The theme for my action research will be on low-level self-harm that does not have the intention to take life, or Non-Suicidal Self Injury (NSSI) and how to reduce it in a residential setting. Within the past year, a new student has arrived at the Mulberry Bush School with NSSI behaviour, and a few other children have since adopted it as their own. NSSI is an unfamiliar behaviour for many members of staff at the school and has caused some anxiety within teams. The main fear is that there may be severe consequences that may result in an accidental death, or develop into suicidal attempts. I will write about an intervention put in place for one of the children who has displayed NSSI behaviours. All names will be changed in line with the General Data Protection Regulations (GDPR, 2016).
Working with and understanding challenging behaviour is central to the work at The Mulberry Bush School (MBS). The theme being explored is characteristic of the work we do and the questions we ask. The school is a Therapeutic Community that works solely with children who have experienced trauma in their early years. The school has a long history of influences from psychodynamic theory, a theory based on the belief that our early childhood experiences impact our present-day behaviour (Fees and Sampson, 2018), this forms one of the core principles of the school.
‘It is through the examination of the communication that children present through their behaviour that themes begin to emerge and their underlying needs can be identified’ John Turberville COO, Mulberry Bush School, (2018)
This principle directly relates to the research question, what is a child who is self-harming, trying to communicate? How best am I going to support what they are communicating?
I am a Therapeutic Childcare Practitioner working directly with the children in their residential homes. A key aspect of my role is to key work a child; this entails being preoccupied with the child’s behaviour and thinking about what it might communicate. In collaboration with the larger network of Teachers, Therapists, Social Workers, etc. who form a treatment team, we then create a treatment plan to meet the child’s needs. The case study will focus on my key child Elsie; her self-harm behaviour forms a large part of the work being undertaken with her.
Working directly with Elsie also means that my colleagues and I are responsible for her general health and well-being. It is our responsibility to create an environment that promotes nurture and safety. Keeping the children safe takes many forms, providing a well-balanced diet, safe from harm from others, and protected from harming themselves. To keep them safe, we follow guidance from several documents, most notable is the Children’s Home Regulations (2015) and the Children’s Act. (2004) which highlights that It is our responsibility to keep children from harming themselves and work towards strategies to prevent this from happening.
As part of my role, I must attempt to understand what Elsie is communicating for me to keep her safe and carry out the therapeutic task of the MBS. The issue is, I have found it extremely difficult to think about her, or spend extended lengths of time with her. I find myself frustrated and angry with her and how she acts. Part of my values explained by MacMahon and Ward (1998) is that before you can truly understand someone, you have to know yourself. Understanding yourself means understanding how others make you feel. Reflection plays a large role in understanding myself and the children; it is through reflection that connections are made, away from the strains of the lived experience (Ward 1998, Thompson and Thompson 2008). Throughout the action research, I reflected on my thoughts and feelings to gain some insight into Elsie’s world, which enabled me to gain a better understanding. This insight is acquired through a variety of means; in my private journal, via team meetings, reflective spaces, and treatment team meetings. All these spaces are designed to examine the underlying communication behind the behaviour.
I chose to focus on one child in the form of a case study to gain a deeper insight into their particular form of self-harm. I will then base the invention on the case study, rather than formulating an intervention based on literature that is then applied to a child/child group (Gillham, 2000). I think this is more in keeping with the MBS philosophy and holding the child central to the work we do.
The Case Study
Elsie was a girl who was referred to The Mulberry Bush School several years ago. She had experienced abuse as a young child, including night time abuse which made her fearful of the dark. Before arriving at the MBS, she exhibited an array of challenging behaviour, including aggression, sexualised behaviour, and smearing. Once Elsie started at the MBS and started to feel safer, some of these behaviours reduced. However over time new ones began to appear, which meant that she often needed to be seen at A & E. She seemed to regard these visits a bit like a day trip, and she appeared to be pleased with them.
