Interpersonal Processes and Self-Injury Gillian Rayner School Of

Interpersonal processes and self-injury Gillian Rayner School of Nursing and Midwifery The University of Salford. Salford.UK Submitted for the partial requirements of the Degree of Doctorate of Philosophy 2010 Contents Acknowledgements Abstract Chapter 1: Introduction and aims of the study P1-10 Chapter 2: Current concepts relevant to interpersonal P11- 44 processes and self-injury Chapter 3: Methodology P45- 87 Chapter 4: Client Themes P88-147 Chapter 5: Staff Themes P148-191 Chapter 6: Interpersonal issues between staff and P192-236 client. Chapter 7: Discussion P237- 284 Chapter 8: Implications for practice P285- 300 Chapter 9: Limitations of the study P301- 303 Chapter 10: Conclusion P304- 315 Chapter 11: The researchers story P316-323 Appendices Appendix 1: Research Information sheet for clients P324-325 Appendix 2: Research information sheet for staff P326-327 Appendix 3: Consent form for clients P328 Appendix 4: Consent form for staff P329 References P330-344 11 Acknowledgments The journey of writing this thesis has been exciting, challenging and apprehensive at times. A roller coaster of emotions has been experienced in differing degrees. From anxiety to loneliness, from elation to feeling stuck, or helpless; however many people have helped and supported me along the way. This thesis would not have been completed without their invaluable contributions. I am immensely grateful to everyone who has helped me in this process. My deepest thanks go to my supervisor Dr Tony Warne for his support, empowerment and containment, especially in my anxious or self-doubting moments. I felt truly liberated to move away from theoretical constraints in the research process and focus on genuine experiences of all participants. I would also like to thank Dr Martin Johnson for his help and support in the earlier part of the research process. I am thankful to lan Anstice and Joanne Johnson for proofreading my chapters and then the whole thesis giving humorous feedback at times really helped. I would like to thank my research participants who were willing and able to share their personal experiences with me when I had only just met them, this thesis would not have been possible without you all. I hope we can make a in clear difference to understanding some interpersonal issues influenced by self-injury and improve care as a result of this. Finally I would like to express my gratitude to my husband Mark and son Jay for their support, interest, tolerance and understanding, while I was busy studying. On explaining my research and work with people who self-harm to Jay (aged 4) he was studying art and nicely explained to his friend at school a few days later, that his mum knew Van Gough (as he self-harmed). So although Van-Gough was not a participant in this research it certainly may have been relevant for him. Thanks to my friends Christine Hogg, Karen Williams and Joanne Johnson who supported me through emotive times and engaged in interesting discussions that helped clarify my thinking. Thanks to my parents who have lovingly supported me through life and have encouraged my recognition that I could change a part of the world for the better. As I grew up they encouraged independent thought and critical debate even when I disagreed with them. They have always wanted to see me succeed in life and I hope they will be proud that this dissertation is finally complete. I finally complete this thesis in Memory of my father Brian Hall who sadly died just before ! finished my Doctorate Thank-you IV Interpersonal processes and self-injury Abstract Most interventions in health and social care settings reside within a therapeutic relationship. However if the staff member is experiencing difficult emotional reactions or thoughts this can interfere with the process of caring or helping. Staff and client perspectives are split into different articles by different authors, or within different chapters of a book. This has reinforced the difference between clients and staff. Arguably professionals are increasingly viewed as human beings with their own reactions to events, rather than detached unemotional helpers. However, the reactions of staff are often not linked to clients. Within the literature on self-injury this has not been clearly described. This thesis makes an original contribution to recognising the interpersonal processes involved when a person self-injures. Three pairs of clients and staff were interviewed about a specific incident of self-injury, with a focus on thoughts feelings and behaviours before during and after the self-injury. They were all also asked about helpful and unhelpful interventions. The data from the interviews was thematically analysed and then synthesised. This resulted in specific and common client perspectives and specific and common staff perspectives. Then each of the client and staff dyads were analysed together with a focus on the interpersonal process. This then produced an account of a synthesised process of these two experiences. Themes included description of self-injury as a cycle of shame, which begins as shame avoidance and then becomes a shame eliciting behaviour, based on other peoples' reactions. Staff and clients described similar emotional reactions, thoughts and psychological defences. Projective identification was used as a method of demonstrating the interpersonal processes between the dyads, with some similar and some contrasting internal experiences. These themes were discussed in depth linking to relevant literature and key implications for practice were then produced. VI Interpersonal processes and Self-injury - Gillian Rayner Chapter 1: Introduction to the study The first chapter of the thesis provides an overview of the background of the study, the aims and purpose of the study and the organization and content of the chapters that follow. Background to the study I began working with people who self-injure as a nurse therapist in a high security mental health hospital. I observed that alongside the experience of sexual abuse as a child, self-injury was a taboo subject and that professionals tended to focus on offending behaviour, rather than other behaviours or reasons why people had begun offending. At this time, I was involved in a group for women who self-injured that was lead by psychologists. Although this clearly was the focus and reason for the "therapeutic" group, it became apparent that the clients and staff were avoiding discussing self-injury and abuse issues at all costs. As a result, anxiety levels increased and clients began to self-injure more following the group. It interested me that in the initial aim of making self-injury a subject that could be discussed and understood, even members of staff were unable to "break the silence" on this taboo subject, for fear of making the clients feel worse. I have also observed many staff in different settings reject people for self-injuring, keep them in hospitals longer, try to engage with them only to feel a failure when interventions did not work, or become scape-goated by other staff in the workplace. This motivated me to join a group of staff in a network called the Northwest Self- Injury Interest Group. There I met like-minded professionals, mainly nurses, and also Interpersonal processes and Self-injury - Gillian Rayner some psychologists and social workers. They all had similar experiences and were working to change care for people who self-injure. In the early 1990's, the group lobbied the Department of Health and the Royal College of Nursing to think about care in a different way and increase guidance for staff working with people who self- injure, but with limited success. However the group did provide thirteen years of support lead by myself and colleagues at the University of Salford for many staff in clinical settings working with people who self-injure. Most of the clients I worked with had histories of childhood sexual abuse, physical abuse and neglect. My understanding of self-injury was based on ideas expressed by clients influenced by their own experiences. This was also supported well within the "expert by experience" and professional discourse. I had begun to conceptualise self- injury as a coping strategy to release tension, triggered by childhood trauma. Whilst this was an accurate understanding for many of the clients that I had worked with in therapy, the mental health settings that I worked in would have been likely to have a large proportion of people who had experienced trauma. This would not necessarily be the case for other people outside of this system. I became acutely aware of my drive to have a tidy theory to fit people into, within a confusing and complex experience of the self-injury process. Many of the clients that I have worked with reported that the treatment following self- injury, especially in A&E departments was negative. In one of my previous jobs in Liaison Psychiatry I worked with the staff in this department to challenge attitudes and cope with the emotional turmoil that the staff reported. I believed that staff needed to be able to discuss and get support and supervision about their reactions Interpersonal processes and Self-injury - Gillian Rayner towards people who were self-injuring, in order to remain in a secure helping therapeutic relationship. When completing my Counselling MA, I studied counter- transference and projective identification. I began to draw upon these concepts to understand interpersonal issues and when I began teaching at Salford University, also incorporated this into my teaching around self-injury. On the self-injury module I chose to focus on staff reactions in the first session, prior to learning about self-injury, assessment or interventions. This ensured that staff beliefs and attitudes were targeted first in order to improve the effectiveness of interventions.

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