn’t settle and felt lonely.

Then, one day in October 1999, I was raped. I’d done what I was always told not to do and walked to the shop on my own in the dark.

I felt disgusted with myself, but I didn’t want to tell anyone for fear of being put through a police investigation. I didn’t even tell my mum until a year later.

I pushed the rape to the back of my mind. I was sure everyone hated me and the world would be a better place without me.

That was the first time I cut myself. I used a kitchen knife to cut my arms, which made me feel better. I didn’t do it again, straight away. I tried to keep going and found a new job in a doctor’s surgery.

Although I enjoyed it, I began to find it hard to deal with other people who were ill, so I was signed off sick. That’s when I started harming myself regularly.

It began with small cuts on my arms. I didn’t know at this time, but when you cut yourself, the body releases hormones to help it deal with the trauma and these give you a natural high.

I was convinced I deserved to be hurt, so I didn’t mind the pain. Every time I felt emotional and weepy, instead of having a cry, I’d cut myself.

Inside I was desperate to talk, but I couldn’t open up. I carried on cutting myself and after a while I began burning myself with cigarettes, pulling my hair out and taking overdoses, too.

My parents were desperate to help, but I wouldn’t let them. I think I was frightened of being rejected, so I was constantly testing people—I thought if they put up with my behaviour, they must really love me.

When my mum tried to stop me hurting myself, I’d just go to the bathroom and carve words such as “evil” or “hate” into my arms to show the world how I felt.

Eventually, I confided in my GP—although not about the rape—and she arranged for me to see a psychiatric nurse. I felt I could talk to her because she was a stranger and it didn’t matter what I told her.

She arranged for me to attend patient groups and have counseling, and my parents paid for me to have psychotherapy.

The therapist made dolls act scenes from my life, which helped me to see how people had treated me and how I’d responded.

I was hospitalised several times—they even sectioned me once to stop me leaving. The nurses had to watch me round the clock because I’d take any opportunity to hurt myself.

I wasn’t trying to commit suicide, although I’d thought about it. Mostly I was trying to survive and hurting myself was a way of expressing what I couldn’t put into words.

It was a cry for help but, strangely, help is hard to accept because it’s not easy to change such a deep habit.

One night I cut myself over and over again. The next day in casualty, the doctor counted my cuts—I had 450 wounds. That shocked me. I realised the cutting wasn’t as comforting as it used to be.

It was a turning point and I decided to try to stop hurting myself. I still had the urge to cut, but I learned the best thing to do when I felt bad was to talk about it.

Slowly, I began to forgive myself. As I became stronger, I saw the need for a national support group looking after the interests of people who harm themselves, so I started one.

I’ve had a great response and my group also helps families and friends of people who self-injure.

My illness was a terrible thing to go through. It’s not always easy to talk to people when you feel so low, but it’s a much better thing to do.

Since I’ve been talking to my mum, we’ve become much closer.

MUM SALLY’S STORY

I WAS so happy when Katie got the chance to fulfill a childhood dream and learn to be a riding instructor. So I was surprised when she called two weeks later, saying she was unhappy and wanted to come home.

I was worried about her, but she wouldn’t talk to me.

I first realised she was cutting herself when she had an argument with a friend. Afterwards, she was very unhappy and one day she told me she’d deliberately cut herself. I felt a mixture of horror and fear—I didn’t know how to deal with it.

She got a new job and seemed to settle down. Then my ex-husband’s new partner moved in with him.

Around this time, I could see Katie was becoming increasingly depressed. She was very difficult to handle—she’d just sit on the sofa pulling great chunks of hair out. She told me she’d been cutting herself and showed me the marks on her arms.

I just couldn’t stop crying. I never left Katie alone unless I had to, but when I did, I’d be terrified I’d come home to find her dead. I often had to take her to casualty and couldn’t sleep for worrying about her.

Then she told her GP what she’d been doing. The doctor referred her to a local psychiatric day hospital, which gave me a break, but sometimes they wouldn’t admit her because they couldn’t be sure they could stop her harming herself.

So her father and I decided to pay for her to have psychotherapy, too. Katie saw the therapist often and I’m sure it helped.

