Self-injurious behavior is associated with diverse psychiatric conditions. Sometimes, SIB is the most dominant symptom, severely restricting the psychosocial functioning and quality of life of the patients and inhibiting appropriate patient care. In severe cases, it can lead to permanent physical injuries or even death. Primary therapy consists of medical treatment and if implementable, behavioral therapy. For patients with severe SIB refractory to conventional therapy, neuromodulation can be considered as a last recourse. In scientific literature, several successful (...) lesioning and deep brain stimulation targets have been described that can indicate a common underlying neuronal pathway. The objectives of this study were to evaluate the short- and long-term clinical outcome of patients with severe, therapy refractory SIB who underwent DBS with diverse underlying psychiatric disorders and to correlate these outcomes with the activated connectivity networks. We retrospectively analyzed 10 patients with SIB who underwent DBS surgery with diverse psychiatric conditions including autism spectrum disorder, organic personality disorder after hypoxic or traumatic brain injury or Tourette syndrome. DBS targets were chosen according to the underlying disorder, patients were either stimulated in the nucleus accumbens, amygdala, posterior hypothalamus, medial thalamus or ventrolateral thalamus. Clinical outcome was measured 6 months after surgery and at long-term follow-up after 10 or more years using the Early Rehabilitation Barthel index and time of restraint. Connectivity patterns were analyzed using normative connectome. Based on previous literature the orbitofrontal cortex, superior frontal gyrus, the anterior cingulate cortex, the amygdala and the hippocampus were chosen as regions of interest. This analysis showed a significant improvement in the functionality of the patients with DBS in the short- and long-term follow-up. Good clinical outcome correlated with higher connectivity to the amygdala and hippocampus. These findings may suggest a common pathway, which can be relevant when planning a surgical procedure in patients with SIB. (shrink)

People diagnosed with Borderline Personality Disorder (BPD) may engage in what are called self-injurious acts. This paper situates self-injury within a larger cultural context in which body modifications are differently evaluated according to inscribed meanings. To provide a framework for ethical interactions with people diagnosed as BPD who self-injure, I draw on two concepts from theories of meaning: signification and uptake. I suggest possible significations of self-injury, but argue that clinicians have a duty to give (...) uptake to the patient's own interpretations of her behavior. Proper giving of uptake, which involves responding to others' communications such that the communicator's integrity is preserved, is crucial to ethical practices for clinicians, and uptake is never simply neutral or objective. This analysis suggests that sense-making about a client's self-injurious acts involves an understanding not only of the client's own interpretation of her behavior and its meaning, but also of the discursive production and function of such signs in our culture. I offer five maxims to guide the therapeutic process for clinicians working with self-injurious behavior in BPD patients. (shrink)

Psychiatric patients may try (or express a desire) to injure themselves in hospital in order to cope with overwhelming emotional pain. Some health care practitioners and patients propose allowing a controlled amount of self-injury to occur in inpatient facilities, so as to prevent escalation of distress. Is this approach an example of professional assistance with harm? Or, is the approach more likely to minimise harm, by ensuring safer self-injury? In this article, I argue that health care practitioners who (...) use harm-minimisation can be considered to be helping physical injury to occur, although they do not encourage the act. I consider why there are compelling reasons to believe that a patient who self-injures is not maximally autonomous in relation to that choice. However, I then move onto argue that allowing a degree of self-injury may enable engagement with psychotherapy (enhancing autonomy) and behavioural change. In these circumstances, allowing injury (with precautions) may not be harm, all things considered. (shrink)

Self-injury is a perilous and increasingly common behavior that is particularly prevalent among youth. Nonetheless, there is a deep-rooted public stigma towards people who self-injure. Consequently, people who engage in self-injury are reluctant to seek professional help or disclose their experiences to others. This article aims to combat stigma and promote help-seeking behavior by debunking the common myths surrounding self-injury in the Malaysian context. Specifically, this article aims to serve as an eye-opener for Malaysian (...) counselors and other mental health professionals to improve their multicultural knowledge, skills, and attitudes when working with those who self-injure. (shrink)

Enactivism has much to offer to moral, social and political philosophy through giving a new perspective on existing ethical problems and improving our understanding of morally ambiguous behaviours. I illustrate this through the case of self-injury, a common problematic behaviour which has so far received little philosophical attention. My aim in this paper has been to use ideas from enactivism in order to explore self-injury without assuming a priori that it is morally or socially wrong under all circumstances, (...) seeking to establish a less implicitly value-laden analysis. Enactivism can help us in making this behaviour more intelligible and contextualising it through examining the relations of individual embodied action and social practices with the help of enactivist theories of habits and affordances. (shrink)

