1. Case Studies
2. Self-Harm case study

Self-Harm case study Southend, Essex

Diagnosis: Borderline Personality Disorder. Target Behavioiur: Self-harm (Patient lives in Southend, Essex)

Nikki (not her real name) is 22 years of age.  She lives with her mother, has a much younger brother, plus two sisters, a couple of years either side of her.  Her father has re-married, and she sees him no more than two evenings per week.  Her mother has her own mental health issues, with a number of (internet dating) relationships behind her.  When Nikki was younger, she was repeatedly sexually abused by her stepfather (her mother’s second husband), as were her sisters

Nikki's main Borderline symptoms are self-harm (cutting), binge-purging, alcohol misuse, and misuse of painkillers (taking up to twenty painkillers in a day)

I’d been working well with Nikki with DBT for several weeks, but she was still very reluctant to let go of her self-harm behaviour

Nikki had said to me that her urges were so intense, and would come on so quickly that she found it impossible to find the space or time to make a choice about how she actually wanted to behave

She would say, "I got the urge to self-harm, and it was so intense that I couldn’t use any of the distracting techniques [simple things like having a shower to try and distract her mind and take her out of wanting to self-harm] that you’d ask me to try, because, by the time I’d got my clothes off, I was reaching for the blade"

So it was clear that there would be only a matter of seconds between the urges to self-harm, and actually cutting herself

So I suggested that when she next got the urge, she should get in to the shower, fully clothed, put the shower on freezing cold, and just stand there.  She found this idea very amusing, not to say a bit weird, which, of course, is the actual point.  Because this activity will freeze all of her senses, and just make her stop for that moment, to assess what’s going on

She tried it, and it worked exactly as hoped.  She stood there in the shower, wondering on earth what she was doing there, freezing cold, her clothes dripping wet

By the time she'd got out of the shower, got out of her wet clothes, dried herself and got herself warm, she found that the urge to self-harm had gone right down

The objective, though, was to completely eradicate these urges.  By now the urges had gone down from about four times in a day to about once every couple of days

But Nikki was still having trouble letting go of the urges completely.  The fact was that the urges would build up and then after a couple of days their intensity would be overwhelming

And so I asked her to try a particular technique called Ice Diving.  I checked with her that she didn’t have any heart or other medical issues, because this is quite an extreme stratagem, and explained that I wanted her to keep a bag of ice in her freezer.  And whenever the urge came on, when it was really intense, she should pour the ice in a large bowl, fill it with water and then dip her whole face into the bowl of iced water.  Then after a few seconds, pull her head out of the bowl

Again, Nikki thought this was a bit barmy, but was very willing to give it a go.  And she tried it and said it was that that really worked for her.  The technical reason as to why it worked would seem to be that the brain will have sensed a threat, brought on by extreme cold, and so the urge to do harm is sidelined, or shut down.  In fact, by the time Nikki had pulled her head out of the bowl, the urge to self-harm had completely gone

The Ice Diving was effective, but the key in my view was not this spectacularly weird, and seemingly miraculous technique, but more to do with the fact that she tried it in the context of a strong, open and trusting therapeutic relationship

At the time of writing, Nikki has been gradually reducing her self-harm and has, in fact, not self-harmed for more than eight weeks.  Her scars have now turned white, almost invisible, when previously they were very deep, and often infected, but they are healing very nicely

We continue to work on her BPD symptoms, but self-harm is now no longer a target behaviour