This seemed to happen as she was learning to feel more settled at night time, but she would wake and become more unsettled again, talking of tummy aches. When staff worked with Elsie during an incident of self-harm, they often felt frustrated and angry, but when they discussed this work in de-briefs at the end of the day, and their reflective groups, they realised that this was their emotional reaction to feeling worried about the risks to Elsie.
In reviewing the literature on self-harm, I found multiple definitions which cover the full range of self-harming behaviour, and the distinction is crucial in terms of planning interventions. Elsie’s self-harm behaviour could potentially fit two definitions, Self Injurious Behaviour (SIB) and Non-Suicidal Self Injury (NSSI). SIB is defined as a behavioural response to environmental or internal stimulus observed in people who have a profound learning disability, SIB is often reactionary and takes the form of headbanging, hitting the body, and biting (Balkom et al, 2017). Whereas NSSI is more deliberate and found in the normative population, and has some links to feelings of isolation and loneliness. Very little studies show the predictive trait for future suicidal tendencies (Bloom, Holly, and Miller, 2012). Although Elsie has Microcephaly (a condition that inhibits skull growth which in turn can affect brain development in the prefrontal cortex leading to learning disabilities (WHO, 2018)) her self-harm behaviour appears deliberate and doesn’t fit the observed behaviour of SIB and might be better placed under the definition of NSSI. Although this is not a perfect match, as the behaviour does not fit the description of NSSI where cutting and self-poisoning are behaviours observed. But it is the deliberate nature of the self-harm that would fit this category; it is possible with the young age that the behaviours Elsie is displaying is an early form of NSSI and left unchecked may result in more typical NSSI behaviour (Klonsky, 2006; Bloom, Holly, and Miller, 2012). Klonsky (2006) also gives us insight into what might motivate the NSSI behaviour, out of the seven functions, one fits the behaviours noted in Elsie, Interpersonal-Influence or, in Elsie’s case, seek proximity to adults. One thing that all the incidents have in common is to achieve having an adult close by and seeming pleased about this.
As for interventions, Different approaches have been suggested for SIB and NSSI. An approach common to SIB is derived from a behaviourist perspective. The intervention is called Applied Behaviour Analysis (ABA) (Chin et al. 2003) and is based on repetition and reward to override the learnt behaviour, this has gained popularity especially in Autistic Spectrum Disorder, and studies have shown promising results (Chin et al. 2003). However, a similar intervention (unrelated to ABA) was put into place for Elsie that used rewards based on how many ‘good’ nights she has had. This intervention resulted in some initial progress; however, the incidents quickly started to increase again, and the intervention ceased. Bomber and Hughes (2013) highlights that external reward systems rely on the ability to regulate internally and a strong sense of self, whereas children such as Elsie, who have relational based trauma lack this ability and need close proximity and sensitive attunement. This response adds further support to the likelihood that Elsie falls in the category of NSSI rather than SIB and gives us further insight into how to meet her needs.
In contrast, interventions suggested for NSSI appear to have a more traditional therapy intervention (Klonsky, 2006). Elsie has already had two years of therapy, and the therapist claimed Elsie made very little progress in this time, this could be due to potential language barrier and a limit in Elsie’s ability to process information due to her medical condition. There is also the possibility that she is not psychologically ready to engage with this level of therapy (Rogers, 1967). With Elsie’s difficulties in engaging with discussions around why she self harms, we can turn to Psychodynamic theory to begin to understand how Elsie’s past experiences may impact on her present-day behaviour.
One element that came up several times in meetings, emails, and reflective spaces is the infantile behaviour that Elsie appears to display. She would speak and act as if she was a toddler, she would want to play with things way below her chronological age, and some adults found they got the best response from Elsie if they spoke to her as you would a toddler. Furthermore, if Elsie were to become upset or unsettled by something, she would go into what can be described as a ‘toddler tantrum’. Winnicot (1964) discusses how as a child grows and develops, they begin to integrate their various life experiences into their personality, thus forming the foundations to healthy emotional development. When a child, like Elsie, has experienced emotional trauma in these early years, this can leave their experiences unintegrated and can lead to regression in later life. McMahon (1998) discusses how providing a primary experience, essentially recreating experiences they should have had during infancy, for unintegrated children can provide the care they need to begin to process and integrate their difficult life experiences. For Elsie, this means finding what early experiences she has missed and try and provide this for her.