The lifetime prevalence of major depressive disorder in adolescents is reported to be as high as 20%; thus, MDD constitutes a significant social and public health burden. MDD is often associated with nonsuicidal self-injury behavior, but the contributing factors including cognitive function have not been investigated in detail. To this end, the present study evaluated cognitive impairment and psychosocial factors in associated with MDD with NSSI behavior. Eighteen and 21 drug-naïve patients with first-episode MDD with or without (...) NSSI and 24 healthy control subjects were enrolled in the study. The Hamilton Anxiety Scale, Hamilton Depression Scale, Adolescent Self-injury Questionnaire, Beck Scale for Suicide Ideation–Chinese Version, Shame Scale for Middle School Students, Sensation Seeking Scale and Childhood Trauma Questionnaire were used to assess depression-related behaviors, and event-related potentials were recorded as a measure of cognitive function. The latency of the N1, N2, P3a, P3b, and P50 components of ERPs at the Cz electrode point; P50 amplitude and P50 inhibition showed significant differences between the 3 groups. CTQ scores also differed across three groups, and the NSSI– and NSSI+ groups showed significant differences in scores on the Shame Scale for Middle School Students. Thus, cognitive function was impaired in adolescents with MDD with NSSI behavior, which was mainly manifested as memory decline, attention and executive function deficits, and low anti-interference ability. We also found that childhood abuse, lack of social support, and a sense of shame contributed to NSSI behavior. These findings provide insight into the risk factors for MDD with NSSI behavior, which can help mental health workers more effectively diagnose and treat these patients. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 10.1 (2003) 29-31 [Access article in PDF] On the Border:Reflections on the Meaning of Self-Injury in Borderline Personality Disorder Robert L. Woolfolk Keywords borderline personality disorder, values, psychotherapy, diagnosis IT IS A PLEASURE to comment on Nancy Potter's elegantly written, provocative paper. Professor Potter raises important and intriguing issues that have not only clinical implications for practitioners, but also are of theoretical significance for (...) those who ponder the conceptual status of mental illnesses and their manifestations.Borderline personality disorder (BPD) is the mental health professional's bête noire. In the diagnostic context, borderline is an adjective that is evocative, albeit imprecise. Persons with BPD tend to the worst of multiple pathological worlds, to fall through the diagnostic cracks, to occupy the boundaries of decorum and safety. Even such intrepid and astute folk as Marsha Linnehan and Otto Kernberg, who have devoted careers to understanding and treating those with BPD, have acknowledged the limited state of current knowledge. Justice Stewart's theory of natural concepts seems to apply to patients to whom we give the label borderline personality disorder: we cannot define the disorder readily, but we know one when we see one. And when we see such a patient it is costly in time and stress and corrosive of one's sense of professional efficacy. So with these patients, any assistance in conceptualizing the problem or in modification of therapeutics is welcome.Professor Potter's phenomenological formulation of self-injury is cogent and helpful in a number of ways. Self-injurious behavior is, when conventionally interpreted, a prototype for irrationality and affliction. It is also dramatic, graphic, and often repugnant. Professor Potter's analysis brings us face to face with what most of us know but sometimes forget or fail to apply: Psychotherapy is a value-laden endeavor. Early on, both Max Weber and Carl Jung were eloquent on this point and we have been reminded often enough of it in the last four decades (Rieff 1966; Woolfolk 1998; Woolfolk and Murphy, in press). Usually it is the moral values residing in the underlying ideologies of treatment and diagnosis that are brought to our attention. The axiological underpinnings of psychotherapy, however, are aesthetic as well as ethical. Professor Potter successfully argues that, as therapists, we may be in the thrall of a parochial aesthetic that produces [End Page 29] a kind of tunnel vision inimical to therapeutic effectiveness and to the ethical treatment of the human beings who are our patients. She has impeccable advice for therapists on this topic: Although none of us can step outside of culture altogether, we can evaluate our attitudes, beliefs, and values from a second-order level (Taylor 1989; Frankfurt 1971). Complete objectivity is an unlikely ideal. But clinicians can, and should, think critically about ways in which prevailing norms and values may be influencing their understanding of the world and their ways of being in it. (Potter 2003, 11) Professor Potter also quite effectively persuades that a comprehensive understanding of disorders that occur mostly in women (e.g., somatization disorder) must effectively comprehend feminist scholarship and the sociocultural realities of gender. The concept of the commodification of the female body has been informative in both the epidemiology and treatment of yet another woman's disorder, anorexia nervosa. And although the linkages of somatic commodification to self-injurious behavior may not appear to be so straightforward, the paper points the way to deeper and possibly richer explanations of phenomena that seem at first glance to be inexplicable.The introduction of the concept of uptake into clinical contexts is also a valuable contribution. Those of us familiar with the traditions of psychotherapy recognize a concept both familiar and central. Uptake has family resemblance to the empathic attitude so extensively discussed by both Rogers and Kohut. Those with hermeneutic leanings will recognize affinities with Verstehen and the Gadamerian anticipation of completeness (Vorgriff der Vollkommenheit). Any truly humanistic approach to treatment or diagnosis must encompass the lived experience of the patient. This is not to... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 10.1 (2003) 25-27 [Access article in PDF] Gender, Body, Meaning:Anthropological Perspectives on Self-Injury and Borderline Personality Disorder Carolyn Sargent THE CENTRAL THEMES OF "Commodity Body/Sign: Borderline Personality Disorder and the Signification of Self-Injurious Behavior" reflect issues that cut across the disciplines represented by this journal and have received increasing attention from anthropologists. Medical anthropologists, as well as psychological anthropologists and others (...) interested in symbolic analysis of the body, have addressed such topics as the culture of biomedicine and the cultural shaping of psychiatric classification, the multiple meanings of body modifications, power relations in therapeutic interactions between doctor and patient, and cultural variation in understandings of normality and abnormality.Curiously, there is little anthropological literature that directly focuses on either borderline personality disorder (BPD) or self-injurious acts per se. Indeed anthropological research on psychiatric diagnosis, classification, and treatment, as well as ethnopsychiatry, include scant reference to personality disorders. One exception is Nuckolls' 1992 article, "Toward a Cultural History of the Personality Disorders," which raises pertinent questions for one of Potter's introductory statements—that the majority of those diagnosed with BPD are women. Nuckolls directly addresses gender ideology and gender roles in the United States in his comparison of antisocial personality and histrionic personality diagnoses. In his paper, he argues that these personality disorders have cultural histories and are strongly congruent with prevailing gender stereotypes, such that men are many times more likely to be diagnosed as antisocial than women and women much more likely to be diagnosed as histrionic (Nuckolls 1992, 37). He also historicizes the emergence of certain behavioral styles that have been seen as characteristic of women and men, and the evolution of psychiatric diagnoses that classify extreme manifestations of these behavioral styles.The issue of why women, rather than men, are more frequently diagnosed with BPD is not elaborated in Potter's article, although she notes the importance of considering the intersection of gender and "identifying behaviors" associated with BPD. Cultural analyses of gender ideology in the [End Page 25] United States might suggest that the connection involves gendered expectations concerning emotionality and relational context but these articulations remain intriguing and underexplored. One might speculate that BPD/self-injury occurs in the context of particular gender ideologies, perhaps in class-based, industrialized societies where the body is highly commodified. It appears that the history of this constellation of symptoms and behaviors remains to be written.Cultural analysis of self-injury, a theme that runs through Potter's article, tends to be embedded in the anthropological literature on body ornamentation, initiation rituals, and "culture-bound" syndromes. Mascia-Lees and Sharpe (1992, 1) describe the body as "a site of adornment, manipulation, and mutilation," practices with roots reaching back as far as 30,000 years, and include as examples head deformation, scarification, foot binding, tooth filing, lip plates, nose rings, tattoos, subincision, and genital cutting.However, the concept of self-injury, as Potter notes, is problematic in the discipline of anthropology given the significance historically accorded to cultural relativism. Correspondingly, body "modification" is not "self-injury" as long as it is socially normative, for example, a facet of an initiation ordeal or body ornamentation (e.g., circumcision, scarification, piercing). Among the rare examples of acts that seem readily identifiable as "self-injury" are New Guinea practices of cutting off a finger to demonstrate mourning and Baatombu (West African) male finger amputation to show grief and anger over a wife's infidelity. Both are, however, considered culturally legitimate and not indicative of pathology.Potter's argument draws heavily on the notion of "body as text," derived largely from literary theory and feminist philosophy (Butler 1990; Jaggar and Bordo 1989). The perspective of "body as text" has influenced anthropological theory over the past two decades, particularly in the interpretive and postmodernist schools of thought. The body as a text of femininity is aptly characterized by Bordo, who argues that the continuum between female disorder and normal femininity is revealed by means of an analysis of symbolic meaning of gender in... (shrink)

