Author: Michelle

Say ‘self-harm’ to most people and they automatically think of cutting. However, the technical definition of self-harm is any coping strategy which gives temporary respite from difficult emotions. It’s also usually done with either the intention to self-punish, to communicate distress or both.

Amongst other things, self-harm can take the form of overeating, undereating, drinking alcohol to excess or taking other drugs, staying in toxic relationships or friendships or getting into physical altercations. Obviously, these aren’t always an example of self-harm, but they can be.

I like to think about self-harm as a habit which has developed in response to adverse circumstances. We all have crutches we rely on to get us through stress, anxiety and trauma. Some of us are lucky enough to have access to a healthy coping strategy – like a physical, creative, relaxing or community-based activity – whilst others stumble across something which gives them the same feeling of relief but has a less positive impact on their health.

It’s important to acknowledge self-harm has ‘advantages’. Any form of physical pain releases endorphins, which is the body’s way of compensating for the discomfort. It can also be a means of release and expression – A way to articulate internal distress or frustration. People are often reluctant or even scared to look at self-harm in this way because they think to do so is to ‘promote’ it. In fact, the opposite is true – it’s only by understanding the true nature of our enemy that we have any hope of fighting it.

Having a realistic view of self-harm also stops us from focussing too much on the behaviour and instead encourages us to consider the reasons and emotions behind it. Because the truth is, whether you’re self-harming or you’re concerned about someone who is, simply stopping the self-harming behaviour shouldn’t be your primary concern.

Of course, if the behaviour puts you at immediate physical risk it’s shrewd to try and think of ways to mediate that. You might find recommended ‘safe’ ways of inducing physical discomfort, like holding ice cubes in your hands, take the edge off temporarily. Ultimately, however, this is the equivalent of giving Methodone to a heroin addict – the reasons the habit began are still present and the chances of relapse are strong. Equally, there’s a lot of evidence to show-stopping self-harming behaviours without addressing the causes and/or finding an alternative outlet can increase the risk of suicide. All that pent-up emotion has to go somewhere.

I’d recommend asking honestly what benefits self-harming behaviours are bringing you and whether there’s another, less dangerous or even healthy means of achieving the same result. If self-harm is a means of expressing internal distress, for example, it might be that trying to articulate those feelings on to a page, in the form of a journal or a blog is helpful. If the ‘highs’ associated with self-harm are more physical and visceral, you could try a high impact form of exercise like boxing. If it’s a way to communicate what’s going on inside, talking to a trusted person or calling a helpline will help you to feel you have offloaded what is troubling you.

If self-harm has arisen out of feelings of anxiety, I’d recommend trying to separate worries you can control from ones you can’t. We tend to collect our anxieties, like rolling several small balls of bluetak into one gigantic one, until they seem insurmountable. Breaking each concern down and asking whether there is anything which can, realistically, be done is a way to feel more in control.

Finally, remember that recovery is like knitting – sometimes you drop a stitch. If you have a bad day and fall back into your old self-harming ways, it doesn’t mean you’re back to square one. Each attempt at recovery makes us a little stronger and teaches us a little more about what is and isn’t effective. New habits take a while to form so pick yourself up and start again, knowing it’ll get a little easier each time.

By Natasha Devon

Natasha Devon MBE is an author and activist and patron of NO PANIC who visits schools, colleges,, universities and events throughout the world delivering talks and conducting research on mental health. Her first book ‘A Beginner’s Guide to Being Mental’ was published in 2018.

Read more, a survivor’s story:   http://Chicken Pie (Recovery from self-harm)

How can No Panic help?
No Panic specialises in self-help recovery and our services include:
Providing people with the skills they need to manage their condition and work towards recovery.
Our aim is to give you all of the necessary advice, tools and support that you will need to recover and carry out this journey. No Panic Recovery Programs

 

By Professor Kevin Gournay.

Obsessive/Compulsive Disorder was at one time thought to be a rare problem. However, like many anxiety states, people who suffer from Obsessive/Compulsive Disorder (O.C.D.) keep their problems much to themselves. It is because of the very irrational nature of many obsessions that many sufferers are frightened and embarrassed about revealing their problems. Thus, until the last few years, the true incidence of the problem was unknown, there are varying estimates of the numbers of people suffering from O.C.D. but there is an agreement that probably more than one million people in the United Kingdom have one form or other of the problem.

