Behavioural and Cognitive Psychotherapy, 2005, 33, 237–242 Printed in the United Kingdom doi:10.1017/S1352465804001973
The Development of Behavioural Coping Skills in a Repetitive and Deliberately Self-Harming Young Woman Malcolm Wheatley St. Andrew’s Hospital, Northampton, UK
Clive Hollin University of Leicester, UK Abstract. This project reports on the effective delivery of a behavioural coping skills programme with a repetitive deliberately self-harming young woman. A simple single case A-B design was employed to evaluate the intervention due to the applied nature of the project and ethical considerations. An assessment period prior to the intervention phase constituted an extended baseline. Data concerning the primary dependent variable, deliberate self-harm, were collected for a 3-month follow-up period. Keywords: Coping skills, deliberate self-harm, adolescent.
Introduction Within society there exists a small number of extremely disturbed adolescents who, despite their age, require detention under the Mental Health Act (1983) and care in a medium secure facility to ensure their own safety. Of these detained adolescents, females frequently present with severe and repetitive deliberate self-harm, and substantial histories of abuse (particularly sexual). These young women attract multiple diagnoses and typically present a complex picture of Post Traumatic Stress Disorder, high rates of dissociative phenomena, flashbacks, psychotic symptoms and, as they mature, a primary diagnosis of Borderline Personality Disorder. The most disturbed and treatment-resistant of these young people may enter secure care during early adolescence and remain for years in a secure environment. The severity of disturbance is well illustrated in a recent paper describing some of the most salient characteristics of young people referred to secure health care (Wheatley, Waine, Spence and Hollin, 2004). These young people present a substantial therapeutic challenge, with their self-harm constituting the most prominent and debilitating behavioural difficulty in their continued detention. In the psychological literature, deliberate self-harm is primarily viewed as a maladaptive coping response to intolerable conditions. Numerous models abound in the literature, though each has in common the view that self-harm is a dysfunctional response. Orbach (1986), for example, emphasizes the communication function of self-harm. Bancroft, Skrimshire and Reprint requests to Malcolm Wheatley, Lowther Adolescent Service, St Andrew’s Hospital, Billing Road, Northampton NNi 5DG, UK. E-mail:
[email protected] © 2005 British Association for Behavioural and Cognitive Psychotherapies
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Simkin (1976) emphasize the coercive nature of self-harm. Gardner and Gardner (1975) point to tension reduction as the most critical function. Faye (1995) describes the addictive nature of self-harm. Traditional behavioural analysis, alongside a detailed interview, may help understand the context and function of such behaviour (Sturmey, 1996). With respect to Moos’ (1990) conceptual organization of coping responses, deliberate self-harm in these young people would be located in the behavioural-avoidance domain; specifically in the emotional discharge cell when tension reduction is identified as the primary function of self-harm. The research base on the treatment of deliberate self-harm is limited. With the exception of some encouraging evidence related to developing problem-solving skills (Salkovskis, Atha and Storer, 1990) and Dialectical Behaviour Therapy (Linehan, Armstrong, Suarez, Allmon and Heard, 1991), psychological and pharmacological treatments of individuals who selfharm have limited proven efficacy. Thus, Hawton et al. (1999) conclude from their review that: “There is insufficient evidence to make recommendations on which treatments are the most effective for patients who have engaged in deliberate self harm” (p. 46). In summary, the available studies suggest that there is a need to concentrate upon the initial development of new behavioural coping skills. These new skills should be learned within a supportive therapeutic environment where the individual is encouraged to adopt an active thinking style and to explore their behavioural responses to emotional distress. Method and results It was hypothesized that the successful delivery of a behavioural coping skills treatment programme would lead to a reduction of self-harm. In turn, this reduction would be reflected in a shift in coping style towards behavioural approach strategies