From the background history, we know that Elsie experienced a great deal of trauma at night. While in the care of her grandmother, Elsie and her sister were caught in a fire, around the age of four years old. Her sister died in the fire and apparently Elsie was found under the staircase by a firefighter. Later she was taken into a children’s home where she suffered abuse at the hands of her carers, again mainly at night. Making sense of this in respect of the present day, the nighttime might be a trigger for Elsie who may be reliving this painful experience at night and then reacting to adults as a transference from her past (treating someone as if they were someone else from their past, Greenhalgh, 1994). This came to light through my own interactions with Elsie at these times, I came away from feeling angry and frustrated. When I reflected on this in various spaces, I came to realise the anger wasn’t mine at all but Elsies in the form of Projective Identification, whereby someone projects their unwanted feelings into another person (Greenhalgh, 1994). As I realised this, I was able to get a sense of the scared girl behind these feelings of anger and had the clarity to be able to make connections to her past.
It is well documented that infants need to feel safe to grow and develop into functional adults. This feeling of safety is created by a strong bond and proximity to their caregiver called an attachment, a term coined and developed by Bowlby (1988). if the bond is healthy and provides safety, this is called a secure attachment. Gradually over time, the infant begins to internalise this attachment and the proximity to the caregiver can decrease as the infant develops an internal working model of their caregiver and the wider world. When this doesn’t happen, or there is a significant break in the attachment process, this can lead to an insecure attachment which is detrimental to emotional and cognitive development (Holmes, 1993). Elsie’s trauma is likely to have had a significant effect on her attachment to adults and her ability to hold others in mind, leading to a drive to be close to an adult. This lack of secure attachment could have led to Elsie taking extreme measures, such as self-harm, to ensure adults keep close to her even during the night.
Winnicot (1964) described a similar phenomenon which he called the holding environment. The caregiver would protect the infant from negative experiences, preempting hunger and tiredness and meeting these needs before the infant realises. Gradually over time, the caregiver would expose the infant to these negative experiences as they develop the ability to cope with these feelings. For Elsie, it would be challenging to experience a secure attachment in the traditional Bowlby sense of a primary caregiver. Elsie, living in a residential setting, has many caregivers. In this way, thinking about the intervention of terms of the Holding Environment is far more useful.
Before the intervention was put in place, two other approaches were tried first. However, they were unsuccessful; they gave a useful indication as to where Elsie was in terms of her emotional development. Initially, a more behaviourist approach was taken; behaviourists tend to view behaviour for its outward presentation and disregard any subjective feeling (Watson, 1913). The behaviourist approach aims to modify unwanted behaviour; in this instance, it was Elsie’s self-harming behaviour. A star chart was set up, and Elsie was positively rewarded for having a ‘good night’ and not self-harming, after a week of ‘good nights’ she would receive a reward. This worked initially, but after a week Elsie reverted back to her self harming behaviour and disregarded the reward chart, eventually this was dropped. Likely, Elsie’s underlying needs of nighttime security and a holding environment were still going unmet. This drive was stronger than the wish for a nice treat at the end of the week, as mentioned above Bomer and Hughes (2013) suggest that this is down to an underdeveloped ability to self regulate, something attained through a secure attachment (Holmes, 1993).
Another intervention that followed after was more based on child development theory and used a phenomenon known as a transitional object. When a child/infant begins to separate from their caregiver, they may use a transitional object to aid this separation (Winnicot, 1986). The transitional object would act as a stand-in for the caregiver, a reminder of the bond between them and the internal working model. Elsie was given a transitional object to help her sleep; however, this appeared to have little effect. It could be that, again, she had not built up a robust enough internal working model to make use of the transitional object, or that through the abuse her internal worldview is unsafe and hostile and based on coping (Holmes, 1993). Also at times, the transitional object began to be used more of a reward for a good night sleep, rather than an aid in it, which falls victim to the same short fallings as the reward chart.