ABSTRACTGrounded in Emotional Cascade Theory, we explored whether rumination and multisensory imagery-based cognitions moderated the relationships between affect and both odds of non-suicidal self-injury, and frequency of the behaviour. A sample of 393 university students completed self-report questionnaires assessing the constructs of interest. Contrary to expectations, rumination did not emerge as a significant moderator of the affect-NSSI relationship. However, the relationship between affect and frequency of NSSI was moderated by the use of imagery. Further, the relationship between negative (...) affect and NSSI was moderated by positive affect, underscoring the need to consider both negative and positive affect in models of NSSI. Most youth who self-injured reported thinking in images while the urge to self-injure was strong, with 53% thinking in images at least half the time. Future work is needed to explore how positive and negative affect work in concert to govern NSSI, and how imagery might eit... (shrink)

The perception of behavior as a moral or conventional concern can be influenced by contextual variables, including status and power differences. We propose that social processes and in particular social role enactment through the exercise of power will psychologically motivate moralization. Punishing or rewarding others creates a moral dilemma that can be resolved by externalizing causation to incontrovertible moral rules. Legitimate power related to structure and position can carry moral weight but may not influence the power holder’s perceptions of (...) rules and general norms of behavior. Social identity theory suggests moralization could be promoted by a concern for shared, defining values. However, the tendency to moralize another’s behavior can be injurious to shared identity. We explored white-collar employees’ perceptions of several categories of noxious or deviant workplace behaviors and regressed these perceptions on the tendency to use legitimate, referent, or reward and punish power; social identity; and the interaction of social identity and power, in particular legitimate power. Only the tendency to influence others through punishment or reward predicted moralization. Alternative causal explanations for the findings were addressed through the absence of any relationships between punishment and reward power and perceptions of deviant behaviors as wrong, upsetting, or requiring punishment. We discuss these results in the context of self and social processes, the social construction of morals and power, and the impact of managers’ behavior on group or organizational ethics. (shrink)

Behavioural experiments are one of the central and most powerful methods of intervention in cognitive therapy. Yet until now, there has been no volume specifically dedicated to guiding physicians who wish to design and implement behavioural experiments across a wide range of clinical problems.The Oxford Guide to Behavioural Experiments in Cognitive Therapy fills this gap. It is written by clinicians for clinicians. It is a practical, easy to read handbook, which is relevant for practising clinicians at every level, from trainees (...) to cognitive therapy supervisors.Following a foreword by David Clark, the first two chapters provide a theoretical and practical background for the understanding and development of behavioural experiments. Thereafter, the remaining chapters of the book focus on particular problem areas. These include problems which have been the traditional focus of cognitive therapy, as well as those which have only more recently become a subject of study, and some which are still in their relative infancy. The book also includes several chapters on transdiagnostic problems, such as avoidance of affect, low self-esteem, interpersonal issues, and self-injurious behaviour. A final chapter by Christine Padesky provides some signposts for future development.Containing examples of over 200 behavioural experiments, this book will be of enormous practical value for all those involved in cognitive behavioural therapy, as well as stimulating exploration and creativity in both its readers and their patients. (shrink)

ABSTRACTThis article engages Bhaskar's category of absence and Foucault's notion of problematization in the context of explaining an example of the historical emergence of political activism. Specifically, it considers the emergence of the ‘psychiatric survivors’ social movement in the UK, with a focus on the ‘politics of self-harm’. The politics of self-harm refers to acts of self-injurious behaviour, such as drug over-dosage or self-laceration, which do not result in death and which bring individuals to the (...) attention of psychiatric services. For many years survivors have protested about the harmful treatment they receive from such services and have campaigned for their reform and for new, non-psychiatric understandings of the meaning of self-harm. The article explains how such activism emerged in the late 1980s. Its contribution is at the interface of critical realism and social movement studies. (shrink)

Anne was sexually and physically abused as a child and adolescent. Since an adolescent, she has had episodes of engaging in self-injurious behavior, where she repetitively cuts her arms with a knife or scissors, sometimes so seriously that she has had to go to the emergency room. She is relatively high functioning as an individual, where her academic cleverness has enabled her to study for a philosophy degree at a top university. Owing to her history of deliberate (...) self-injury, psychiatrists have diagnosed her with borderline personality disorder. In moments of anger and emotional upset, like when her psychiatrist has seemed cold toward her or her session has stopped early, she reverts to cutting her arms.Borderline... (shrink)

Non-suicidal self-injury is a complex behaviour, routinely engaged for emotion regulatory purposes. As such, a number of theoretical accounts regarding the aetiology and maintenance of NSSI are grounded in models of emotion regulation; the role that cognition plays in the behaviour is less well known. In this paper, we summarise four models of emotion regulation that have repeatedly been related to NSSI and identify the core components across them. We then draw on social cognitive theory to unite models of (...) cognition and models of emotion in developing a new cognitive-emotional model of NSSI. Our model articulates how emotion regulation and cognition can work in concert to govern NSSI, and offers several new research questions that can be addressed within this framework. (shrink)

‘Deliberate self-harm’, ‘self-mutilation’ and ‘self-injury’ are just some of the terms used to describe one of the most prominent issues in British mental health policy in recent years. This article demonstrates that contemporary literature on ‘self-harm’ produces this phenomenon (to varying extents) around two key characteristics. First, this behaviour is predominantly performed by those identified as female. Second, this behaviour primarily involves cutting the skin. These constitutive characteristics are traced back to a corpus of literature produced (...) in the 1960s and 1970s in North American psychiatric inpatient institutions; analysis shows how pre-1960 works were substantially different. Finally, these gendered and behavioural assertions are shown to be the result of historically specific processes of exclusion and emphasis. (shrink)