and away from an avoidant coping style. A pilot project was conducted with three adolescent patients from the Lowther Adolescent Service to establish adequacy in the reliability of the dependent measures and to establish a clear structure and format for the treatment programme. The pilot project confirmed the ease and willingness of young people to report on their use of agreed coping skills. In addition, the pilot project allowed examination of the other main dependent measure, namely incidents of self-harm. It was established that self-harm could be reliably measured by reference to the continuous Behavioural Monitoring Programme already in place on the unit and by further cross-referencing recorded incidents to the case notes. The definition of self-harm employed for the project was accepted as workable. Deliberate self-harm was clearly defined in broad and inclusive terms: “Any acute and intentional actual or potential self-injurious behaviour, whether with or without suicidal intent, including both internal bodily damage (e.g. self-poisoning) and external damage (e.g. self-mutilation)”. Finally, the structure for the Coping Skills Intervention was found to be appropriate for all three pilot subjects. The structure included the following elements; objectives; functions of self-harm; rating scales; agreed coping skills; crisis plan and relapse prevention. One young woman (K) was selected for participation in the present study in order to trial the intervention with a comprehensive evaluation. She was aged 18 years and 11 months at the start of the project, had a formal diagnosis of Borderline Personality Disorder, and had been resident in the medium secure adolescent service for 53 months. Throughout this time, she had presented repetitive deliberate self-harm, primarily involving head banging, cutting, and inserting items into her vagina. She had not responded to treatment efforts and had not demonstrated a sustained period longer than 3 weeks without incidents of deliberate self-harm. The primary functions of
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No. Coping Skills Used and Freq. D.S.H.
35 30 25 20 D.S.H.
15
Coping Skills
10 5 0 1 Baseline
2
3
Assessment
4 5 6 7 8 9 10 11 Baseline Time Periods (23 days) Intervention
12
13
14
Follow-up
Figure 1. DSH and use of coping skills in baseline time periods
K’s deliberate self-harm were established through behavioural analysis, clinical interview, and reference to both the clinical literature and previous assessments and interviews with similar young people in the Lowther Adolescent Service. For K, the primary identified functions were to communicate distress, to release tension, and to avoid painful memories. K also identified a fear of being discharged from hospital. The treatment goal was therefore formulated as the acquisition of new coping skills to replace deliberate self-harm, so facilitating progression to a less secure unit rather than discharge to the community. A simple A-B case design was employed in view of the applied nature of the research. However, a 6-week assessment period prior to initiating the intervention served to extend the baseline, and follow-up data for self-harm were collected for 3 months after the intervention. The treatment phase was set at 4 months to allow adequate time for a treatment effect to be observed. Given the applied nature of the project and ethical constraints, the baseline was established by K in that it was determined by the length of time, in full days, that were required for 10 incidents of deliberate self-harm to be displayed. The eventual baseline period was established as 23 days. Each data point along the X axis in Figure 1 therefore represents a 23-day period. The final point of the assessment and intervention phases (points 3 and 10 respectively) are prorated values. Behavioural measures were collated on a weekly basis throughout the course of the trial. These measures included frequency of deliberate self-harm and use of coping skills. Two recording methods were used to measure frequency of self-harm. The Behavioural Monitoring Programme was an established Unit programme for collecting behavioural data on a continuous basis. For validation, these recordings were then cross-referenced with entries made in the clinical notes. Only when an instance of deliberate self-harm was recorded in both systems was it included as an event for the purpose of the trial. There was high inter-observer reliability (Pearson’s r = 0.98) for these data sources with respect to number of incidents during each baseline time period.
