Articles: A Practical Approach in the Treatment of Self-Inflicted Violence
By Catherine Allen
The challenge of self-harm
"I need to see blood, and for other people to see me bleed. That's my way of showing that I'm trying to get rid of the badness in me." "I hate my body, and don't feel as if it belongs to me. When one person had finished using it another took over. I hurt my body because I hate it." Statements like these, from people who deliberately harm themselves, go some way towards explaining why this problem is so often met with intense emotional reactions from others, whether professionals, families or other carers. The range of emotions evoked, including panic, hopelessness, anger and even hate, makes a consistent, therapeutic response very difficult to achieve. As a result, people who harm themselves often receive a poor service when they turn to professional systems for help.
When providers of mental health services turn to the literature for guidance, they face a number of difficulties. First, although deliberate self-harm is not uncommon amongst people referred to their services, basic texts are unlikely to be of much use. Psychiatric texts focus on the diagnostic status of patients who harm themselves, and the poor prognosis associated with the likely diagnoses, while a scan of basic psychological therapy textbooks is unlikely to produce any mention of this problem at all. The literature focusing on clients with severe learning disabilities makes many suggestions that are relevant to others who harm themselves, particularly those living in institutional contexts, but often assumes an intensively staffed environment.
Problems of definition
In addition, there are problems of definition. Deliberate self-harm may be equated with suicidal intention. Many people who harm themselves do also experience suicidal wishes, and may have attempted suicide. However, most self-harmers can make a clear distinction in their own minds between behaviours which are suicidal in nature, and other self-harming actions which may be much more frequent and serve other functions. For example, one young woman said: "I didn't want to die this time, I just needed to hurt". There may also be confusion with the much more rarely seen problem of intentional self-mutilation. Tantam & Whittaker (1992) review the literature on what they describe as self-wounding and self-poisoning, distinguishing these behaviours from suicide attempts and from intentional self-mutilation, where the aim is 'to rid oneself of an offending organ or body part'. They also distinguish between self-wounding and self-poisoning. I have chosen to retain the term 'deliberate self-harm', as many people who poison themselves without suicidal intent also wound themselves. The clients described here use a very wide range of methods to hurt themselves, including scratching, cutting, stabbing, scalding or burning themselves, use of caustic substances on the skin or on cuts or scratches, and over-use of prescribed -- or other -- medication. This last may be intended to be sedating, to make the person feel sick or poisoned, or to induce non-fatal physical harm. One young man, knowing that paracetamol in overdose could produce liver damage, routinely took small overdoses of paracetamol, with the expressed intention, not of dying, but of damaging his liver. The medical consequences range from the slight to the severe: one client of mine had severed his Achilles tendon, another spent a prolonged period in hospital having perforated her bowel. The behaviours described, and their functions as understood by sufferers, closely resemble the patterns described by Cauwells (1993), who also makes the point that self-harming behaviours are often mistakenly assumed to be impulsive in nature, an assumption many of my clients would challenge.
This paper does not aim to be a comprehensive review of the literature on deliberate self-harm. Reviews are available by Feldman (1988) and by Tantam & Whittaker (1992). The aim is rather to empower helpers effectively to work with this challenging and needy population, by describing the reasons people give for hurting themselves, looking at a case example where a relatively straightforward psychological intervention yielded very positive results, and reviewing some of the issues around the provision of services to this client group.
Why do people harm themselves?
When one asks people about their reasons for harming themselves, their explanations fall into three main categories:
How do services respond?
Service responses range along a continuum, from 'the Counsel of Despair' to 'naive therapeutic optimism'. Though services rarely respond with the extreme versions given below, readers may recognise elements of their own or other services in the following caricatures.
Proponents of the Counsel of Despair argue that these are clients with personality disorders, that they are therefore incurable, and that they will only be reinforced in their self-harming behaviour if anyone indulges them by listening sympathetically and trying to help. The naive therapeutic optimist, on the other hand, believes that this is someone who desperately needs therapy, and that, once the person's appalling early history has been properly 'talked through', the problem will go away.
Each of these positions inevitably leads to the provision of an inappropriate service. The Counsel of Despair ignores the fact that people who engage in serious deliberate self-harm rarely disappear; in fact they frequently make contact with a whole range of different services, none of which is very willing to take them on, and they often have a long mental health career. The choice may well be between providing a well-planned therapeutic service or a chaotic one driven by crises. The concept of personality disorder as a global 'illness entity' is of course open to much debate, which is beyond the scope of this paper. The argument that a diagnosis of personality disorder is much more likely if a psychiatrist dislikes a particular patient, or finds him or her a nuisance (Lewis & Appleby, 1988), is, however, highly relevant to people who harm themselves. It is also important to note that the Counsel of Despair ignores recent developments in using a wide range of different psychological approaches with clients who would usually be labelled 'borderline' or 'personality disordered'. These include specialised forms of psychodynamic psychotherapy (e.g. Stevenson & Meares, 1991), cognitive therapies (e.g. Linehan 1993), problem-solving training (Salkovskis, Ather & Storer, 1990), and integrative approaches such as Cognitive-Analytic Therapy (Ryle, 1990).