O.C.D. of course comprises both obsessive thoughts and compulsive behaviour and sufferers may exhibit either obsessions or compulsions alone or, more commonly, a mixture. There is no doubt, that O.C.D. affects people across all cultures, occupations and radical groups. Before describing some of the current approaches, it is worth underlining that obsessions and compulsions per se are part of our lives. There is not one person who has not been preoccupied with an irrational idea, compelled to give in to a superstitious behaviour or who has not been troubled by thoughts relating to guilt, perfectionism, or some aspect of conscience. O.C.D. sufferers have these traits but some or all of them are magnified many times over.

What causes O.C.D?

Many years ago obsessions were thought to be caused by development factors and during much of this century most treatment approaches centred around psychoanalytic theories. However, in the last few years, it has become clear that the basis of O.C.D. is to be found in slight differences in the structure and chemistry of the brain. These differences in themselves do not actually result in any other abnormalities but do seem to provide the basis for O.C.D.

Our knowledge of these brain differences is expanding with the recent advances in brain imaging. We are now able to scan the brain using some of the more recent developments, for example, magnetic resonance imaging and positron emission tomography, also known as MRI and pet scans. However, despite the recognition that certain parts of the brain are different in O.C.D. sufferers, we still do not know how these structural differences relate to the precise mechanisms of O.C.D. Neither are we absolutely sure how the brain chemistry of O.C.D. sufferers vary from the so-called norm.

Another interesting line of research is in the area of genetics and recent work carried out in several parts of the world has indicated that there may be a considerable genetic basis for O.C.D. However, the more the picture unfolds, the more complex O.C.D. becomes and it is probable that O.C.D. comprises a number of different problems with some commonalities, it is also clear that the structural and chemical causes are not the entire answer.

Obsessive and compulsive thinking and behaviour can also be learned from a range of experiences for example, during childhood, following traumatic events of one kind or another and, by exposure to a mother, father or significant other relative with O.C.D. Thus, people may be born with a biological disposition to O.C.D. but never develop the full problem, while others are born with the same predisposition but, when subject to sufficient learning experiences, develop the problem in a full-blown form.

All this might sound rather complex and, indeed, as most of you know many GPs and even some mental health professionals are surprisingly ignorant about O.C.D. but it is important to see that the condition is not caused by one simple factor.

Treatment

I will now look at some of the common treatments for O.C.D. and give a conclusion based on research findings rather than give a personal opinion.

Psychotherapy

Traditional psychoanalytic and psychodynamic psychotherapy was, for many years, the only psychological approach used in this problem and, indeed, many patients with O.C.D. still have experiences of receiving this sort of treatment. While some patients may report receiving some benefit from these modes of treatment, the benefit is rarely reflected in change in the obsessional thoughts or ritualistic behaviour.

Psychodynamic and psychoanalytic therapies are talking treatments which aim to resolve predominantly subconscious or unconscious conflicts and thus, in the light of research findings on the nature of O.C.D. it is obvious that chasing supposed unresolved conflicts is unlikely to achieve anything over a placebo effect. Gradually mental health professionals are accepting that these treatments are ineffective and fortunately most services have abandoned these methods as a way of helping people with O.C.D. Although, unfortunately, in some areas of the country there are still psychiatrists, psychologists and others who continue to use these out of date ineffective methods.

Relaxation

While relaxation training can be quite helpful for certain types of anxiety; there is no evidence that it is helpful in the treatment of obsessional thoughts or compulsive rituals although, being relaxed helps us all. Indeed, it is so ineffective that many researchers choose to use relaxation as a placebo treatment when trying to evaluate other treatments. Relaxation may, of course, be helpful in reducing general anxiety but anyone with O.C.D. is wasting their time putting effort into using relaxation methods as anything more than a secondary supplement to other forms of treatment.

Hypnosis

Patients still ask for hypnosis and it is easy to see that sufferers think that their obsessional thoughts could be susceptible to this method. However, sadly this is not the case and hypnosis treatment represents the sort of magic wand which has no place in the treatment armoury against O.C.D. My advice to anyone contemplating spending their money on this method, (it is not available on the NHS for the treatment of such problems), is that this is truly a waste of money and the only person benefiting will be the hypnotist and his or her bank manager.

Behaviour Therapy

Behaviour therapy revolutionised the treatment of obsessional rituals at the beginning of the 1970s and brought the first real hope for sufferers. Treatments were based on the simple idea that if you helped people delay their responses to the compulsion to carry out a ritual such as handwashing or cleaning, they would experience a decline in their response and thus are able to “break the habit”. Response prevention is linked to exposure, whereby the patient is asked, in graduated doses of difficulty, to face up to the primary source of their compulsion, i.e. the thing which they feel is contaminating them. Much of the time patients realise that their contamination fears are irrational but nevertheless any exposure to anything resembling the source of the fear produces huge anxiety which is only temporarily reduced by the ritual.