There is growing evidence that some individuals engage in both self-harm and aggression during the course of their lifetime. The co-occurrence of self-harm and aggression is termed dual-harm. Individuals who engage in dual-harm may represent a high-risk group with unique characteristics and pattern of harmful behaviours. Nevertheless, there is an absence of clinical guidelines for the treatment and prevention of dual-harm and a lack of agreed theoretical framework that accounts for why people may engage in this behaviour. The (...) present work aimed to address this gap in the literature by providing a narrative review of previous research of self-harm, aggression and dual-harm, and through doing so, presenting an evidence-based theory of dual-harm – the cognitive-emotional model of dual-harm. This model draws from previous studies and theories, including the General Aggression Model, diathesis-stress models and emotional dysregulation theories. The cognitive-emotional model highlights the potential distal, proximal and feedback processes of dual-harm, the role of personality style and the possible emotional regulation and interpersonal functions of this behaviour. In line with our theory, various clinical and research implications for dual-harm are suggested, including hypotheses to be tested by future studies. (shrink)

Several recent lines of inquiry have pointed to the amygdala as a potential lesion site in autism. Because one function of the amygdala may be to produce autonomic arousal at the sight of a significant face, we compared the responses of autistic children to their mothers’ face and to a plain paper cup. Unlike normals, the autistic children as a whole did not show a larger response to the person than to the cup. We also monitored sympathetic activity in autistic (...) children as they engaged in a wide range of everyday behaviours. The children tended to use self-stimulation activities in order to calm hyper-responsive activity of the sympathetic (`fight or flight’) branch of the autonomic nervous system. A small percentage of our autistic subjects had hyporesponsive sympathetic activity, with essentially no electrodermal responses except to self-injurious behaviour. We sketch a hypothesis about autism according to which autistic children use overt behaviour in order to control a malfunctioning autonomic nervous system and suggest that they have learned to avoid using certain processing areas in the temporal lobes. (shrink)

Following Strawson, many philosophers have claimed that holding someone responsible necessitates its being appropriate to feel or express the negative reactive attitudes (e.g., resentment) toward her. This view, while compelling, is unable to capture the full range of cases in which we hold others responsible in ordinary life. Consider the parent who holds her five-year-old responsible for not teasing his sister, or the therapist who holds her patient responsible for avoiding self-injurious behavior. Holding responsible in such cases (...) requires enforcing normative expectations, but these norms can (and typically should) be enforced without involving the negative reactive attitudes. To demonstrate this, I consider how responsibility attributions function in psychotherapy, as well as in other contexts where the negative reactive attitudes do not have a natural home. (shrink)

This paper examines the culture, the dynamics and the financial underpinnings that determine how medical research is being conducted on children in the United States. Children have increasingly become the subject of experiments that offer them no potential direct benefit but expose them to risks of harm and pain. A wide range of such experiments will be examined, including a lethal heartburn drug test, the experimental insertion of a pacemaker, an invasive insulin infusion experiment, and a fenfluramine "violence prediction" experiment. (...) Emphasis, however, is given to psychoactive drug tests because of the inherent ethical and diagnostic problems involved in the absence of any objective, verifiable diagnostic tool. Effort is made to provide readers comprehensive reference sources to evidence-based reports about the serious risks these drugs pose for adults and children so that the reader may judge whether the benefits (if any) outweigh the risks for children. The first ethical issue raised by these experiments is: did the severity of illness in these children justify their exposure to short and long-term risks? The ethics of the experiments will be evaluated by referring to existing codes of medical research ethics-the Nuremberg Code, the Declaration of Helsinki, and the federal Code of Regulations. The thirteen cases presented will demonstrate that children are being used in ever more speculative experiments, often in the absence of a therapeutic intent, but a significant chance for causing harm and / or discomfort. Some of the experiments were designed to explore the mechanisms of pathology and pharmacological interventions, or the response of neurological brain receptors to chemical provocation ("challenge"). Others were designed to test the safety or efficacy of new drugs, even to test these drugs on healthy children who were hypothesized to be "at risk." Children and adolescents have been subjected to "forced dose titration" experiments that induced a spectrum of severe adverse effects, including insomnia, extreme restlessness, agitation, (akathisia) and self-injurious behavior. FDA reports show that suicide is a significant issue in psychotropic drug trials-in pediatric trials the problem is even greater. The paper aims to demonstrate how the enactment of the Better Pharmaceuticals for Children Act (incorporated into the Food and Drug Administration Modernization Act, FDAMA), set in motion a radical shift in public policy by providing huge financial incentives to pharmaceutical companies to test new or patented drugs in children. Federal policy shifted from one aimed at protecting children by setting limits on permissible research risks, to a policy aimed at broadening the inclusion of children as test subjects. It will be shown how the FDA and the Department of Health and Human Services lifted regulatory restrictions to permit research involving greater than minimal risk to be conducted on healthy children, claiming that all children are potentially "at risk" of a future condition. Children were in this way deprived of regulatory protections. An argument will be made that the approval of nontherapeutic, harmful experiments-such as exposure of toddlers to lead poison-under the current gate keeping system raises serious doubts about the sustainability of institutional review boards (IRBs) as protectors of human research subjects. Children, who are precluded from exercising the adult human's right to informed consent, are being exploited as commodities for commercial ends. It is the position of the author that nothing less than the enactment of a federal law mandating a radical overhaul of the current research review system, with independent checks and balances, will provide children the legal protections they need. Ten specific recommendations are offered to protect children from harmful experiments. (shrink)

Several recent lines of inquiry have pointed to the amygdala as a potential lesion site in autism. Because one function of the amygdala may be to produce autonomic arousal at the sight of a signi¢cant face, we compared the responses of autistic children to their mothers’ face and to a plain paper cup. Unlike normals, the autistic children as a whole did not show a larger response to the person than to the cup. We also monitored sympathetic activity in autistic (...) children as they engaged in a wide range of everyday behaviours. The children tended to use self-stimulation activities in order to calm hyper-responsive activity of the sympathetic (`¢ght or £ight’) branch of the autonomic nervous system. A small percentage of our autistic subjects had hyporesponsive sympathetic activity, with essentially no electrodermal responses except to self-injurious behaviour. We sketch a hypothesis about autism according to which autistic children use overt behaviour in order to control a malfunctioning autonomic nervous system and suggest that they have learned to avoid using certain processing areas in the temporal lobes. (shrink)

Stigmata, wounds resembling those of Christ, have been reported since the 13th century. The wounds typically appear in association with visions following prolonged fasting. This paper argues that self-starvation holds the key to understanding this unique event. Stigmata may result from self-mutilation occurring during dissociation, phenomena precipitated in part by dietary constriction. Psychophysiological mechanisms produced by natural selection adjust the salience of risk in light of current resource abundance. As a result, artificial dietary constriction results in indifference to (...) harm. A variety of data links dramatic dietary constriction, reduced serotonergic functioning, altered states of consciousness, and self-injurious behavior. Catholic representations of Christ's crucifixion provide a cultural context that both motivates and lends meaning to the experiences of individuals whose predispositions and life histories increase the likelihood of dietary constriction, dissociation, and self-mutilation. Examining this case raises interesting questions about both the evolutionary and the cultural grounds for defining individual psychopathology. (shrink)

