Self-harming is a manifestation of emotional distress; an indication that something is wrong rather than a primary disorder. For each person the contributing circumstances are individual but commonly they include difficult personal circumstances, past trauma (including abuse, neglect or loss), or social or economic deprivation, together with some level of mental disorder.
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It can include suicide attempts as well as acts where little or no suicidal intent is involved. The RCP states that 1 in10 young people will self-harm at some point, but it can happen at any age. It is more common in young people, women, homosexuals and bisexuals. Cutting is the most common form of self harm.
The crisis point of self-harming appears to be strongest at the developmental stages where separation is a concern (Gardner 2008); adolescence is one of those stages. It is partially dependent on certain characteristics, i.e. narcissism, aggression, hypersensitivity and omnipotence, all of which are heightened in adolescence, and might explain why self-harming is so prevalent in adolescents.
Self-harm is about people in distress and are diminished further by being referred to as ‘self-harmers’ or ‘cutters’ etc
“Such terminology can prevent those who use it from trying to understand the complexity of what is going on for those with whom they are working”. (RCP 2010, p21)
For many people self-injury remains a secret activity. Trusting others to keep their problems confidential is a cause of great anxiety. Young people may have particular difficulties with disclosure of self-harm. In particular, they fear that by disclosing their self-harm they will lose control to others:
“Their lack of control can exacerbate their self-harm” (Mental Health Foundation, 2006).
Motz (2003) states:
“Deliberate self-harm makes public the private pain and expresses that which cannot be spoken, or even thought about. It replaces and prevents thinking. It also inscribes a meaningful narrative on the body itself, with the hope that it will be understood and responded to by others”.
As well as the self directed meanings, self-injury can also be directed at others, for
example, to generate response, attacks carers who fail to protect, communicate rage
and distress, defence against intimacy (regulates distance) and enlists help, support or
concern, often in the therapist.
Motz (2003) suggests it is not usually a suicide attempt more an attempt to stay alive, expressing or communicating something to others, possibly in the hope that a need can be met, although at times there is clear risk of death.
Gardner (2008) believes the scars caused by cutting symbolise psychic pain to the outside world, an expression of something which can’t be spoken, or even thought about. It is a coping mechanism.
“It is a meaningful narrative on the body itself, with the hope that it will be understood and responded to by others” Gardner (2008).
The common ground is that they are longing to break free, and this is how it can be positively viewed by the therapist who can then begin to help them to find another way of expressing their pain.
The symbolic significance of the skin and its mutilation is central in understanding self-harm. Bick (1968) wrote about the capacity of the infant skin to serve as a container to experience; an infant receiving positive mother love introjects the experience of being contained which protects the infant from anxieties of ‘falling to pieces’. A quality Gardner (2008) recognises in her work with adolescents who self harm.
Pines (1993) studied the significance of skin-to-skin contact in early bonding, providing the foundations for the construction of an integrated self. Cutting the skin expresses a divided self and is, in a sense, a reflection of the earliest relationship between the self and another. Nursing the self-inflicted wounds can be seen as a re-enactment of the early infantile experience of being tended to and cared for by another, usually though not always, the mother. This is the other side of the divided self, the caring, nurturing and attentive aspect.
“Cutting the skin can be seen in part as a compensation for the lack of more intimate contact during infancy, a memorial for that deprivation; the wounds become a ‘route of remembrance’. Pines (1993)
Gardner (2008) puts huge significance to the therapeutic relationship in relation to this:
“The idea of the therapeutic relationship acting as a second skin allows release of the pressure on the person’s actual skin, and attacks on the therapy can be held and dealt with by the therapist” p36
Symbolism of the parts that are attacked is often seen, e.g. arms evoke memories of a mother’s arms that are intended to comfort, but didn’t, or held down and beat them. Scars all over, keep people away. It can also be an attack on the body of the mother, as symbolised by the woman’s own body, or cutting out ‘bad’ parts or sexual parts.
Signing with a scar (Straker 2006), a primitive way of using the marks on the body as a direct way of communicating one’s state of mind to another; a private language which has unique significance and meaning – ‘not just a message’. Self-injury meets the need to mark, in a concrete way, suffered experiences. Understanding the meaning of their wounds, and enabling these people to talk about the events they represent is a crucial step in helping them to find other forms of self-expression.