Gradually, she gained confidence in the people caring for her and she began talking in depth about how she was feeling inside.

Katie took an interest in how the events in her life had affected her and looked at the different ways in which she could have responded.

She transferred the energy she put into self-destruction to understanding herself.

One day Katie was looking up self-harm on the Internet and didn’t find much information. So she came up with the idea of starting a support group.

I was worried she’d be taking on too much, but she set up The Self-Harmers Alliance and has made a great success of it.

She believes self-harm is such a taboo subject that sufferers are denied the help they need.

When Katie was ill, I remember wishing I could go through it, instead of her.

Now when I look at her, I see a very capable young woman who’s achieved so much. I’m very proud of her.


Coventry Evening Telegraph
May 17, 2002

All Blood and Guts—But is this Art? Big Crowd Witnesses Artist’s Unique Self-Mutilation Show at Warwick Arts Centre
By Samantha Clarke

WEIRD Franko B, who cuts his naked body in the name of art, brought his controversial self-mutilation show to Coventry yesterday.

A crowd of 120 turned up to see the six-hour sell-out show, in which the Italian-born artist appeared naked and allowed blood to trickle from a four -inch self-inflicted cut in his stomach.

The adults-only show, held at Warwick Arts Centre, was organised as part of the fifth annual Fierce! performance art festival. Spectators paid up to pounds 6 a ticket. They were taken to a waiting area, before being led into a separate room where they saw Franko on a one-to- one basis for just two minutes.

Franko B’s act drummed up a storm of controversy last week when details of his performance were first revealed.

Tory shadow culture secretary Tim Yeo said the show was a waste of time and money and he was outraged it had received funding from the Arts Council and West Midlands Arts.

But Mark Ball, Fierce! festival director, defended the act, which Franko B has performed worldwide.

Mr Ball said: “With this show, Franko B is trying to create a beautiful image of a naked wounded man. What I think he is trying to do is to show vulnerability.”

Protester Jon Fletcher, from Stratford, was at the arts centre to condemn the performance, which he called “disgusting.” He claimed it trivialised the issue of self-mutilation.

He waved a sign saying “Stop this show, self-harm is not art!”

He said: “It is not art to cut yourself. If I slashed my arms with a knife right here in the foyer, would people stand back and think “that’s art,” or would they think I had some serious mental health issues?”

“It wasn’t as intimidating as I thought it would be, although I was still freaked out by it. I went to it because I wanted to see what it was all about. But when I was in there I couldn’t bring myself to look at the cut.” –Jo Royce, aged 20, a Warwick University student

“It was really weird because the whole atmosphere in the waiting room was chatty, and as your number gets closer it gets really scary. The experience was amazing. You can’t help but stare at him.” –Steven Kelly, aged 23, is marketing the Fierce! festival

“He was very, very scary. He sat in the corner and then I went in and he came right up to me and stared at me which was really scary. It was worse than I thought it would be.” –Jo Taylor, aged 20, a psychology student at Warwick University

“I thought Franko B was really good. When I was in there I was really intimidated at first, but I relaxed when he spoke to me. He was explaining why he did this. He said he liked the way he provoked reaction.” –Greg Smith, aged 23, a musician, from Birmingham


The Daily Telegraph (London)
May 24, 2002, Friday

Self-Harm—the Damaging Facts. Why Would Anybody Deliberately Hurt Themselves? Barbara Lantin reports on a frightening addiction.

When Eleanor Ridgeway took a call from the casualty unit of a hospital one evening, her first thought was that her teenage daughter, Lydia, had been involved in an accident. But the doctor’s tone was strangely hostile. Lydia, he said, had been persistently cutting herself and, on this occasion, had needed stitches to her wrists. Eleanor was stunned.

“I suppose I had had my suspicions that Lydia was self-harming,” says Eleanor. “She would leave bloody tissues around and tell me that she had cut herself shaving. I realise that she wanted me to find out, but I didn’t because I didn’t want to. “I knew she had been in a state of anxiety for several months—we talked a lot—but I thought that once she got her GCSE results, things would get better. She did outstandingly well but it didn’t improve her self-esteem. When this happened, I felt very frightened. It could have been fatal, though I did not believe that she was a suicide risk. I didn’t understand it at all.”