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The use of coping skills was recorded by K throughout the intervention phase. These recordings were discussed on a weekly basis with nursing staff who were able to offer corroboration of K’s use of coping skills. Only when there was corroboration by nursing staff regarding the use of a coping skill was it recorded as such for the purposes of the present project (using Pearson’s r inter-observer reliability was 0.96). The Coping Responses Inventory (Moos, 1990) was administered prior to and at the end of the treatment phase. Figure 1 illustrates incidents of deliberate self-harm and use of coping skills during baseline, assessment, intervention, and throughout the 3-month follow-up period. The Assessment phase was used to formulate the function of K’s deliberate self-harm and to develop the behavioural coping skills programme. The primary coping skills developed with K involved three elements. First, she was actively encouraged to use a diary to record her feelings, to monitor her mood and to rate her risk of deliberate self-harm. Such ratings served to prompt the use of her Cue Card when necessary. Second, the development of a Cue Card, which she kept on her person, which contained validation, responsibility and self-worth statements, along with statements reassuring her of her safety and the likely consequences of self-harm. Third, she used a Flashcard, developed in collaboration with the nursing team, which she could present to named staff members to gain time and support and, in particular, assistance in problem solving the present crisis. Specific coping strategies, such as distraction activities and grounding strategies, were detailed on this Flashcard. The distraction activities involved listening to her personal tape player, reading a favourite book of short poems, completing her puzzle book. The grounding strategies that K had been coached in using included the use of a grounding object (cuddly toy), holding and squeezing the hand of a named nurse, and smelling a herb bag specifically provided to help with grounding. The Flashcard was therefore used primarily as a form of communication with staff for situations where the Cue Card had failed to work, and more active input and guidance from staff was required. The pre- and post-Intervention CRI scores indicated a significant change on one domain, an increase in the “Problem Solving” domain of the Inventory from a T-Score of 35 at pre-intervention to 46 at post-intervention (normal population mean = 50, SD = 10). The remaining 7 subscale scores showed only minor differences between pre and post scores, each difference being less than 7 points, suggesting a non-significant shift. The amount of regular and PRN medication, along with the amount of therapeutic time spent with K, were monitored throughout the trial to assess two of the primary potential internal validity threats within the methodology. With respect to psychotropic medication, the total sedation index was computed from the combination of regular medication prescribed on a weekly basis. It was assumed that all medications were being prescribed at an appropriate therapeutic dose, and the total sedation index score was achieved using the conversion tables in the Maudsley Prescribing Guidelines (1996) to yield a single value figure. These data are presented on a weekly basis throughout the phases of the project. In addition, the number of administrations of PRN psychotropic medication was recorded on a weekly basis and graphed alongside the weekly sedation index. Those results are presented in Figure 2. The remaining major validity threat concerns other psychological therapeutic input. In order to ameliorate this, the quantity of therapeutic input received by the young person was quantified during two one-week periods. The first was within the baseline period and the second half way through the treatment phase. All group and individual therapeutic contact was recorded
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12
Sedation Index and Freq. PRN Use
10 Sedation Index P.R.N.
8 6 4 2
43
40
37
34
31
28
25
22
19
16
13
10
7
4
1
0 Weeks Baseline
Assessment
Intervention
Follow-up
Figure 2. Use of Medication during Experimental Period
by means of an assistant psychologist conducting continuous observation for 5 days of the week between 9.00 a.m. and 5.00 p.m. The total number of hours of therapeutic input was subsequently calculated. During the baseline period a total of 16 hours of therapeutic input was delivered to K, compared to a total of 13 hours during the middle week of the treatment phase. This monitoring allowed for those treatment variables to be excluded as possible explanations for the observed changes.
Conclusion The results indicate that K used the agreed coping skills and that their use was associated with an immediate and substantial decrease in deliberate self-harm. Furthermore, this gain was maintained during the 3-month follow-up period. The pre- and post-intervention CRI profile indicates a significant improvement in the use of problem solving responses when faced with stressful situations. This finding suggests that it is the development of problem solving responses that mediates the observed treatment effect. However, an alternative hypothesis to account for these changes can be proposed. K had identified a fear of discharge, and the treatment goal was therefore formulated in terms of “progression to a less secure unit”. It may therefore have been this explicit revision of the treatment goal that facilitated her use of the agreed coping skills and the reduction in deliberate self-harm. If one adopts a conventional anxiety-model to understand this fear (Beck, Emery and Greenberg, 1985), the treatment goal of taking a graded step towards the fear is sound and should lead to further steps closer to the ultimate goal of successful discharge. Continued monitoring of K’s use of coping skills during the follow-up period (and a longer follow-up) would have strengthened the current design. Replication with other young people is required to establish this therapeutic approach as an effective approach to a distressing problem.
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