In the lead up to the beginning of the final intervention, we, as a team, noticed that Elsie’s self-harm would often start very small and unalarming. She would claim to swallow little bits of paper, or fragments of plastic. This would escalate until she swallowed something that would require hospital attention, regardless of nurture and support we gave. A few times, after the initial swallowing of bits of paper, our house manager suggested we sat outside her room until she fell asleep. This appeared to help Elsie as she no longer attempted to swallow anything and would eventually fall asleep, I then took it a stage further and suggested we start a new settling routine. Once Elsie was settled to bed, an adult would position themselves outside her room with the door open until she fell asleep, before she swallowed anything. Elsie’s behaviour was interpreted as unconscious communication that she needed to have someone close to her. The reason we do not see the self harm behaviour is likely due to the fact that she can seek proximity to an adult at any point. It is also likely that night times are a time of fear for Elsie due to the high level of abuse around this time. The intervention serves to strengthen Elsie’s primary experience by increasing the proximity to the caregiver and taking the Holding Environment back to the early infancy stages, where the infant can’t bear to be separated from their caregiver. This provision is to repair and strengthen Elsie’s internal working model and integrate these early life experiences, and ultimately help her feel safe.
Data Collection Methodology
When the self-harm first began to occur, three months before the intervention was put in place; several different behaviours were happening at the same time. I began to record these incidents in a spreadsheet to monitor when and how often the different behaviours occurred and to see if any patterns formed. As the other behaviours started to become less frequent, I maintained the spreadsheet and used it to monitor incidents of self-harm. Each day I recorded whether or not Elsie had harmed herself and in what way. This way, I had a quantitative data stream to assess if there is any change in the number of self-harm incidents. I recorded her incidents for six months, three months before the intervention was put in place and three months during the intervention. The intervention is ongoing, so there is no data for after the intervention; however, the intervention was stopped intermittently due to Elsie living in two different houses within the school. One she lived in during the holidays (All school holidays and one weekend a month known as the Weekend Home) where the intervention took place, and one she lived in term time without any intervention. The data accounts for both holiday and term time, but a distinction is made where she is at any given moment. Due to my absence, most nights, the data was gathered through a variety of means; structured observation, electronic diary entries (My Days), and members of staff’s observations. Although involving multiple people in the recording reduces the reliability of the date, incorporating a variety of data to cross-reference the accounts offsets this. I used this method to be able to see the impact of the intervention over a long period easily. With qualitative data, you can make charts easily, which give you a clear idea of the progress made. Once the qualitative data had been collected over six months. I also gathered feedback on the intervention through emails and team meetings. This feedback was mostly informal and open-ended intending to use it to analyse the larger data set; however, this was not my original intention, I first planned to write a questionnaire that I intended to circulate the two teams (Holiday and Term time) to receive feedback. This way would have been a more controlled approach producing a better insight into the intervention, but due to the current pandemic, I chose to change the former method as members of both teams was dealing with an increased workload (Baser, Taylor, and Wilkie 2006; McNiff and Whitehead, 2011).
There are ethical considerations to be taken into account in regards to the research. The research is considered to be intrusive by the British Psychology Society (2020) and in need of consent for participation. As a child, Elsie has a diminished ability to consent, and this consent needs to be obtained by the parent or guardian (UWE, 2014). The school has permission from Guardians/social workers to record information about the children as this is a vital aspect of the work we do to monitor the behaviour and develop appropriate strategies. In terms of confidentiality and the use of data, this is generally covered under the General Data Protection Regulations (GDPR) as stated earlier all names are changed and any data stored is encrypted with a password, no personal information is shared outside of people who need to know.