Lydia had in fact been injuring herself secretly for two years with increasing frequency. Self-harm is typically conducted in private—the tools, like the scars, kept hidden from view. For this reason, the scale of the problem is hard to assess. It has been estimated that one in 600 adults injure themselves badly enough to need hospital treatment but according to a recent US study, one American student in eight inflicts deliberate harm on themselves.

The injury can take many forms. Cutting with razors or knives on the arms and legs is the most common, but some hit, burn, pick or scratch themselves. Many inflict more than one type of injury.

Self-harm is often misinterpreted as attempted suicide or attention seeking. And although there are circle—notably among groups of middle-class adolescent girls—where cutting is regarded as a badge of honour, self-injury is generally recognised to be a mechanism for expressing and dealing with deep-seated distress.

“Generally, people who deliberately hurt themselves do so because they feel that they need to, and that the act itself makes them feel better for a while and more able to cope,” says psychoanalytic psychotherapist Fiona Gardner, author of a new book on young women who self-harm.

“People report overwhelming feelings of misery, emotional distress and hopelessness which lead them to the apparent solution of inflicting pain on their bodies. To those who are self-harming, cutting serves as a way of owning and controlling the body. When a young woman who cuts herself feels overwhelmed or upset by others and by her own complicated and apparently uncontrollable needs, she can turn and attack her body and through her aggressive action find some comfort and relief.”

Experts are reluctant to talk about the profile of a typical self-harmer. However, some patterns have emerged from the little research that exists. Girls are seven times as likely as boys to injure themselves. Although the behaviour usually starts in adolescence, nearly a third of the 76 women interviewed for a survey conducted by the Bristol Crisis Service for Women said that they had begun hurting themselves in childhood, often in a haphazard and superficial way. The youngest age of onset reported was six.

Most of the women identified experiences that they felt had led them to self-harm. In two thirds of cases, these had occurred in childhood. Nearly 50 per cent reported childhood sexual abuse, neglect and emotional abuse. Around 25 per cent referred to lack of communication, physical abuse, and loss and separation. An adolescent who starts to injure herself may be being bullied at school or feeling under pressure from exams. She may have concerns about her sexuality or about how to deal with boys. There may be conflict at home, or family illness.

“An important underlying theme is a deep sense of worthlessness or low self-esteem, which can silence the expression of emotions and drive them inside until such time as they explode in self-injury,” says Lesley Warner of the Mental Health Foundation.

“For many people—although they may wish to stop doing it—it remains a way of coping with those feelings they cannot express.”

Breaking the cycle isn’t easy. Trying to force somebody to stop injuring themselves—by removing the means or watching them closely—is unlikely to succeed and could make things worse. “If you force them to stop, you may be depriving them of their means of survival,” says Katie Foulser, who used to self-harm and now runs a support group, the Self-Harm Alliance. In her experience, talking therapies are more useful, particularly cognitive behavioural therapy (CBT) or an eclectic (multi-disciplinary) approach.

The support of family and friends is also valuable. The Bristol Women’s Crisis Service has produced a booklet for this group, which points out that poor communication about problems and feelings can lead a child to express herself through self-injury. “Opening up communication in your family and making sure that everyone’s needs and feelings are valued and that they are appreciated and loved will help considerably,” it says. “If you feel that there are problems in your family that you cannot tackle alone, seek help.”


The Guardian (London)
May 25, 2002

Saturday Review: arts: Come into My Parlour: Would You Like to be Alone in a room with This Man and His Bleeding, Self-Inflicted Wounds? Emma Safe queues up for a ticket and does exactly that.

“Stop this show now: self-harm is not art.” A lone protestor waved his angry objection, written in thin Biro on a sheet of foolscap. As demonstrations go, it was a pretty feeble effort, and the crowd gathered to see performance artist Franko B seemed unconvinced. And yet a mood not unlike nervous panic was beginning to creep into the proceedings. Normally taciturn individuals chatted inanely; serious-minded theorists cracked silly adolescent jokes.

