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We have all had moments in our life — including episodes that may trigger self-harm behaviour — which our minds tend to delineate into happy or sad, good or bad, favourable or unfavourable.

While there is no growth without these experiences, the emotions they stir up can often feel overwhelming in the moment. From seemingly minor stressors like being stuck in traffic and getting late for work, to more painful events like the end of a relationship, losing a job, being reprimanded by a loved one — or in more distressing cases, experiencing emotional pain so intense that it may manifest as self-harm behaviour — each of these moments can feel deeply consuming.

These experiences often create in us, feelings of disappointment, sadness, guilt, regret or anger. We all pick our poison when it comes to these situations, and we all cope in different ways. Such is the human condition that no two people respond to the same problem in the same way. Some of us may retreat inside ourselves and not feel like interacting with the outside world, while others may feel extreme anger and lash out at others .The remedies employed by our minds to deal with negative emotions can be diverse. It may seem paradoxical, but in some of us these emotions can be so uncomfortable that the only way to cope is by causing another type of hurt to ourselves. Let us use an example to understand further. Think about the most anger-provoking situation in your life, where someone treated you unfairly. It can be you being blamed for something you never did, or someone else being rude or unjust with you. It can even be something as benign as you being cut off in traffic. Now how many of us in this situation, would have hit the steering wheel in utter frustration. One might guess many! Of course, this is a completely normal and acceptable response as long as it did not physically damage us, others or hopefully the steering wheel. In some individual’s however , emotions are dealt with in more severe ways of harming the self, and in those cases, we call it as “self-harm behaviour”(SHB). Alternate terms for such behaviours are “deliberate-self harm”(DSH) or “non-suicidal self-injurious behaviour” (NSSI).

SHB is defined as an ‘ intentional self-inflicted destruction of bodily tissue without suicidal intention, and for purposes not socially sanctioned.’ It is a growing clinical and public health problem, that needs our attention. Common ways that individuals do this can include cutting, burning, scratching, or self-hitting. SHBs become significant when they occur repeatedly, and are used as a way to cope with negative emotions. It is important here to note that self-harm is different from suicide, and often has a complex relationship with it. Although suicide attempts are aimed at causing one’s own death, self-harm is not aimed at ending one’s life but rather, it is a coping mechanism that brings about relief. This statement may confuse you and may make you wonder how this works? To understand this, we must dispel some myths about self-harm. First, many people hold the belief that these are acts which are carried out to grab attention. This however, is a very small facet of the entire entity that we term as self-harm, and in many cases, it is not true. Second of all, that repetitive self-harm in any case requires the aid of a mental health professional and while a momentary coping mechanism, it is an unhealthy one that needs treatment. What purpose does it serve? Well, when the  experiences of individuals who have engaged in self-harm were studied, one of the most common responses received was that it helped individuals to cope with the intensity of emotional pain by and large. It serves as a relieving mechanism when some individuals are affected by negative experiences, be it rejection, disappointment or loss. Due to such an intense experience, the pain is perceived as intolerable, and by inflicting physical pain on oneself, individuals who self-harm distract one sort of pain with another, that is physical and tangible. Thus, it serves as an emotional regulator, particularly in the context of negative emotions. Indeed, research has shown that the act of self-harm is preceded by negative emotions, and followed by an increase in positive emotions. This is one mechanism by which self-harm may help affected individuals deal with their thoughts and feelings. Another mechanism by which it helps, is in the context of human relationships. It can serve to mediate or avoid the demands of a relationship should one feel unable to cope with its complexities. Lastly, it may also serve to generate attention in moments where the affected person feels isolated, misunderstood, or neglected in a relationship. When we mean ‘relationship,’ it is not a mere referral to romantic relationships, but even in platonic, parental or any relationship of value. Thus, broadly speaking SHB serves as a regulatory mechanism to cope with isolation. But we know well and above that not all individuals engage in SHBs. Studies have shown that SHBs are associated with a number of mental health conditions, such as depression, personality disorders, Post-traumatic stress disorder (PTSD), substance abuse along with other anxiety and mood disorders. Not to mention, although explicit definitions exclude suicide as a motive, there is an elevated risk of suicide if SHBs are repeatedly engaged in. There is no single cause for why some individuals engage in this behaviour, but a number of individual and environmental factors have been shown to play a role. The former includes factors that we discussed previously such as difficulty in regulating emotions, and mental health conditions. The latter include adverse childhood experiences, and the ways in which we form and respond to relationships. (Attachment patterns)