Looking at the quantitative data for the first three months leading up to the intervention, 27th August to 27th November 2019, the only pattern I noticed was that every incident of self-harm occurred at night after she was settled to bed. This data supports the idea that the behaviour may be connected to her previous night time abuse and/or the lack of an internal working model. There were no incidents for a week in the first part of September 2019 when the reward chart was put in place, after that initial week the number of incidents began to rise again. During this time there was little discrepancy between the holiday house and the term time house, with incidents being spread relatively (more time spent in term time house) evenly between the two with 35 incidents recorded in 3 months.
After a week of a high number of incidents at the end of October, the intervention was put in place during the November half term. This intervention saw a dramatic drop in the number of incidents with no incidents for three weeks after the intervention. There were four incidents the two weeks before the Weekend Home at the beginning of December, which dropped off again after the intervention was reinstated. Over the final three month period after the intervention, the number of incidents had dropped significantly. It stabilised both during the holidays and term time with only six incidents (Including the four incidents before the weekend home) since the intervention was put in place. This gives strong support that the intervention was successful and was providing Elsie with some kind of therapeutic benefit. Furthermore, Elsie may be able to transfer the feeling of being held at night over to the term time house, evident in the reduction of incidents in both houses.
What was noticed during the Christmas holidays was that she sometimes struggled to settle at night and would either mess up her room, attack members of staff, or threaten to self-harm, where one time she was successful. Through team meetings and reflecting at the end of shifts, it came to light that a pattern had occurred. When a particular adult (myself being one) was settling her or if she had many adult changes throughout the evening, she would then find it difficult to settle. As a team, we modified the routine so that only the adult that settled Elsie would sit outside her room, and that adult would not change, giving Elsie a sense of consistency. On reflections and general observations from others, it seems that the particular adults who she finds challenging to settle with appear to lack a sense of a calm, stable demeanour in her presence. I personally found Elsie’s behaviour frustrating and put in boundaries a little firmer than necessary, and this would escalate Elsie’s disruptive behaviour. Both of these patterns are precisely what does not contribute to a Holding Environment. Both consistency and what Bion (1962) would call reverie, a sense of inner calm that is ready to receive emotional communication, are essential aspects of a Holding Environment (Winnicot, 1964) and contribute to a child’s sense of safety. Informally, the adults who didn’t convey a sense of reverie either stopped settling Elsie to bed or through introspection and discussion it in reflection developed the ability to communicate reverie. Both these actions strengthened Elsie’s sense of a holding environment.
Turning now to the qualitative feedback gathered from various emails and meetings during and since the intervention took place. The feedback from the holiday house was mostly supportive. They reported a positive impact on Elsie and her general well being and believe the incidents have dramatically decreased. As mentioned above, the intervention worked better with certain members of staff, but on the whole, Elsie responded well to the intervention. Some adults expressed how they wondered if it was still necessary and was time to begin stepping down the intervention. One individual didn’t think it was required at all. The term time house didn’t see how they could facilitate the intervention as it involved having one adult outside Elsie’s room until at least 10/11 pm and claimed it was resource-heavy.
After the initial six-month data collection Elsie and the rest of the holiday house needed to go into isolation because of the Covid-19 virus. This unique situation led to members of the term time house working in the holiday house and following the intervention. The term time adults were then able to feedback, again taken from emails. This feedback more negative. Some feedback mentioned how it felt like we (the adults) were invading Elsie’s privacy and not letting her have a normal childhood. It’s worth highlighting that Elsie has this intervention once she has been settled to bed, and at any other point during the day she can find privacy. Also in the initial process Elsie would ask whether an adult would sit outside her room, seemingly pleased when told there would be. These feelings seemed to reflect Elsie’s response to different adults as she split the adult group. If a term-time adult settled Elsie it would most likely be a difficult night, ending in physical interventions, if a holiday adult settled her she would be fine. Klien (1946) would describe this type of behaviour as splitting, where an infant projects bad/negative feelings into one person/team and the good/positive feelings into another. It is hard to tell whether the feelings the adults are expressing are their own that could be redirected into Elsie who is playing them out, or Elsie’s feelings being played out in the adults. Either way, this goes to show for this intervention to be successful, consistently, and reverie is a vital component.