Apprehension was probably to be expected. At last year’s Fierce!, the West Midlands’ annual performance festival, nine people fainted, overwhelmed by the stench of TCP and the sight of Franko B siphoning blood from his veins. The year before, Franko had launched the same festival with I Miss You, silencing audiences with his “action painting,” parading his punctured body down a canvas catwalk, trailing a Pollock-like design of bloody drips behind him. Yet, however excruciating he was to watch, on both occasions spectators had at least enjoyed the reassurance of a large audience. This year there would be no such comfort, no hiding behind the tall guy at the back, no closing your eyes or rushing off to the loo to avoid the issue altogether. For his show Aktion 398, Franko B had arranged to meet his audience in a terrifyingly intimate series of one-to-one encounters. At pre-allocated times, in groups of 20, we followed a gallery attendant down Warwick Arts Centre’s shabby institutional corridors, past clattering kitchens and emergency exits. We should have guessed that Franko would not greet us in a conventional gallery space but would be buried deep in the belly of the building. Obediently, we removed our shoes, muted our uneasy chatter, took a numbered ticket and filed into the waiting room until we were summoned by an unnervingly sterile usher wearing white coat and plastic gloves. There was no going back now.

All vestiges of certainty gone, there we sat, like patients awaiting test results, glumly contemplating the magnolia breeze-block walls and our mismatching socks. You could hear people’s minds racing. Had we, like participants in a Milgram experiment, blindly followed authority without really thinking? Had we been conned into this? If we heard screams coming from the adjacent performance space, would anyone even flinch? What was Franko B going to do to us?

I was all set to join the protestor outside, convinced I was about to meet Frankenstein, not Franko B. Too late: “Now serving 75.” The grotesque usher-cum-dentist was looking directly at me.

Alone with Franko inside a small room, I wasn’t sure which of us was more vulnerable. He had his back to me, facing the corner, naked and painted white, wearing only a plastic collar—the type vets issue to injured animals to protect them from themselves. I was struck dumb. “Hello, Franko,” I managed.

He turned to face me, arms folded above a painful looking wound.

“Does it hurt?”

“A little,” he confessed.

I had an overwhelming urge to free this impoverished beast from his wretched prison with its lurid yellow walls—but I needed to rescue myself first. I escaped with poetry—Giacomo Leopardi, a poet the Italian-born Franko admires. I hoped that with more meaningful words, I could somehow transport us out of this unbearable situation.

Others responded differently: some were too scared to approach him at all, some wanted to touch the wound, shake his hand or talk about their day. Most courageously, one visitor stripped naked and urinated on the floor.

Everybody’s two minutes was different, but common to nearly all the post-performance reports was a feeling that the spectator, not the artist, was the one under scrutiny. Franko had created a situation that denuded people, stripping us of all points of reference and denying us the safe rules of etiquette.

This was no sensationalised art-gimmick or gory bloodletting conceived to shock; nor was it a pitiable self-injurious cry for help. Despite his unnerving countenance, Franko was modest, rational, and polite. He thanked me for my poetry, tried to comfort those who were frightened, listened, and responded to people. After just a few seconds with the artist, our absurd physical predicament didn’t seem important. What mattered was the intensity of the connection and communication between us. Risking total humiliation and freeing himself so completely of all inhibitions, Franko had offered us the space to do the same—what we did with it was up to us.

Two minutes of this unshackled liberation, though, seemed more than enough for many, who (a little too readily, perhaps) returned to the bar to engage in fully clothed encounters with uninjured individuals, evidently relishing the security of conventional, knowable limits.


Daily Star
May 30, 2002

Pain’s Now My Only Comfort
By Jane O’Gorman

Question: SINCE my boyfriend left me, I’ve had an irresistible urge to hurt myself.

Our break-up was very traumatic. Since then I’ve been scratching my arms, burning my legs and playing with knives. I just know that one day I’ll injure myself seriously.