Now that we are equipped to understand what SHB includes, it is imperative that we understand one important thing. It is our duty to support individuals with SHB to seek help. This is because our experiences as human beings serve to bring us together, and the situations that cause affected people to harm themselves, are not different from the fundamental human experience of pain and suffering. We must embrace the bad to grow, and the way to do so is through social support, lending an ear, and encouraging the act of seeking help. You are not alone. The first step has been made when help is sought. This can sometimes involve emergency care, in cases where the attempt was severe, or if it is associated with depression. Emergency management involves intensive mental health treatment, sometimes entailing in-patient admission, medication and the extensive use of therapeutic practices to help individuals from repeating the behaviour. This is done through a number of different modalities, such as crisis intervention, which serves to administer and teach the patient a number of practical skills and solutions to cope with the crisis that may have triggered the event. Cognitive behavioural therapy (CBT), another type of therapy can help patients understand how thoughts, emotions and behaviours are linked, and often times we can have mal-adaptive ways of thinking about things that happen to us, which can be addressed and changed in therapy. Dialectical behaviour therapy (DBT) utilises a multi-disciplinary team helping individuals to tolerate and cope with intense emotions, distress, to be more mindful in the various situations of life, and to be effective in communicating in our relationships. In conclusion, there are a vast plethora of resources to help treat, seek support for, and to understand this common, yet troublesome behaviour. Help is just around the corner.

Summary : Self-harm behaviour (SHB) is defined as the ‘intentional self-inflicted destruction of bodily tissue without suicidal intention, and for purposes not socially sanctioned.’ Alternate terms include Deliberate self-harm (DSH) or Non-suicidal self-injurious behaviour(NSSI). The common age group at which it is seen is adolescence and young adulthood. Although SHBs do not entail an attempt to end one’s life, they are typically associated with an elevated risk of a suicide attempts in the future. SHBs have a multifactorial aetiology, and typically serve a purpose in the interpersonal or intrapersonal context of an individual, the former including coping with relationship demands, rejection and the latter include emotional regulation. SHBs are associated with various mental health conditions, such as depression, personality disorders, Post-traumatic stress disorder, and other mood as well as anxiety disorders. However, they can also occur as isolated phenomena. SHBs require public awareness and understanding, and are prone to be misunderstood. Any individual engaging in SHBs should be encouraged to seek support and help from a mental health professional. Initial management can include in-patient admission if the person is at a high risk of repeating, for diagnostic clarification and initiation of treatment. Treatments include medication initiation if required, with further management provided through several different options of psychotherapy, principle ones including Crisis Intervention, Cognitive behavioural therapy (CB)T and Dialectical behaviour therapy( DBT). It is important to prioritise the individual’s choice in treatment, and empathy goes a long way in helping them feel understood. After all, negative experiences and the emotions they generate are a fundamental human experience. We have much more in common with affected persons than we know.

The word ‘Narcissism’ is frequently used throughout today’s world, being often prescribed as a label for those that appear to be boastful, power-hungry or manipulative. It is a word that is employed as a pejorative for anyone who on occasion, fails to adhere to pro-social values, displays excessive self-centredness, and has no problem in throwing others into harms way to get what they want. These individuals are often labelled “narcissists.” Unfortunately, due to the widespread popularity of the word in the modern lexicon, the psychological meaning of the term, what it entails and how it can manifest, has been completely lost.