Fonagy and Target (1995) offer a way of understanding why some people choose, or feel compelled to rely upon, a violent action rather than using other forms of self-expression. They suggest that developmental difficulties in attachment impair the capacity for mentalisation: i.e. the inability to put into words feelings of anger and fury, forcing them to be managed in a physical way.
“Violence, aggression directed against the body, may be closely linked to failures of mentalisation, as the lack of capacity to think about mental states may force individuals to manage thoughts, beliefs, and desires in the physical domain” p53.
Not all DSH have been abused, but difficulties in past attachments from abandonment, physical or mental abuse is well documented. Anna Freud’s (1936) Identification with the Aggressor is a focus on negative or feared traits. I.e. if you are afraid of someone, you can conquer that fear by becoming more like them.
The function of self-injury for people who have been sexually abused can include release of tension and anxiety and also reveals the creation of a split self, where the body represents the victim and the mind that attacks it is the aggressor, allowing the mind of the self-harmer to temporarily be freed, split off from the brutality the body has suffered (Motz 2003). This reflects the defence of splitting, an attempt to protect good objects by attacking the bad ones-in this case the badness is located in the body. It can be soothed and cared for by the body that attacked it; attacker and carer existing together. Nursing the wounds is often an important part in the ritual of self-harm and is significant in the ‘story’ of the client and material the therapist may use to bring awareness.
The sense of release and euphoria quickly fades, and the desire to act again, is intensified as feelings of guilt, depression, shame and emptiness return, explaining the circular aspect of self-harm that gives it the sense of a perversion, addictive and compulsive, mirroring the cycle of violence and perversion first described by Welldon (1988) where violent fantasies are generated as a form of release and escape, but ultimately fail to comfort and further action is needed to achieve the same effect again.
As well as helping in the regulation of emotions, self-harm can help regulate unpleasant self-states, for example dissociation or depersonalisation (feeling unreal or in some extreme cases as if you are dead). These self-states, common after trauma, are extremely distressing and unsettling and harming self can bring a return to the reality of the moment or to an increased sense of being ‘alive’. It is when in these states of mind that a person can harm themselves and feel no pain. (Gardner 2008)
The significance of self-harm for a client can be gleaned only through sensitive analysis. Therapy should be based on close analysis of the thoughts and desires that gave rise to their behaviour (Motz 2003). Understanding the reasons why is the first stage in enabling them to find other, less violent, ways to articulate their distress and alleviate their pain.
There is much debate about what should be the main focus of therapy; addressing the problems that underlay the behaviour, arguing that when these problems are resolved the behaviour will cease, or, the behaviour itself be the main focus, particularly when the it is especially frequent or particularly severe, or associated with significant mental health disorders, as failure to do so place the person at risk. Which is the effective option for any one individual is likely to depend on a number of factors, such as the severity of the self-harm, whether the individual is highly suicidal or not, their capacity to function generally, their own preference for therapeutic approach and a thorough understanding of how self-harm relates to other aspects of their life.
The Assimilation Model (stiles et al 1990) is a useful model for the therapist to assess the level of assimilation a client has of their problem, and then work with the client to move the problem from one level to the next. This can provide sub goals, levels in the model, and:
“allows the appropriate responsiveness to the clients requirements as they emerge…”(Stiles 2002) p359.
That is to say, the way of responding to the client who is trying to suppress unwanted thoughts (level 1) would differ from the way of responding to a client who has already formulated a problem to work on level 3.
The therapist must make an assessment of safety at the start of therapy and this will determine the path they first take. The very first task must always be to assess the client’s safety and to keep them safe; where, how and with what are they harming themselves? Is blood loss under control, is it life threatening? Are there safety factors in place: a support network, medical care, do they have dependent children, is there suicidal intention, have they talked in detail about ‘ending it’, which must be assessed at each session.
The dilemma for therapists is to build a working alliance based on respect, warmth, and trust in an inherently unequal relationship while asking clients to reveal intimate details. Therapists balance the risk of alliance strains against the need to help clients confront painful experiences.
It is important and necessary for a therapist to be supported through reflective practice and supervision, and acknowledge counter transference and its underlying meaning and have a thorough understanding of the psychological theories involved with self-harm clients. Gardner (2001) states that working with someone who self-harms requires:
“.. patience, hopefulness in the face of despair and the capacity to know about and manage intense countertransference feelings, some of which are experienced in the body as well as the mind”
The lack of interest to stop self-harming behaviour can be frustrating for some therapists and may explain why the self harming client has been reported as one of the “most frustrating client behaviours” (Deiter et al 2000)
Therapy attempts to facilitate a desire to change while avoiding potential power struggles and attempts to control the client (e.g. forcing or demanding clients stop injuring). Miller & Sanchez (2004) state:
“Attempts to control clients typically increase resistance to change and is considered unethical”.