Should people include beef in their diet? This chapter argues that the answer is “no” by reviewing what is known and not known about the presence in cattle of three psychological traits: pain, desire, and self-consciousness. On the basis of behavioral and neuroanatomical evidence, the chapter argues that cattle are sentient beings who have things they want to do in the proximal future, but they are not self-conscious. The piece rebuts three important objections: that cattle have injury information (...) but not pain; that cattle have goal-directed behavior but not desire; and that the absence of evidence for bovine self-consciousness should not be taken as evidence that cattle lack self-consciousness. In sum, what is known about cattle cognition shifts the moral burden of proof on to the beef eaters. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 10.1 (2003) 23-24 [Access article in PDF] Did You Hurt Yourself? Katherine Morris PEOPLE WITH BORDERLINE PERSONALITY DISORDER (BPD) frequently deliberately injure themselves, to the extent that "the diagnosis [BPD] rightly comes to mind whenever recurrent self-destructive behaviors are encountered" (Gunderson, 2001, 54) quoted by (Potter, 2003, 1). How are we to understand this puzzling and disturbing behavior?Situating her approach to this question (...) within a general framework that sees the body as a "text" that requires "interpretation," Potter deliberately avoids answering this question in the way we might expect. It is doubtful, she argues, that every act of self-injury has a meaning, and a fortiori doubtful that every such act has the same meaning. Her discussion includes a section, informed by medical anthropology, in which she attempts to distinguish pathological self-injury of the sort that occurs with BPD from such culturally acceptable (or at least culturally understood or tolerated) body modifications, such as tattooing, scarification, and body piercing. It also includes a section in which it is suggested that the meaning of some self-injurious behavior may indicate cultural rather than individual pathologies (e.g., the "commodification" and "objectification" of women's bodies in Western culture). The principal issue for her, however, is how a clinician is to work out the meaning of a particular individual's self-injuring behavior when it does indeed have an individual meaning, and the prerequisite for doing so, she argues, is the cultivation of a virtue she terms giving uptake.The general tenor of her argument seems to me to be admirable: the issues are dealt with subtly and with ethical, anthropological, and philosophical sensitivity. There are nonetheless a number of questions I want to raise. The Framework It is of course fashionable in certain quarters these days to speak of the body as a text. One might, however, wonder to what extent this metaphor is illuminating. After all, texts, one might think, are by definition linguistic; yet part of the point here is precisely to move away from the narrow "speech-act" focus of "traditional philosophical analyses of communication" (Potter 2003, 1-16).The point of the metaphor according to Potter is to "suggest that the body, like other mediums of communication, must be interpreted and that its meanings are not given or inevitable" (Potter 2003, 2). Again, however, this invokes a number of fashionable but questionable ideas: an easy reliance on the difficult idea that "how we experience the world is shaped by our conceptual scheme" (Potter 2003, 3), a structuralist account of signification (Potter 2003, 3), and the concomitant notion that all communication involves interpretation, indeed that the listener (or observer) "relies on linguistic and other conventions [End Page 23] to infer meaning" (Potter 2003, 4). As a general account of communication this seems to me to be wildly off the mark: we very seldom interpret others' words, we very seldom "infer their meaning." The supposition that we always do is the direct consequence of the externalizing of the relation between "signifier" and "signified" that constitutes the heart of structuralist linguistics. 1Now, it may well be that the sort of self-injuring behavior that is the focus of Potter's essay precisely does require interpretation. Insofar as it is expressive behavior (and again Potter is right to question whether it is necessarily always such), it seems to be importantly different, in just these respects, from many other forms of expressive behavior. In the first place, it is different (in just these respects) from the culturally tolerated forms of body modifications discussed in section 2; for members of the culture in which body piercing or tattooing is acceptable or tolerated, such behavior is understood without the need for interpretation. In the second place, it is different in just these respects from natural expressions (e.g., moaning as an expression of pain). And in the third, it is different in just these respects from the expression of thoughts in (at least nonmetaphorical) language (which, one might add, is all the more reason not to think of the body as a... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 10.1 (2003) 33-35 [Access article in PDF] In the Spirit of Giving Uptake Nancy Nyquist Potter IT IS BOTH WONDERFUL and daunting to now be in the middle of a dialogical exchange on the messy and difficult topic of self-injury and how ethically to interact with patients who self-injure. It is wonderful that authors such as Carolyn Sargent have contributed very helpful examples (...) from the discipline of anthropology that expand the ideas I have been grappling with. And it is daunting to begin to sharpen and correct my thoughts along the lines that the commentators suggest. In the spirit of giving uptake both to the praise and the criticism I have received, I first situate the "Commodity/Body/Sign" article in the context of my larger project and then focus on one problem area: my claim that giving uptake is necessary to ethical healing practices. Giving Too Much Uptake to the Dsm Rob Woolfolk is right that borderline is diagnostically imprecise. But what initially caught my interest in this personality disorder was its pejorative connotations. I will mention my favorite example, which comes from a past chairman of the psychiatry department at New York University that "borderliners are the patients you think of as PIAs—pains in the ass," (Medical World News 1983). Why are the patients who exhibit the behaviors associated with borderline personality disorder (BPD) so disliked, I wondered? Who are these patients, and what are they doing that brings upon themselves such rejection? My investigation, in other words, has been focused on behaviors and their meanings, using a philosophical lens to examine underlying assumptions. I completely agree with Woolfolk and Carolyn Sargent that much more analysis needs to be done on BPD, and I am eager to do it. It is true that I do not take up larger questions about the gendered nature of this diagnosis in general (Sargent, Woolfolk), nor do I challenge the validity of the diagnosis in this article (Woolfolk). In my view, that larger project must be held in abeyance until more philosophical probing on a number of other issues is done. Hopefully, my book-length project will benefit from continuing guidance from these authors.I focus first on self-injury for two reasons. First, it is the most common symptom for which people with BPD come to clinical attention (Gunderson 2001, 22). Second, of all the behaviors associated with BPD, self-injurious behavior is the kind that people most tend to dig in their heels about when its status as pathological is questioned. Gunderson cautions that "because the diagnosis of BPD underscores a serious, long-standing mental health problem, the diagnosis should not be offered too readily to anyone who cuts or otherwise self-mutilates" (2001, 23). I add to that caution that we ought not too readily assume that self-injury is pathological: Lynne Cox (2003) swam to the Antarctic Peninsula in water temperatures of 32° Fahrenheit and with 25 foot waves; she suffered nerve damage and numbness in her extremities. Self-injurious behavior? [End Page 33] Pathological? Cox trained for two years to accomplish this feat. In problematizing self-injury, I raise questions about some associations and assumptions we make. Calling into question the whole taxonomy requires looking at symptoms, behaviors, and criteria as a whole, and that cannot be done until systematic analysis of concepts such as self-injury, impulsivity, identity disturbance, and manipulativity are undertaken. To put things in terms of Woolfolk's reasonable criticism that he wishes I would "give less uptake to the framers of the DSM-IV," I appreciate that point. But I do think that those of us who are not ourselves clinicians must do our research carefully and proceed conservatively rather than attempting to tear a house down that may not need to be condemned. Methods and Morals Woolfolk says that the concept of uptake is "familiar and central" to therapy; Katherine Morris says it is "simple and uncontroversial"; Sargent says it is "unexceptionable"; and Christa Krüger says it may be "very difficult if not more or less doomed... (shrink)