Early treatment programmes were carried out while the patient was in hospital and the method often involved having the assistance of a nurse 24 hours a day to enable the patient to be able to resist the urge. The treatments were very successful although, as one can imagine, in-patient care with 24-hour nursing cover is very expensive. However, one reason for changing this mode of treatment was that patients often thought they could hand over the responsibility to a hospital or nurse or the therapist involved in the treatment.

Thus, during the 1970s treatment became much more outpatient focused, and therapists transferred their treatment efforts to the home setting. Indeed, when I worked with Professor Marks at the Maudsley Hospital in the 1970s, I spent a considerable amount of my time in patient’s homes, helping them to deal with their obsessive fears.

These response prevention treatments remain the main approach for people with obsessional rituals and the outcome of these methods is still excellent, with approximately 70% of patients who complete treatment reporting 70% or greater improvement in their symptoms. Nevertheless, behaviour therapy has never proved to be dramatically effective for obsessional thoughts although, there are some cases, which do respond to pure behavioural methods.

In the last few years, better results have been obtained by using cognitive therapy in conjunction with behaviour therapy with obsessive thoughts. Cognitive therapy involves helping the patient to rationally change their thinking and therapists have developed a number of strategies to help patients deal with their obsessional worries. Commonly, cognitive behavioural procedures can help people with obsessional thoughts in between 10 and 20 sessions of treatment. However, good quality research on the cognitive approaches to obsessional thoughts is still in its infancy and we await larger studies.

Drug Treatment

Drug treatments have been used with O.C.D. Antidepressants such as Annaframil (chlomipramine) may be helpful in some cases, particularly where depression is prominent. However, antidepressants only seem to confer truly long-term gains when combined with behaviour therapy. Newer compounds such as Prozac are currently being researched but, as yet, there is no evidence that they are useful in O.C.D. Further, all drugs have side effects thus, and one must balance these against benefits.

Conclusion

O.C.D. can be a crippling syndrome but behavioural methods may provide substantial benefits. No Panic and similar self-help organisations may provide benefits via not only the dissemination of behavioural advice but by collective support that professional treatments rarely provide. Sufferers should however take heart and the treatment outcome continues to improve. The future recovery prospects for people with O.C.D. is bright but as yet sufferers still need to work hard at getting better. The No Panic help-line will provide details of self-help materials and useful books.

Professor Kevin Gournay is an Emeritus Professor at the Institute of Psychiatry. He has more than 35 years of experience and is the author of more than 130 articles and books. He is based in Cheshunt Hertfordshire.

How can No Panic help?
No Panic specialises in self-help recovery and our services include:
Providing people with the skills they need to manage their condition and work towards recovery.
Our aim is to give you all of the necessary advice, tools and support that you will need to recover and carry out this journey. No Panic Recovery Programs

By Professor Kevin Gournay

Behaviour therapy is rooted in experimental psychology and most books will tell you that behaviour therapy is based on the principles of Pavlov (of the salivating dogs) and Skinner (of the rat box). However, in my view, much current behaviour therapy is based on a practical, pragmatic approach rather than fossilised psychological therapy.

The original applications of behaviour therapy can be traced to the 1950s when Joseph Wolpe, a South African psychiatrist working in America, applied systematic desensitisation to the treatment of simple phobias. This approach was based on the idea that if you taught people to relax, this was incompatible with feeling anxious. Wolpe called this process “Reciprocal Inhibition”, i.e. one emotion cancelling out another. As well as using relaxation, Wolpe also taught his patients to evoke feelings of anger or sexual arousal in association with their phobic fear and these were as successful as relaxation. Wolpe’s original ideas still have some utility today. Perhaps, the next time you are anxious you should try to imagine something which makes you angry or something which … (write to the editor with your views on this).

During the 1960s and 1970s, behaviour therapy rapidly expanded and treatment became much more based in real life. For example, helping the patient to enter their phobic situations, often with the help of a therapist, or training the patient to deal with obsessional impulses by sitting out the anxiety or performing some kind of competing activity. Certainly, by the 1980s behaviour therapy was indicated for approximately 30% of problems going to outpatient psychiatrists and these included not only obsessions, simple phobias and complex phobias such as agoraphobia and social phobia, but also sexual difficulties, social skills problems, a whole host of habits and, more recently, the application of behaviour therapy to physical illnesses such as asthma, irritable bowel syndrome and even cancer.

In recent years, behaviour therapy has grown to embrace cognitive therapy. This involves treating thoughts in the same way as one treats behaviour, i.e. treating thoughts as recurrent and habitual patterns which are open to modification. Therefore, for example, in the cognitive therapy of depression, depressive thoughts are treated as learned bad habits and patients are trained to identify the when, where and how of these thoughts and to replace negative thoughts with more realistic or coping thoughts.