I was completely numb when he walked out. Even though he’d been abusive, I never imagined that he’d leave. For two weeks I lay curled up in bed unable to eat or sleep. Now it’s been eight weeks and I still feel completely empty. Life has no meaning.

The only time I feel I’m still alive is when I hurt myself. The sharp pain seems to bring me back to my senses.

I’ve had a rotten life. My parents didn’t bother with me and I was bullied at school. My ex-boyfriend was a pig, but at least he was there for me.

JANE SAYS: Please seek help immediately. Your doctor may prescribe medication and therapy. If you have a computer, seek out selfinjuryuksubscribe@yahoo.com.

The Self Harm Alliance can also help—you can phone them on 01242 578820, Wednesdays to Sundays, 7pm to 8pm.

You are certainly not alone in your despair and plenty of people out there want to help you. It’s important that you take positive steps and act now. Good luck.


Herald Express (Torquay)
May 31, 2002

SELF-HARM is escalating “alarmingly” among young people, Teignbridge MP Richard Younger-Ross told the House of Commons.

He raised the issue in Parliament at the request of Teignbridge Youth Council. During an adjournment debate he called for steps to be taken to ensure that medical staff identify people who harmed themselves and said there was a need for schools to be aware of the problem and available support.

“We must find a way of responding to these vulnerable young people,” he said. “The rate of self-harm is escalating in an alarming fashion.

“Fifty-five per cent of those at the Youth Council meeting knew someone who had harmed themselves. These people are 100 times more likely to commit suicide than the rest of the population. It is essential we find practical ways of providing help and support.” Mr. Younger-Ross called on the Government to address the issue of self-harm in its new suicide strategy.

He said he would be making submissions in consultations on the strategy and asked anybody who wanted him to make specific points to contact him through the Newton Abbot office.


American Family Physician
June 1, 2002

Recognizing and Managing Deliberate Self-Harm
By Anne D. Walling

A wide range of poisonings and injuries are included in deliberate self-harm (DSH), which is a significant health problem in some communities. After rising for several years, incidence rates for DSH have declined in the past decade, especially among men 15 to 34 years of age. The rate has remained stable among women. Although most patients initially present to an emergency department, the important role of the family physician is stressed in a review by Sinclair and Hawton. Self-poisoning accounts for more than 90 percent of cases of DSH. Substance abuse by patients with DSH depends on availability and perceived toxicity. Antidepressant drugs are used frequently. Use of selective serotonin reuptake inhibitors (SSRIs) has increased while use of tricyclic agents has decreased.

Tricyclics are much more dangerous, with a death rate from overdose of about 34 per 1 million prescriptions compared with a rate of two per 1 million for SSRIs. Nonprescription medications can also carry dangerous overdoses in DSH. In Great Britain, paracetamol (acetaminophen) overdose formerly accounted for one half of all cases of hepatic failure. Legislation limiting the number of tablets that can be purchased at one time is credited with reducing the number of fatal self-poisonings by 21 percent. Less common manifestations of DSH include skin cutting and mutilation of the eyes or genitalia.

Repetition is important in assessing patients with DSH. After the first episode, about 10 percent repeat self-harm within one year. One third of patients with a history of multiple episodes repeat within one year. Other factors predictive of repeating DSH include alcohol or substance misuse, previous psychiatric illness, unemployment, and low social status. The acts are highly impulsive, making availability of method crucial in repetition. Approximately 1 percent of patients with DSH die by suicide within one year of an event of self-harm. The risk of suicide is greater if the acts of DSH were planned and committed alone, a suicide note was written, attempts were made to avoid discovery, medical attention was not sought, or the patient was angry that the suicide attempt failed.

After treatment of the presenting poisoning or injury, patients must be screened for psychiatric illness. More than 70 percent are likely to be depressed, and approximately 36 percent abuse alcohol or other substances. About one half have significant comorbidities, and many have a history of being sexually abused as children. Systematic reviews have not found good evidence for pharmacologic or psychologic therapies for DSH, but low-dose neuroleptic agents are associated with a reduction in repetition. Brief psychologic interventions targeting depression and hopelessness, and encouraging problem-solving have shown promise in clinical studies.