al treatment of episodic substance intoxicated states with or without self-inflicted injuries. Patients later can develop comorbid medical illnesses associated with nonadherence of treatment or iatrogenic conditions, both of which result in complex end-of-life-care decisions. Institutional familiarity of repeat patients often leaves healthcare providers feeling responsible for the patient despite having little influence over the patients' ultimate behavioral outcomes. This article describes a patient with chronic alcohol abuse, treatment noncompliance, severe personality disorder, recurrent suicidal ideation, self-injurious (...) class='Hi'>behavior, alcoholic cirrhosis, and suicide attempt resulting in multisystem injuries leading to an ethical conflict regarding end-of-life care.... (shrink)

Risk-taking behaviours often reflect ambivalent ways of calling for the help of one’s close friends and family – those who count. It is an ultimate means of finding meaning and a system of values; and it is a sign of the adolescent’s active resistance and his attempts to find his place in the world again. It contrasts with the far more insidious risk of depression and the radical collapse of meaning. In spite of the suffering it engenders, risk-taking nevertheless has (...) a positive side, fostering independence in adolescents and a search for reference points, it leads to a better self-image and is a means of developing one’s identity. It is nonetheless painful in terms of its possible repercussions: injuries, death or addiction. But let us not forget that the suffering is upstream, perpetuated by a complex relation between a society, a family structure and a life history. Paradoxically, for some young people who are suffering, the risk is rather that they will remain immured in their world-weariness, with a potentially radical outcome (i.e. suicide). The turbulence caused by risk-taking behaviours illustrates a determination to be rid of one’s suffering and to fight on so that life can, at last, be lived. (shrink)

: Traditional definitions of pain assume that an individual learns about pain through verbal usages related to the experience of injury in early life. This emphasis on the verbal correlates of pain restricts our understanding of pain to the context of adult human consciousness. In this paper we instead support the idea that our understanding of pain originates in neonatal experience and is not merely a verbally determined phenomenon. We also challenge the definition of pain as a merely sensory message (...) related to peripheral tissue trauma. We aim to move beyond this definition by considering the relationship between the centre and periphery, taking into account certain phenomena such as phantom limbs and interoception. We show that pain helps an individual to develop a sense of awareness of himself immersed in a social context, and is thus a complex and adaptive phenomenon, that supports bodily integrity and social behavior. Keywords : Awareness; Consciousness; Experience; Pain; Self-representation Dolore e coscienza negli esseri umani. Ovvero, perché il dolore favorisce l’identità e la rappresentazione di sé Riassunto : La definizione classica di dolore presuppone che l’individuo ne apprenda l'uso verbale attraverso esperienze dolorifiche legate all’infanzia, favorendo una maggiore attenzione per i correlati verbali del dolore. Questo spesso relega il dolore nel contesto della coscienza dell’uomo adulto. Il presente lavoro si propone, in primo luogo, di sottolineare alcune evidenze, a partire dall'esperienza neonatale, a sostegno dell’idea di dolore come esperienza umana e non solo come fenomeno determinato verbalmente. Un secondo aspetto emerge dalla definizione di dolore, il concepirlo come un semplice messaggio sensoriale in seguito a lesioni dei tessuti periferici. Ci si propone, pertanto, di andare oltre tale ipotesi considerando il rapporto tra centro e periferia, a partire da alcuni fenomeni come l’arto fantasma e l’interocezione. Il dolore aiuta inoltre a sviluppare un senso di consapevolezza di sé immerso nel contesto sociale; si tratta dunque di un fenomeno complesso e adattivo, dall’integrità fisica alla dimensione sociale. Parole chiave : Consapevolezza; Coscienza; Esperienza; Dolore; Rappresentazione di sé. (shrink)

The treatment of persons who frequently present to the healthcare system following repetitive foreign body ingestion has been addressed in the psychiatric literature. However, there has been little exploration of the ethical considerations regarding the treatment of these patients. The complexity of their medical and psychiatric presentation raises fundamental ethical questions regarding the duty to treat, patient autonomy, justice, and futility. Careful ethical analysis is particularly important in this context, since the frustration that medical professionals may feel in response may (...) lead to false assumptions that can negatively impact patient care. A careful exploration of these questions can increase awareness and understanding, which in turn can lead to improved treatment of patients who repetitively ingest foreign bodies. Care for patients who inflict self-harm, particularly by repetitive foreign body ingestion, is not futile. The patients have a right to treatment and are entitled to resources. Efforts should be made to provide a more comprehensive treatment approach to these patients. (shrink)

Until comparatively recently, say the middle of the last century, spinal cord injury was fatal as pressure sores and other infections took their toll. Those with severe brain injuries, unable to move or even communicate, fared even worse; without movement or feeding such patients were nursed until nature took its course. Over the last few decades medical and nursing advances have enabled some of these vegetative patients to survive for considerable time, provoking, at times, ethical and legal dilemmas. Though they (...) survived, without overt behaviour or clear communication their carers were frequently unsure how much residual function remained. Now real progress is occurring in this area thanks to the application of neuro-scientific methods by some outstanding groups of workers. Subjects with severe brain injury may begin in complete, unresponsive coma but then ‘lighten’ to one of three categories. In vegetative state (VS), patients are apparently awake but without evidence of voluntary behaviour and have no apparent awareness of self or environment, whilst in minimally conscious state (MCS) patients have some behaviour beyond the reflex but are not able to communicate effectively. These conditions usually result from widespread brain damage at either or both cortical and subcortical levels due to injury or anoxia, though they can also be seen in end stage neurological conditions like Alzheimer’s. In locked in syndrome (LIS), patients ‘awake’ from coma, usually due to stroke, aware of their surroundings and their situation but unable to speak or move, beyond eye lid control and eye movement. For many, LIS will be recognised from Bauby’s extraordinary account in ‘The Diving Bell and the Butterfly,’ though, incidentally, it was presaged in Samuel Beckett’s novella ‘The Unnameable.’ LIS reflects a profound disconnection between brain and body, except for the upper cranial nerves involved in eyelid movement. The overriding question is how much awareness these patients have.. (shrink)