It is important for us to understand the origins of the term, that stem from the Greek mythological figure ‘Narcissus.’ The story of Narcissus goes on to state that he was an attractive male figure who rejected the advances of many potential lovers. However, upon rejecting the proposal of a nymph by the name of Echo, he is cursed by the gods to fall in love with his own reflection. As a result, Narcissus sits next to a pool of water, forever in love with his own reflection. When he realises that the object of his love cannot love him back, he slowly withers away and dies, admiring his own reflection. It is interesting to note that even though this story is over a thousand years old, it aptly captures the features of dysfunctional or ‘pathological’ narcissism that may manifest in affected individuals. Before we delve into what makes narcissism pathological, it is important to note that narcissism is a personality trait that exists on a spectrum. It denotes an individual’s healthy investment into the self. If manifested in healthy amounts, it enables a person to invest into themselves, and appropriately invest in others so that individuals can have a stable sense of themselves. Thus, Narcissism in healthy amounts allows us to have confidence in ourselves, and above all, it empowers us to navigate the world with its disappointments. We become inspired to have dreams, to love others, to be self-confident and above all, to face failure. All of these desirable qualities characterise the term, “healthy narcissism.” Thus, in psychological terms, healthy narcissism is a personality trait that we all aspire to have.

On the other hand, Narcissistic personality disorder (NPD) is a mental health condition that results in an individual having pathological levels of narcissism, which dominates the individual’s perception of themselves, and how they interact with others. One word synonymous with NPD is grandiosity, that means to say that affected individuals often have an excessive, unrealistic perception of themselves. This can manifest in the form of seeking to be idealised and admired to disproportionate extents, to manipulate others to satisfy one’s own needs, and being unable to tolerate criticism, often responding with extreme rage, or disappointment. Combined with this, is an inability to appropriately care for, and have empathy for others. This may lead to a pattern of relationships that may be characterised by one-sidedness, domination, or neglect. Patients with this disorder often have unrealistic expectations of themselves and of others, and in that sense, the grandiosity is pervasive to their detriment. To simply put it, patients with NPD can come across as bold, charming, extraverted but at the same time display excessive self-centredness, a constant need for admiration, a sensitivity to criticism, along with difficulty regulating their emotions, and manipulativeness.

At the same time, not all patients with NPD present in this manner. There is a subtype of patients with the disorder, who can present with features of introversion, a tendency to avoid confrontation, an apparent humbleness, but with an attitude of grandiosity which seems to suggest that ‘the world has done me wrong, I am special and people don’t know it yet.’ When we traditionally think of narcissism, we are attuned to think of the first subtype, and not the second. In fact, affected individuals can often fluctuate between these two states of ‘grandiosity’ and ‘vulnerability.’ There is a complex relationship and a commonality between these two. While many of us may have encountered people displaying these features, it is important to note that all of us are capable of, and probably have shown certain aspects of what is described above. That is because these are universal emotions, and can be seen in normal individuals as well. What matters is their intrusiveness and persistence in all aspects of life, that separate NPD from normal human behaviour. An accurate diagnosis can, and should be made only by a mental health professional.

As is common for mental health conditions, there is no single cause for NPD. One important factor to consider is that we must not judge affected people based on their behaviours, but understand where they stem from. In the story of Narcissus described above, one thing not mentioned is that narcissus is born from a childhood traumatic experience. Impressively, clinical studies have shown a consistent pattern of adverse childhood experiences seen in adults with the disorder, such as physical or emotional abuse and neglect. These factors, combined with biological (genetic) and socio-cultural factors cluster together to result in what we may see in an affected person. It is important to note that NPD does not merely entail rude, self-obsessed persons who manipulate others, but instead an entire cluster of symptoms which involve a difficulty in managing one’s self esteem, that stem from an inability to deal with and accept oneself for who they are. It is surprising to hear, that NPD presents with a substantially higher risk of developing depression, substance-use, and a tendency towards self-harm and suicide, especially when a person faces a major setback, leading their fluctuating self being unable to cope with a normal failure of life. Coupled with the fact that the disorder involves having a fear of, and predominance of negative emotions, such as guilt, shame, loss, and setting unusually high standards to the point that the person may be setting themselves up for failure.

It may be a revelation to note that although patient’s with this disorder can be destructive towards others, the greatest harm they cause is often in their own lives. This does not mean that there is no hope, in fact it is far from it. It may be difficult for all of us, but rather than blaming someone with this disorder, we must try to empathise with them. One major factor shown to alter the course of the disorder, is treatment. Often, patients with the disorder are referred after ultimatums by friends and family, face an acute failure in life, have relationship failures, or to cope with associated mental health conditions. As professionals in the mental health field, it is important for us to build alliances with these patients, help set realistic goals, and attend to their relationships and self-esteem. Developing a nurturing and accepting environment in therapy can go the extra mile to help patients tolerate distressing emotions, and manage their own expectations of themselves. It is essential to explore their motivations, and to help transform situational motivation into a long-term commitment to helping themselves. These things help them to develop a sense of agency, trust, and face self-defeating patterns. NPD is far from a sinking ship, and we must help these persons by showing them that they can help themselves, through consistency, nurturance and managing expectations.

