Learning that there is a better way than self-harm

A new behaviour therapy programme is helping people to manage emotional pain

Prof Marsha Linehan, University of Washington, Kathleen Lynch, Minister for State with responsibility for Mental Health, and Daniel Flynn, Cork Mental Health Services.

Prof Marsha Linehan, University of Washington, Kathleen Lynch, Minister for State with responsibility for Mental Health, and Daniel Flynn, Cork Mental Health Services.


A new programme is being rolled out across the country to teach people who are severely suicidal and who repeatedly self-harm that there is a less destructive way to manage their emotional pain.

Those who repeatedly self- harm are often diagnosed with borderline personality disorder (BPD), which is characterised by difficulties in managing emotions, in suicidality and continual self-harm.

Dr Marsha Linehan, a psychologist at the University of Washington, has led a crusade to find an effective treatment approach for BPD and has been credited internationally with developing the most effective treatment to date – dialectical behaviour therapy (DBT).

Linehan spent a week in Ireland at the start of the year training health practitioners in her techniques.

For people with BDP – which is also known as emotionally unstable personality disorder or emotional intensity disorder – standard DBT cuts suicide in half, cuts emergency department visits in half and cuts inpatient admission by 73 per cent when compared with other expert non-behavioural treatments.

“Dialectical behaviour therapy – DBT – is a trans-diagnostic intervention that has varying levels of intensity depending on the person’s level of disorder,” Linehan says. “You must match the intervention to the individual’s needs, and highly suicidal individuals need the full standard treatment.”

Daniel Flynn, principal psychology manager with Cork Mental Health Services, is co-ordinating a national research and implementation programme for DBT. He says suicidality and self-harm are significant problems in Ireland, which has a higher incidence of male self-harm than the international average.

Suicidality and repeated self- harm account for 8 per cent of all emergency department self- harm attendances. The most common forms of deliberate self-harm in Ireland are overdosing, cutting and burning.

“We are lucky in Ireland to have such detailed data on deliberate self-harm available [through the National Registry of Deliberate Self-Harm],” Flynn says. “However, we know that the 10,000 presentations to our emergency departments nationally is not fully representative of the problem. It’s like an iceberg. Those attending the EDs [emergency departments] is what you see above the water, but there is a huge mass under the water that we don’t see – people in quiet desperation hiding their suicidality and self-harm and not learning there is another way of managing their emotional pain.”

Flynn and the National Office for Suicide Prevention are training 16 teams to deliver Linehan’s treatment.

The first DBT programme run by Flynn and his team was in the North Lee Adult Mental Health Service in Cork, an area with one of the highest rates of deliberate self-harm in Ireland.

First programme
Twelve clients participated in the first programme in 2010, an evaluation of which showed a reduction in self-harm incidences, emergency department visits, hospital admissions (number and duration), borderline personality symptoms, depression and hopelessness. The results also demonstrated substantial cost savings.

Following the success of that programme, funding was secured from the National Office for Suicide Prevention to expand the programme to the three remaining adult mental health sites in Cork city and county (South Lee, Bantry and Mallow). The office established the DBT National Project Office in June 2013 to support the administration of a national roll-out of the therapy.

Teams are now running in Dublin, Donegal, Cavan-Monaghan, Louth, Meath and Kildare and new teams are in the process of being set up in Waterford, Wexford and Sligo. The areas are selected on the basis of their incidence of suicidality or repetitive self-harm.

The standard DBT programme is run over 52 weeks. It involves one hour of individual therapy every week and 2½ hours of skills group, where clients are taught mindfulness, distress-tolerance skills, emotion-regulation techniques and interpersonal effectiveness skills. Clients have access to a phone-coaching service to help them apply these skills in their day-to-day lives.

Those given priority for DBT treatment are the group most at risk of ending their lives – those who present repeatedly at emergency departments having self- harmed or attempted suicide.

In 2012, 118 individuals presented to emergency departments five times or more having repeatedly harmed themselves. The full DBT programme is for people who are chronically unwell, while those who are treated earlier or younger require less intensive interventions.

Treatment available
Flynn says: “It is important that people understand that there is treatment available – whether you call it emotional dysregulation, chronic self-harm and suicidal ideation or borderline personality disorder – and we are expanding our range of services.

“For a lot of the people we see, this is a very hidden problem,” he adds. “They don’t talk about their self-harming and there is a huge relief when they finally acknowledge that this is how they have been coping.

“If you are at a place in your life where you feel you don’t need to be here any more or are harming yourself as a way of coping with distress, you need to talk to somebody. We encourage people to look for help, talk to your GP and link in with the mental health services.”

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