Page 54 - SEN114 September/October 2021

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■ A cry for help.
How we think about self-harm
Self-harm is a prolific concern right now, with around one fifth of fifteen year olds thought to have self-harmed at some point. Self-harm is most commonly related to overwhelming emotions in response to adverse experiences. The overwhelming emotions typically include depression, anxiety, anger, shame, self-hate and hopelessness. These are often a response to adverse experiences that include the loss of a loved one, bullying, academic pressure, familial tension, abuse and trauma. Assessments and treatment for self-harm consider personal factors such as the person’s social situation, state of mind, experiences past and present, and their emotions.
However, if the person hurting themselves has a moderate, severe or profound learning disability, a completely different approach is adopted, starting with giving it a different name, usually ‘self-injurious behaviour’ or ‘self-injury’. Self-injury is usually considered a biological issue or a behavioural issue.
The biological considerations ask if the self-injury might be the product of a person’s disability. Some syndromes have self-injury correlated strongly with them, such as Lesch Nyhan; self-injury is also a behaviour strongly associated with autism, with around fifty percent of people with autism displaying self- injury at some point.
Self-injury is also considered from a behavioural perspective, usually under the broad umbrella of ‘challenging behaviour’. The behavioural approach considers whether self-injury is a way
“Based on the assumption that behaviour is “triggered” by an event”
for the person to communicate something functional: a physical pain; a sensory need; a desire to escape or avoid something; a need for attention; or to gain a tangible goal, such as food, drink or a preferred activity.
These two dominant considerations have impacted practice considerably, so that if a person is displaying self-injury at a concerning level, it is typically responded to biologically through medication and behaviourally with a behaviour plan. Behaviour plans generally require behaviour charts, and behaviour charts typically ask one big question:
What happened just before and just after the person hurt themselves?
Or what were the ‘antecedents and consequences’ of the behaviour? This is based on the assumption that a behaviour
is ‘triggered’ by an event preceding the behaviour – and that the behaviour was used to achieve what happened immediately after the event.
For example, Joel is sitting in the lounge. Someone turns on the TV to EastEnders. Joel starts to hit his head. A staff member supports him to his bedroom where he is able to calm down.
What triggered Joel’s self-harm? The sights and sounds of the TV.
What did Joel’s self-harm achieve? Escape from the sights and sounds of the TV.
This approach has many benefits (and it is a far cry from our not-so-distant history of institutionalised care, with interventions including over-medicating and aversive therapies). This functional approach is centred around Joel’s experiences and tries to make sense of Joel’s behaviour and respond accordingly. However, it exclusively focuses on the moment in time: it seeks to make sense of self-injury in relation to what happened just before and just after Joel hurt himself.
And herein lies the problem
The small amount of research which asks people with learning disabilities about their own self-harm does not reflect this ‘here and now’ approach. Here are the three things that people with learning disabilities most commonly express in relation to their own self-harm:
Emotional regulation
Emotional regulation is about the need that we all have to work at regulating our emotions – we all feel our emotions going up and down to varying degrees, and we all have to learn to tolerate or manage the difficult feelings of loss, anger, disappointment, fear, etc. These emotions have to be processed
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