Bipolar disorder Pendulum: stories and information Self-management Self-Harm During Lockdown Warning: This article discusses self-harm, including describing these experiences and providing suggestions for helping those affected by self-harm. The COVID19 pandemic has had a huge effect on many people. Research is starting to show that many are struggling more with their mental health during this time. For people with existing mental health conditions, including bipolar disorder, COVID19 presents many challenges. The pandemic has created a great deal of uncertainty. Many of us have faced loss as a result of COVID19. Moreover, restrictions like the lockdown and social distancing can disrupt our relationships and leave some more at risk of feeling lonely of disconnected. When people are under increased stress, difficulties like self-harm can become more common. Research has shown that self-harm is prevalent amongst people with bipolar disorder. For many it can be a way to cope with or escape from seemingly unbearable feelings or situations. Self-harm is complex, and can have many different triggers, and take many different forms. The research about the effect of COVID19 on mental health is in its early stages, and so it’s not clear if rates of self-harm have increased or not. However, where the pandemic leads to feeling isolated or disconnected from others, and creates emotional problems like low mood, this is likely to have an effect on self-harm for many people. In this article we provide advice and suggestions to help those who might be struggling with self-harm at the moment. Help for people who self-harm Whilst the advice and suggestions below may help, they will not replace more tailored support or therapy. Research into different talking therapies for self-harm shows that approaches like Cognitive Behavioural Therapy (CBT) and Dialectical Behaviour Therapy (DBT) can be helpful. Therefore, if you are struggling with self-harm at the moment, it is important to seek help from services. Consider talking to your GP, or if you are in crisis, attending a local emergency department. If you are already in touch with clinical services, we would suggest keeping them informed of your current situation. However, we recognise that getting help from services can be very hard at times, and the pandemic has created new barriers to getting help in some settings. Getting support or therapy from services may take longer as a result, and so below are some further suggestions for managing your self-harm in the interim. Understanding your self-harm Building an understanding of your self-harm can help. For example, knowing what can trigger feelings related to self-harm may help you to avoid these situations. If scrolling the news regarding COVID19 often leaves you feeling distressed and overwhelmed, it may help to stop doing this or to limit yourself to a set amount of time. If feelings related to loneliness lead you to want to self-harm, it may help to arrange in advance a regular telephone or video catch up (i.e. Skype, Zoom) with friends or family. For people who self-harm with a particular method, it can sometimes help to make sure any objects you would usually use (e.g. razor blades) are not available at home, or at least not easily accessible. If you live with someone you trust you could consider having an agreement that they will hold access to these things, so that you would need to talk to them first when struggling, before you are able to access any objects you might usually use to harm yourself. If there are certain times of day, or times in the week, you tend to find most difficult, then it may help to plan ahead and think of distracting or pleasant activities you could do at those times. Some talking therapies can help you to further understand your self-harm and support you in spotting way to manage these difficulties. Planning ahead Thoughts about or urges to self-harm can be distressing, but they do not last forever. Typically, these thoughts and feelings come and go, like waves. We can think of the biggest waves as times of crisis, when thoughts or urges around self-harm are strongest. In the middle of this wave, when you’re feeling extremely distressed, it can be very difficult to imagine being out on the other side. During these times our thinking can become narrowed and focused on the same distressing themes, emotions can feel overwhelming, and it can be hard to think beyond this state. It can therefore help to plan ahead. Having a plan ready for how you will get through the next wave can help you to keep yourself safe during these most difficult times. Consider finding a time when you feel in a better place to think through what you’ll do when faced with the next wave. Below we list some of the things you might include in a plan: 1) Contact information for helplines or services It may help to also have a plan of when you might try different services. If you are experiencing suicidal thoughts and you feel like you cannot keep yourself safe then it is important to contact the emergency services. There may be other states you recognise, where thoughts about self-harm are less pronounced, where it may be better to contact a helpline. COVID19 has of course impacted on many services, but helplines such as the Samaritans are still running, and many clinical services are finding ways to offer online support. 2) Contact information for friends and family who may be able to listen and help This could even be something you agree with others, thinking about when you might call them (e.g. “next time I am feeling this way, I’ll give you a call”) and what it would be helpful for them to do (e.g. just listen, offer practical support, come with you to a walk-in centre or hospital, etc.). If there is someone you trust and feel comfortable talking to, it can help to have an agreement with them that you will contact them first to talk through what is going on, before you do anything else. For some people this can create a break in the chain between distressing thoughts or feelings and harming yourself. 3) Suggestions for activities that will help you to feel better Soothing activities may be particularly helpful. It can be hard to think of what to do in the middle of a crisis and so having a ready-made list of things that you personally find soothing, positive or distracting may help. This will be very individual of course. Music might be great for one person, but not another, so it’s important to think of what works for you. Finding activities or objects that together engage all 5 senses (sight, sound, touch, taste, smell) can be helpful (e.g. scented candles, photos, music). Check out a list of possible activities from Harmless 4) Harm minimisation techniques For some people finding another activity that replaces something of the experience of self-harm, but in a less harmful or damaging way, can be useful. Examples might include holding onto an ice cube, drawing on yourself with a red marker pen, or screaming into a pillow. These are sometimes referred to as “harm minimisation”. Recent research shows these techniques do not work for everyone though, and it likely depends a lot on the particular meaning and reasons behind your self-harm. The key is therefore to find something that works for you, personally. 5) Reminders of positive memories This can include objects, photographs, videos, music, etc. These could be physical objects you keep together in an accessible place or digital files you keep on a phone or other device. Feelings like a lack of connection to others, or not belonging, or being a burden on others, have been linked to self-harm. Having tangible reminders of important moments of connection or times when you’ve been an important part of another’s life may help counter difficult feelings. It can help to take a moment to try and bring back the memories linked to the reminder and allow yourself time to savour these memories (what could you see, hear, feel at the time?). This can be difficult to do in the middle of a crisis and might be something you first need to practice during easier times. When thinking about which reminders to choose there may be some reminders associated with more difficult feelings (e.g. loss) that may be better to avoid for this activity. Summary Self-harm can be very different from one individual to the next, and so we realise what helps for one person will not help for all. COVID19, whilst affecting everyone at the moment, will also affect each of us differently. With the suggestions above it will therefore be important to think about what might work for you, what would be worth a try, and which things you know will be less helpful. An important final suggestion we’d like to give is to try and stay connected with those you care about and are able to talk to. Social support can help increase our resilience when faced with adversity. Below we’ve provided some further links that may be helpful: Royal College of Psychiatry information on COVID-19 and self-harm The Samaritan's website (they now offer online self-help support as well as their helpline) Harmless – An organisation supporting those who self-harm Dr Peter Taylor is a Senior Clinical Lecturer at the University of Manchester in the Division of Psychology & Mental Health. His research focuses on understanding self-harm and evaluating therapies for those who struggle with these experiences. Dr Rosie Beck is a Clinical Psychologist working in community Mental Health Services. Her clinical interests include Dialectical Behaviour Therapy and compassion focused approaches.