Summary: Narcissistic personality disorder (NPD) is a mental health condition characterised by pathological levels of narcissism, with core features of difficulty in regulating one’s self-esteem, a fragile grandiose sense of self, difficulty in regulating emotions, sensitivity to criticism, excessive admiration-seeking, and manipulative behaviour. Affected individuals may also have difficulty in empathising with significant others. Grandiosity can often fluctuate with vulnerability, a second subtype of clinical presentation, where individuals present with introversion, avoidance behaviour, high levels of neuroticism, and a self-victimizing form of grandiosity. Affected individuals often fluctuate between the two states. NPD is also associated with a high rate of other mental health conditions, including depression, anxiety, substance abuse, and suicidality with self-harm behaviour. Childhood adverse experiences such as abuse, neglect are a common finding in this disorder, along with genetic and socio-cultural risk factors. NPD can be readily addressed by mental health professionals in the form of psychotherapy which focuses on establishing realistic expectations, a strong therapeutic alliance, and an open therapeutic space to nurture the patient’s wounds that often express themselves in the form of defensiveness, manipulative behaviour and rage.

Cognitive Behavioural Therapy (CBT), as the name suggests, is a therapeutic modality incorporating both cognition and behaviour. Cognition refers to the mental processes such as attention, memory, thinking, reasoning and decision-making. Behaviour is the observable action that a person undertakes, based on their cognition. CBT is based on the principle that our thoughts, feelings and behaviour are interconnected and changes in any one of these modalities can bring a change in the other two domains. To put this simply, the thoughts we have can influence our feelings and, in turn, our behaviour; our behaviour can influence our thoughts and feelings; and the way we feel about a situation can impact our thoughts and behaviour in that situation.
For example, if you are cooking and put in too much salt by mistake, you might have an automatic thought, an idea that just seemed to pop up in your mind: “I can’t do anything right.” This thought might then lead to a particular reaction: you might feel sad (emotion) and avoid cooking or trying to do anything new (behaviour). This can create a cycle where any subsequent mistake is seen as proof that you can’t do anything right, causing increasing distress and avoidance behaviour. However, if you examined the truth of the first thought and looked for alternative evidence, you might conclude that you had overgeneralized and that, in fact, you actually do many things well. Looking at your experience from this new perspective would probably make you feel better and lead to more functional behaviour. This is the crux of CBT: identifying and altering inaccurate and/or unhelpful thinking and behaviour to reduce distress.
Effectiveness of CBT
CBT is one of the most widely researched therapies and has proven effective in treating many concerns including depression, anxiety, phobias, bipolar disorder, personality disorders, eating disorders, panic attacks, substance use or other addictions, anger issues, insomnia, low self-esteem, relationship issues, grief, chronic pain and stress management. It recognizes that we might not be able to modify our circumstances, but by modifying our attributions and thoughts about a situation, we can feel and act in better ways.
How it works and what it entails
CBT focuses on the inaccurate or unhelpful thoughts people have in situations and identifies the underlying beliefs people form based on these thoughts. By collecting evidence for these beliefs and reframing these thoughts, CBT provides realistic, alternative perspectives which can positively impact one’s emotions and behaviours. It uses a process of disputing and challenging one’s negative thoughts. Behavioural changes are also emphasized to bring about new positive outcomes. Homework is assigned to clients to help track progress and bring about changes outside the therapeutic setting. New skills and coping techniques are taught and modelled to provide the client with novel ways of responding to their situations.
CBT is an active therapeutic modality requiring active participation of the client. The client and therapist work together to set goals, identify errors in thinking, find alternatives and implement adaptive behaviours. It involves self-reflection on the part of the client into their motives, biases, judgements and assumptions. These are discussed and modified in therapy so that they become adaptive. The client is also self-empowered through techniques to monitor their thoughts and feelings and gradually becomes independent and capable of regulating themselves.