Behaviour therapy is now much more widely available although, as most of you know, some areas are better than others. Currently, behaviour therapy is offered by about 100 nurse behaviour therapists nationwide, by some clinical psychologists and, encouragingly, by an increasing number of psychiatrists and general practitioners who have learned behavioural procedures in their training. General practitioners now receive 3 years training before going into general practice and very often they spend some of this time with a department of psychiatry and may spend some of that attachment with a behaviour therapist. Indeed, since 1978, I have been responsible for giving dozens of psychiatrists and GPs a period of apprenticeship in behaviour therapy and I can vouch for the fact that some of these GPs spend a considerable amount of their time helping patients with behavioural procedures. In years to come there will be many more GPs and psychiatrists using this approach as, thankfully, there is now considerable evidence to show that the stranglehold of the old psychoanalytical approaches is lessening and doctors are now much more interested in acquiring skills in procedures which are known to be efficacious.

Whether you are referred to a psychologist, a nurse, or a doctor with a background in behaviour therapy is, in some senses immaterial. What probably counts most is having confidence in that person and if you have a good rapport with your therapist, this is probably much more important than whether they spent 7 years at medical school or completed a period of specialist training after qualifying as a nurse. The research carried out on who makes the best therapist indicates that the results of treatment are much the same for nurses, doctors and psychologists and therefore you should have no concerns provided the person has undertaken the appropriate training. Currently, in this country, there are several ways to train in behaviour therapy and although there are, of course, cutbacks in the educational provisions in the health service, training in behaviour therapy is gradually becoming more accessible to a larger number of health professionals. Overall the results of behaviour therapy with anxiety states are very good. The rule of thumb is that 70% of people who complete treatment will improve by 70% or more and this figure probably holds for obsessional rituals as well. However, treatment outcomes with obsessional thoughts are not quite as good, although behaviour therapy is still worth trying.

Patients very often ask me about the drugs they have been prescribed and probably 50% of those referred to me are taking some sort of medication. Overall, the evidence is that most medications prescribed for phobic states are not very helpful. Certainly, tranquillisers produce very significant problems in the medium and long term and I have no need to describe the horrendous addiction problems which have occurred with hundreds of thousands of people. Like tranquillisers, beta-blockers often work in the short term but in the long term, there is no real evidence of their efficacy. In my textbook on agoraphobia, we reviewed the evidence regarding beta-blockers and could find no long term evidence that they were in any way successful. The one group of drugs which may be successfully combined with behaviour therapy is antidepressants, although it is likely that they are only helpful where major depressive illness accompanies the problem or in some specific cases of obsessive/compulsive disorder. In my view, there is very little reason why antidepressants should be prescribed in phobic disorders as any benefit for phobics as a group is probably outweighed by the longer-term difficulties associated with antidepressants, which can include a very significant weight gain. Although there is some encouraging evidence that people respond to antidepressants, one must bear in mind that many of these studies are only of a few months duration and that there is very little evidence that in the long term, people who take antidepressants do any better than people who don’t. Overall, therefore, the message is that antidepressant drugs can be helpful in certain cases of phobic anxiety and obsessive/compulsive disorder but this represents a small minority. Anyone being offered medication for their condition should seek to find out why the medication is being offered, for how
long it is being prescribed, what evidence there is that it is useful in that particular kind of condition and, last but by no means least, ask for a full account of side effects.

Overall, therefore, behaviour therapy is a useful treatment for many phobics. It can certainly transform people’s lives but it is by no means a panacea. While there is little doubt that many patients can have their symptoms markedly alleviated by behaviour therapy, there is, in my view, no real cure for any of the phobic and obsessional problems which come for treatment; rather people may at best aim to become 98% better. There are, of course, some rare exceptions to this and in my career, I can certainly remember more than a handful of patients who have described themselves as cured. Overall, though, my feeling is very much that phobic disorders are underpinned by a genetic cause as well as the causes which are rooted in learning and, although my treatment approach is very much a psychological one I still believe that we should place considerable research effort into looking for genetic and biochemical aspects of phobic and obsessional disorders.

Professor Kevin Gournay is an Emeritus Professor at the Institute of Psychiatry. He has more than 35 years of experience and is the author of more than 130 articles and books. He is based in Cheshunt Hertfordshire.

How can No Panic help?
No Panic specialises in self-help recovery and our services include:
Providing people with the skills they need to manage their condition and work towards recovery.
Our aim is to give you all of the necessary advice, tools and support that you will need to recover and carry out this journey. No Panic Recovery Programs