Many people believe that only humans have the cognitive and behavioral capacities needed for suicidal behavior, such as reflexive subjectivity, free will, intentionality, or awareness of death. Three counterarguments — based on (i) negative emotions and psychopathologies among nonhuman animals, (ii) the nature of self-destructive behavior, and (iii) the problem of model fidelity in suicide research — suggest that self-destructive and self-injurious behaviors among human and nonhuman animals vary along a continuum.

I shall examine one way that careproviders may come to judgments of “futility” in cases that are less than clear-cut, in the hope that, if such judgment is unwarranted, it may be avoided.

Peña-Guzmán (2017) argues that empirical evidence and evolutionary theory compel us to treat the phenomenon of suicide as continuous in the animal kingdom. He defends a “continuist” account in which suicide is a multiply-realizable phenomenon characterized by self-injurious and self-annihilative behaviors. This view is problematic for several reasons. First, it appears to mischaracterize the Darwinian view that mind is continuous in nature. Second, by focusing only on surface-level features of behavior, it groups causally and etiologically disparate (...) phenomena under a single conceptual umbrella, thereby reducing the account’s explanatory power. Third, it obscures existing analyses of suicide in biomedical ethics and animal welfare literatures. A more promising naturalistic approach might seek a theoretical understanding of the social/ecological circumstances that drive humans and perhaps other animals to self-destruction. (shrink)

This study explored representations of self-injury in Japanese manga. A content analysis of fifteen slice-of-life manga published between 2000-2017 was conducted, focusing on forty scenes that depict eighteen characters engaging in self-injury. Most depictions of self-injury reflect a stereotypical perception of “self-injurer,” a young girl cutting herself to cope with negative emotion. Characters receive informal support from friends and partners, while parents are portrayed as unsupportive and even triggering. An emergent trend was observed among manga targeting (...) male readers to label self-injuring women as “menhera” - mentally vulnerable damsels in distress - inviting a fetishistic gaze on the self-injuring female bodies. (shrink)

Abstract:This symposium includes twelve personal narratives from healthcare professionals who have worked with patients whose behavior, attitudes, or life situations make providing care challenging. At the lower end of the estimates, at least 15% of adult patient encounters are with patients described as "difficult" by the treating team, and these encounters often evoke feelings of dread, frustration, and anger in healthcare professionals. Verbal abuse of staff, repeat hospital admissions due to self-injurious behaviors, and negative beliefs about health (...) may make providing care to this group of patients a daily struggle. Despite these challenges, healthcare providers—especially those who work in an in-patient setting—are obligated to treat all comers, sometimes at the expense of their own mental health. This symposium aims to learn from health professionals' stories the kinds of struggles they face, the lessons they draw from those struggles, and the constructive responses they employ to work successfully with challenging patients. (shrink)

Theories of affective influences on cognition posit that negative mood may increase cognitive load, causing a decrement in task performance (Seibert & Ellis, [1991]. Irrelevant thoughts, emotional mood states, and cognitive task performance. Memory & Cognition, 19(5), 507–513), or cause a shift to more analytic thinking, which benefits tasks requiring attention to detail (Schwarz & Clore, [1983]. Mood, misattribution, and judgments of well-being: Informative and directive functions of affective states. Journal of Personality and Social Psychology, 45(3), 513–523). We previously reported (...) that individuals who are higher in the trait of emotional reactivity performed better on an inhibitory task with increasing negative mood whereas low-reactive individuals showed the converse pattern (Gabel & McAuley, [2018]. Does mood help or hinder executive functions? Reactivity may be the key. Personality and Individual Differences, 128, 94–99; [2020]. React to act: Negative mood, response inhibition, and the moderating role of emotional reactivity. Motivation and Emotion, 44(6), 862–869). Because high-reactive individuals are more accustomed to negative affect (Nock et al., [2008]. The emotion reactivity scale: Development, evaluation, and relation to self-injurious thoughts and behaviors. Behavior Therapy, 39(2), 107–116), we speculated that negative mood engendered analytic thinking but without a task-incongruent increase in cognitive load – thereby facilitating performance. Here, we induced a heuristic or analytic approach to information processing prior to performance of an inhibitory task and expected different results pending the thinking style induced. In the heuristic condition, increasing negative mood was associated with better performance for high-reactive participants but not their low-reactive counterparts. In the analytic condition, increasing negative mood was associated with better performance irrespective of emotional reactivity. Our results are consistent with the notion that negative mood engenders analytic thinking which may benefit response inhibition provided it does not increase task-incongruent cognitive load. (shrink)