Although the therapist may want the cessation of self harming to be the primary goal, the clients may not be ready to change. Research carried out by Miller & Rollnick (2002) indicates that confrontation, education, and authority elicit client resistance, whereas collaboration, evocation, and autonomy facilitate therapeutic alliance and foster an environment ready for positive change. Often there is ambivalence about stopping:
“Ambivalence is the state in which a person feels two ways about something and has a role in most psychological difficulties” (Miller & Rollnick 2002).
Rogers’ Person-Centered Therapy (PCT) approach creates a safe, accepting and honest environment, building rapport and trust and allowing the client to feel valued as an individual. It is a non-directive process of freeing a person and removing obstacles so that normal growth and development can proceed and the client can become independent and self-directed. The core conditions facilitate this process.
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Bryant-Jefferies (2003) believe this non directive style is sufficient to move someone towards change. However, Kress (2008) suggests there are limitations to this approach and in order to move a client successfully around the cycle of change, direct challenges to their distorted behaviour and introducing new ideas at the appropriate time is an important aspect of therapy.
Kress (2008) adopted approaches to this particular client group that have previously proved effective in cases of addiction; Motivational Interviewing and the Trans-Theoretical model (TMM) (Prochaska & DiClemente, 1983; Prochaska et al 1992) because:
“People who self harm often struggle to resist the impulse” (Brain et al 1998), and provide a direction for therapy.
One of the key constructs of the TTM is the Stages of Change Model (Prochaska and DiClemente 1983) demonstrating behaviour change as a progression through a series of stages. They also proposed that therapy is most successful when the client is ready for change and the process of therapy is specific to the particular stage the client is at. Prochaska et al (2001) demonstrated that:
“The client is more likely to complete therapy if change processes are appropriate to their current stage of change”
Prochaska and Norcross (2001) state that optimal psychotherapeutic success is achieved if the stage of readiness is first accessed and then the process is tailored to that stage, which changes as the client progresses to the next stage:
“Once the therapist knows a clients stage of change, then it will be clear which relationship stances to apply in order for them to progress to the next stage” p312.
The TMM suggests that processes of change are differently effective at certain stages of change. For example, consciousness raising will help a client progress from pre-contemplation to contemplation; by increasing their awareness the client can begin to see benefits to psychotherapy. Self re-evaluation and emotional arousal to their problem are other examples of processes of change that are required to be worked through before change is often possible.
Norcross (2001) believes that it is more useful to adopt processes associated with the experiential, psycho-analytical and cognitive processes for consciousness raising, awareness, self evaluation and readiness in the pre-contemplative and contemplation stages and more behavioural changing processes in the later action and maintenance stages:
“trying to modify behaviour without awareness is a common criticism of radical behaviourism” p312
Motivational interviewing (MI) is considered:
“directive, client-centered counselling style for eliciting behaviour change by helping clients explore and resolve ambivalence” (Rollnick & Miller, 2002, p. 326).
It departs from traditional PCT through this use of direction, where therapist sets out to influence clients to consider changing, rather than non-directive exploration of self. It recognises and accepts that clients who need to make changes in their lives approach therapy at different levels of readiness. MI attempts to increase the client’s awareness of potential problems, consequences of their behaviour, and risks faced as a result of their behaviour. They are helped to envisage a better future, and become increasingly motivated to achieve it. Either way, the strategy seeks to help clients think differently about their behaviour and ultimately to consider what might be gained through change.
Critics argue MI is manipulative; the therapist is using their power and knowledge to get their way, possible if care is not taken. It is important to understand that it is client centred allowing personal choice at all times. Ethical problems may occur if there is a mismatch between readiness and intervention, which is why assessing the client’s motivation to change and only intervening at the appropriate stage is important:
“It is a subtle balance of directive and client-centred components, shaped by a guiding philosophy and understanding of what triggers change. If it becomes a trick or a manipulative technique, its essence has been lost” (Miller, 1994).