It is worth pointing out at this point that other factors can be at play. As Elsie’s behaviours started in September 2019, she went through a change in her medication. She was being weaned off a drug given to reduce her anxiety. The withdrawal came with many side effects, and the weaning process was lengthened, and she was given a new drug. The other side effects eased off, but the self-harm remained. After the intervention was put in place and just before Christmas, Elsie’s drug dose was increased again. This medication change could have had a significant effect on her behaviour; however, the timings of her medication increase does not appear to affect the level of incidents experienced.
Another factor that could be at play is a larger pattern in her general behaviour. It appears that over time Elsie has had a large array of challenging behaviour, Ranging from smearing, self-harm, sexualised behaviour, and aggression, among other things. It could be that Elsie cycles through different behaviours as one becomes ineffective. Even in the short time, Elsie has been with us; she has cycled through three other behaviours. First, she wet the bed, and this stopped as she began to self-harm, now as the self-harm has stopped for the past six weeks we appear to have gone into a new phase where she is refusing to eat.
The main things I have learnt from this action research is that self-harm does not always mean that someone wants to take their own life. Self-harm, like any other behaviour, can be a form of communication that something isn’t right. For Elsie, it was that she wasn’t ready to be left alone at night. Working alongside Elsie to help her feel safe at night has shown the importance of the primary experience and the holding environment in the residential setting, how it builds the foundations on which the children can adopt healthy coping mechanisms. What is especially important is how staff working directly with the children need to hold this space for the children with reverie and consistency, however one adult can’t do this alone, it takes a whole team working together to create a holding environment.
From my professional point of view, it has reinforced the value of reflective practice and to examine my feelings in regards to the children. The action research has shown me that holding a calm and open space for children to express their feelings enables them to feel safe and better understood and better equipped to meet their needs. I also feel more confident in being flexible in my approach to challenging behaviour and how sometimes you need to take things further back in development than you might expect. In some ways, you have to meet the child where they are functioning at currently and build them up slowly to what is expected for their chronological age.
As for the research question itself, I found that although the research stayed close to the original question, and the data collected remained steadfast in its purpose, this project became less about self-harm and more about providing a girl with what she needed for her to feel safe. I think it would be difficult to extrapolate to the broader theme of self-harm in general as the reasons for self-harming differ from person to person, and each would need a different approach. One child may be doing it to relieve an affect-regulation, while another does it for interpersonal-influence.
The method worked well in providing a simple way to track the number of incidents over a long period and could be recorded by anyone making it likely to have a complete data set. It was fact-based and avoided the emotional interference that comes with people. This simplicity in turn made it easy to interpret and analyse once the data was collected. However, it came with some shortfalls. The focus was on only one child, although the original thinking was to go deeper into the reasons as to why, and it helped this particular child. What it lacks is the ability to generalise to the specifics of self-harm behaviour, there isn’t a specific tool to use in all or most instances of self-harm, although I am dubious as to if one exists. Also, the method lacks the quality interpersonal experience; there was a missed opportunity to get a real sense of the experiential difference from a night where Elsie self-harmed and one where she was physically aggressive, was there a different emotional feel to it? Could it be managed differently? Could a daily questionnaire be created to capture these feelings and give more depth to the action research?
My advice for practitioners working with self-harm behaviour is to pay attention to the behaviours before and after an incident, consider this with your emotional response, as these are key to understanding the motivation behind the behaviour, the behaviour is communication Record the incidents if it is an ongoing theme, see if there is a pattern and if it has any connections to their past. Don’t underestimate the importance of the primary experience; it is the foundation of a healthy mind.
As for Elsie, the work will continue as her nights are still unsettled due to changes in staff, although they are still free from incidents of self-harm. When this settles down, we will consider beginning the process of transitioning back to a regular bed time routine with the help of a transitional object.
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