Although clinical understandings of self-injury, the deliberate mutilation of body tissue, have developed significantly since the phenomenon was first studied, the predominant stereotype of who self-injures is still White, teenage girls.1 White girls as well as White women are, indeed, at risk for SI, and sociocultural explanations appealing to oppressive socialization—particularly the influence of Western beauty norms—have been offered to explain their high rates of SI. Yet evidence exists to challenge this conception that SI is exclusively a White, (...) female issue: Black women, South... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 10.1 (2003) 17-21 [Access article in PDF] Self-Injury:Symbolic Sacrifice/Self-Assertion Renders Clinicians Helpless Christa Krüger Keywords feminism, iconic communication, moral conflict, oppression, psychiatrist/psychologist roles, societal norms. POTTER'S PAPER CONSIDERS self-injury in women diagnosed with borderline person ality disorder (BPD) to be a form of body modification where the body is used to communicate meaning. She touches on symbolism as a possible explanatory theory (...) for this sort of self-injury. She also refers to the culture of body commodification as underlying self-injury. She then argues that clinicians have a duty to give uptake to the patient's own interpretations about the meaning of the self-injury. Giving uptake is a virtuous approach for ethical interactions with people diagnosed with BPD who self-injure, and it aims to preserve the communicator's integrity, along with other benefits. Potter offers five maxims for giving uptake properly. However, I shall argue that giving uptake can be very difficult for clinicians, and that an appreciation of this difficulty depends on an expansion and linkage of some of the theories that she touched on. Self-injury is revisited experimentally as a double-edged sword of symbolic sacrifice and iconic-symbolic self-assertion. This revisiting aims to illustrate how clinicians might be caught in a double bind, where giving uptake properly might be very difficult if not more or less doomed to fail.Potter's paper starts by situating self-injury in a broader discourse of body modifications. In this discourse the body is being used as a text, a tool to communicate meaning. The meaning that is communicated might be difficult or impossible to articulate otherwise (by using words, for example). The meaning of the communication is embedded in a context of social, cultural, religious, political, and other norms. Potter explores possible interpretations of the meaning of self-injury in women with BPD, including an interpretation of self-injury as symbolic sacrifice. She suggests that a cultural understanding/nonunderstanding of the meaning of a particular instance of self-injury is an important determinant of whether such self-injury is considered pathological/nonpathological. She then shifts the focus to the present-day culture in which women's bodies are commodified and objectified, and where women become alienated from their bodies. Self-injury might then be interpreted as an attempt to re-own one's body as a part of oneself. This re-owning is a socially transgressive act that violates repressive norms for the bodies of women. [End Page 17]Notwithstanding these possible significations of self-injury, Potter then argues that clinicians have a duty to give uptake to the patient's own interpretations, instead of jumping to conclusions (my oversimplification) about the meaning of the self-injury. Giving uptake, then, constitutes a framework for ethical interactions with people diagnosed with BPD who self-injure, and it aims to preserve the communicator's integrity. Potter offers five maxims for giving uptake properly.At the risk of losing their essence, I translate the five maxims for practicing psychiatrists as involving the following: critical self-reflection about one's own conceptual framework and cultural context; being receptive to the patient's conceptual framework and cultural context; giving the patient the benefit of the doubt; being open to the emergence of new meanings of self-injury; and keeping a range of possible interpretative options open, rather than insisting on having the final word. We should try to understand what the world looks like from the patient's position. All of this requires some moral effort.Potter describes a number of benefits that result from giving uptake. Giving uptake is a crucial corrective to the human tendencies of becoming overly committed to prevailing societal norms and conceptual schemes (stuck in our ways), of imposing our views on others, and of silencing or distorting the communications of our patients. Giving uptake allows clinicians to be dialogically responsive and to treat patients with respect and dignity. Giving uptake fosters trust in a therapeutic relationship where clinicians do not exploit their patients' vulnerabilities. Giving... (shrink)

SELF-INJURY IS A COMPLEX phenomenon that is encountered on a regular basis by health care professionals in mental health care. In this article, I use the concept of epistemic injustice to examine this complex phenomenon and argue that this helps us to understand developments in the way we think about and support people who self-injure. Individuals with lived experience have important knowledge about the nature of self-injury and particularly how it relates to them. If the credibility of (...) this knowledge is denied, for example through accusations of emotional instability, manipulation and attention seeking, then we may cause epistemic and non-epistemic harms. The former by denying the capacity for knowledge, by not... (shrink)

Self-medication behaviour is the use of natural materials or chemical substances to manipulate behaviour or alter the body’s response to parasites or pathogens. Self-medication can be preventive, performed before an individual becomes infected or diseased, and/or therapeutic, performed after an individual becomes infected or diseased. We summarized all available reports of self-medication in mammals and reconstructed its evolution. We found that reports of self-medication were restricted to eutherian mammals and evolved at least four times independently. (...) class='Hi'>Self-medication was most commonly reported in primates. Detailed analyses of primates suggest that self-medication is a life-history trait associated with body size, absolute brain size and longevity, but we found no support for the hypothesis that self-medication evolved to reduce the costs of social living. Large, longer-lived species might thus benefit uniquely from self-medication. (shrink)

The present study investigated the mediating role of negative emotion in the relationship between cybervictimization and non-suicidal self-injury, and the moderating role of friendship quality in the indirect relationship. This model was tested with 1,326 Chinese adolescents who suffered from cyberbullying in the last 1 year; 727 were boys and 591 were girls, and their mean age was 13.67 years. Participants filled out questionnaires regarding cybervictimization, negative emotion, friendship quality, and non-suicidal self-injury. After demographic variables were controlled, cybervictimization (...) was significantly positively associated with non-suicidal self-injury. Mediation analysis revealed that negative emotion partially mediated the association between cybervictimization and non-suicidal self-injury. Moderated mediation analysis further indicated that the mediated path was weaker for adolescents with higher levels of friendship quality. These findings underscore the importance of identifying the mechanisms that moderate the mediated path between cybervictimization and non-suicidal self-injury among adolescents. (shrink)

The first aim of the study was to identify when deliberate self-harm behavior ceased in patients with borderline symptoms undergoing dialectical behavioral treatment. The second aim was to compare patients who ceased their self-harm behavior early or late in the course of treatment, with regard to demographics, comorbidity, and symptom severity. The study used a naturalistic design and included 75 treatment completers at an outpatient DBT clinic. Of these 75 patients, 46 presented with self-harming (...) class='Hi'>behavior at pre-treatment. These 46 participants where split into two groups, based on median amount of time before ceasing self-harm behavior, termed early and late responders. Treatment duration varied from 16 to 160 weeks. Patients were assessed pre- and post-treatment using measures of depression, hopelessness, personality traits, quality of life, and global assessment of symptoms and functioning. The majority ceased their self-harming within the first year, and the average number of weeks was 15.5. Twenty-five percent of patients ceased their DSH behavior during the first week of treatment. For the remaining patients, the cessation of DSH continued gradually across a 1 year period. We found no differences between early and late responders with respect to demographics, comorbidity, symptom severity, or treatment outcome. None of the patients committed suicide. The findings indicate that self-harming behavior decreases gradually across the first year after starting DBT. (shrink)

Harm minimisation has been proposed as a means of supporting people who self-injure. When adopting this approach, rather than trying to stop self-injury immediately the person is allowed to injure safely whilst developing more appropriate ways of dealing with distress. The approach is controversial as the health care professional actively allows harm to occur. This paper will consider a specific objection to harm minimisation. That is, it is a misguided collaboration between the health care professional and the person (...) who self-injures that is morally and clinically questionable. The objection has two components. The first component is moral in nature and asserts that the health care professional is complicit in any harm that occurs and as a result they can be held morally responsible and subject to moral blame. The second component is clinical in nature and suggests that harm minimisation involves the health care professional in colluding in the perpetuation of self-injury. This element of the objection i... (shrink)