PCT creates an environment that is safe and accepting allowing a relationship of trust, which can be a real issue for someone who has been abused or has had a traumatic experience. The significance of self-injury can be gleaned only through sensitive analysis of the thoughts and desires that gave rise to self-harm, and its psychological function.
Through reflective and empathic listening, the therapist conveys a sense of collaboration with the client, through acceptance, understanding of ambivalence, and ultimate support of their autonomy to change or not change.
In psychodynamic working the unconscious will emerge in the transference relationship with the therapist and skilful interpretation can reveal what is not verbalised. Understanding the reasons why a person self-harms is the first stage in enabling them to find other, less violent, ways to articulate their distress and alleviate the pain that they feel.
The client needs to not feel judged by a therapist who has a clear understanding of their problem and is not frightened of them or their wounds – a reason a therapist might suggest a ‘no self harm’ rule; it is not helpful to the client because it is taking away their coping mechanism and autonomy. Because self harm clients are not able to express their trauma verbally other types of communication can prove useful, e.g. art, writing, poetry.
By trusting themselves to therapy they are subjecting themselves to a situation which risks further abandonment and loss and rejection and so therapy breaks and endings need to be mindfully managed, which in turn can also provide material for the therapist to work with e.g. unresolved loss as defined in Worden’s (2006) tasks of mourning model.
Whitlock et al (2007) writes about the internet as an “inescapable and powerful tool”. For those who self-harm it may be a means of expressing suppressed feelings and of connecting with others like themselves. Because self-expression and healthy connection are critical components of recovery, the Internet may have a productive and effective place in treatment. “These qualities, however, also make the Internet a potentially dangerous place for clients who use online experiences as a substitute for development of offline skills and relationships” p1142
The indirect victims are therapist or carers, who witness these acts and the scars that they produce. The failure to protect individuals from self harming can induce feelings of guilt in these others and managing these responses is an essential part of the management of self harm. The violence attacks the minds of others who attempt to stop or prevent it, fearing that suicide is the ultimate outcome. Managing self harm requires the capacity to ‘hold’ it as a therapist in order for the client to find other ways to communicate unbearable states of mind. The pull of the death instincts and their masochistic nature means they are intent on creating despair and hopelessness in the therapist, through projection, who can get caught up in the destructiveness rather than the recovery. Gardner (2008) states:
“the task is for the therapist to stay in contact with the part of the client that wants to preserve life and to retain their own capacity to think about the experiences they are being shown and made to feel without losing themselves in the hopelessness and horror”
Counter-transference responses are sources of information, providing therapists with material about the intentions and states of minds of their clients. The dilemma for the therapist is to accept the self-harm as important while enabling their client to give it up, if and when they choose to, or are able to, and become free of its hold on them. Gardner (2008) believes the task of the therapist is to retain hope and show them that despite their assaults on themselves they can withstand this assault and re-integrate aggressive and loving feelings in a safe and manageable way:
“The capacity of the therapist to withstand the hostility and their own distress conveys hope for the possibility of containment, and understanding….. It is challenging for a therapist”
Projection is the unconscious act of denial of a person’s own attributes and imagining another has them. Clients project their pain, an indication that unconscious ideas are trying to break through the conscious mind so by recognising this is happening and then bringing it into awareness a therapist can help a client identify it, accept and understand it and eventually integrate it.
“patients are trying to live with overwhelming emotional pain and project this into staff through various communications such as self injury â€¦ physical assaults and vicious personalised attacksâ€¦the unconscious hope is that the therapist can do something positive with the communication.,.” (Aiyegbusi, 2004)
Clients often show their scars to their therapist in the hope of a response. It is important how the therapist responds to their wounds, however difficult that may be. It may be a determining factor as to whether the therapist wishes to work with this client group.
Until a client can look back, bring into awareness and embrace their injured selves they will continue to act from their storyline places. In therapy there might be a lot of anger, pain, hurt or sorrow in this process but by making the past conscious and stop acting from it and blaming it, healing is possible – the past must be recognised, owned, accepted, forgiven and dropped.
Working with someone who self-harms requires patience, hopefulness and the capacity to know about and manage intense countertransference feelings. The therapist must feel confident in working with these people, strong because the outcome she is working towards may not be attainable or it may take a long time. Despite its challenges, and the risk of injury that can overshadow the work, engagement is possible and allows the person who self-harms to develop their capacity to think about, symbolise and communicate their experiences and eventually reduce their reliance on violent methods of self-expression.