NCJ Number
168182
Date Published
1997
Length
5 pages
Annotation
This paper focuses on three clinical issues for forensic psychotherapy in dealing with patients who manifest deliberate self-harm (DSH): diagnosis, formulation, and management.
Abstract
Regarding diagnosis, DSH is a symptom of internal distress; usually there is a continuum of self-harming activities, some of which are tolerated by society, or even encouraged. Borderline personality disorder is perhaps the most common diagnosis because of the often chronic nature of the problem. The other diagnostic feature of borderline personality disorder is the presence of intermittent psychosis. A psychodynamic formulation should accompany behavioral description and psychiatric diagnosis. DSH is a cruel attack on the body. Such attacks are usually a bodily re-enactment of a previous trauma, where the traumatic response is somatized either because the situation is so overwhelming that the patient cannot think, or because the patient is traumatized at a developmental stage before full thinking skills are developed. Regarding the management of such patients, their anxiety will be such that involuntary detention is the only answer. Medication (either antidepressants or sedatives) can have a place, and this can be experienced as a concrete type of soothing. Ongoing psychological care is needed and should never be abruptly withdrawn. Probably the most important therapeutic task is the proper attention to the countertransference. Supervision of all staff involved with the patient will help to prevent the formation of "special" relationships and the enacting of split-off feelings and objects. A clinical vignette is included to illustrate some of the principles discussed.