Naive therapeutic optimism can be equally damaging to people who harm themselves. There is a tendency to believe that any kind of counselling, even from an untrained, inexperienced helper, is better than none. Unstructured, unfocused counselling always has the potential to be harmful (Sachs, 1983), and more severely disturbed or impulsive clients are most at risk of suffering negative effects, especially if faced with 'therapeutic techniques aimed at breaking down, challenging or undermining habitual coping strategies or defenses' (Lambert & Bergin, 1994). Many of my self-harming clients have experienced unstructured, unfocused or confrontational counselling', often from relatively inexperienced or untrained helpers, and describe two main difficulties with it. The first is the degree of ambiguity they experience about what they are supposed to be doing and why; for people who have often experienced horrifying punishments in childhood for 'getting things wrong' this can be a paralysing difficulty. The second is that in an unstructured setting they are more likely to be overwhelmed by a flood of painful feelings and memories, returning in an uncontrollable way. One recent client was referred to me after this process triggered her only serious suicide attempt, and her only psychiatric hospitalisation. Individual psychotherapy for people who harm themselves is, therefore, a task for the trained and experienced therapist. However, as this paper will argue, there is much that the competent helper, whatever his or her background, can do to help.
A case example: Tony
Tony first came to the attention of mental health services at the age of twenty-nine, when an acute episode of depression precipitated by a family crisis led to a brief admission to psychiatric hospital. Whilst in hospital, he disclosed that the catalogue of injuries described in his medical notes were self-inflicted, and he was referred for psychological help.
During our initial meetings, he told me that he had been harming himself since childhood, the earliest episode he could remember being an eye injury at the age of eight or nine. Despite frequent and severe self-harm, and repeated treatment in casualty departments, he had managed to keep the cause of his injuries completely secret. Although he had taken considerable pains to maintain this secrecy, he also had a strong dislike and distrust of doctors, and health service workers in general, which he attributed to their failure to realise what was happening and confront him. He expressed great relief that this problem was now out in the open, but initially found it quite difficult to discuss.
What he told me about his early history was that his father had left when he was an infant, and relatives had told him that his mother had experienced great difficulty in providing basic care around that time. Although he was living with his mother at the time of referral, his relationship with her was poor, something which he attributed largely to her drinking.
Tony's account of his self-harm at the time of referral was that it occurred in response to difficult situations or experiences, was usually carefully planned and executed in a very controlled way and that he felt no pain at the time of the injuries, but began to feel pain up to two hours later. He described the functions as 'Being in control, being the only person who can hurt me', and 'Getting rid of the badness in me'. He could sometimes control the wish to harm himself by using distraction, but felt that this was a fragile coping strategy.
Psychological work with Tony had a number of distinct phases. The first priority was to establish a good relationship, as his experiences of professionals had left him suspicious and wary. The limits of confidentiality, my likely responses to future self-harm and his degree of control over the therapeutic process were made explicit and explored in detail.
The second phase involved the completion of a record form detailing the circumstances, thoughts and feelings around urges to harm himself, using a similar format to that used in the cognitive-behavioural treatment of any other difficulty (see, for example, Fennell, 1989). During this time, Tony was managing to resist most of his wishes to harm himself, but close examination of the record form enabled us to see that he was doing so by avoiding likely internal or external precipitants. This emphasised his feeling that his capacity to carry on coping was fragile, and it also suggested a line of intervention.
The third phase focused on an adaptation of the technique of exposure and response prevention used in the treatment of Obsessional-Compulsive Disorder (Rachman & Hodgson, 1980). Rather than blocking or avoiding his wishes to injure himself, Tony began to try and 'sit with' them, using deep breathing techniques to try to contain his agitation. He continued to record conscientiously, and we saw a steady diminution of both the strength and the frequency of the thoughts of self-harm. We also noticed two other phenomena. First, Tony began to have a series of nightmares and flashbacks. These related to his childhood, and included an image of being face down on a vomit-soaked pillow, unable to move. Once he had talked these through with me, he found that he could put them to one side, and was clear that he did not wish to discuss them in more detail. Second, he made a number of attempts to harm himself during this phase, in response to stressful events in his life. However, he reported that he had been unable to persevere with these beyond the level of superficial cuts because of an immediate awareness of pain.
The final phase of work with Tony is ongoing. His life circumstances have continued to be stressful and difficult. For a year after the end of regular treatment sessions he came to see me occasionally, using this appropriately as an alternative to acting on infrequent wishes to harm himself. At present, he comes very occasionally, for five minutes every four to six months. He manages very occasional wishes to harm himself without external help, but, perhaps because of his early history, we have agreed that he will not be 'abandoned' by our service before he feels ready.
It is important to note that the course of Tony's therapy went unusually smoothly. With such a long and serious history of self-harm, I would have expected the process to be much more difficult. I attribute this to his powerful motivation to improve his life, our shared model of his difficulties and perhaps to the fact that he was able to transfer to treatment the exceptional self-control that he had previously required for slow and calculated self-harm. However, the outcome of this intervention raises a number of more general issues. First, the success of the exposure and response prevention technique suggests that deliberate self-harm can be placed in the category of compulsive or addictive behaviours. This supports Tantam & Whittaker's (1992) view that self-wounding should be seen as an addictive behaviour. Second, the implementation of response-prevention seems to have precipitated both the retrieval of early, suppressed memories and the reduction of Tony's capacity to shut out sensations of pain. This suggests a link between early traumatic experiences, self-harm and strategies for managing pain, which merits exploration. Third, the sequence of events suggests that therapists working with this problem need a broad range of experience and competence, which can encompass cognitive and behavioural techniques, attention to the therapeutic relationship and boundary-setting, and skills to address the retrieval of traumatic early memories and other issues which arise in helping survivors of abuse.
The case above describes a situation in which individual psychological therapy had a dramatic effect on a long-standing and serious problem of self-harm. However, although the first reaction of many non-therapists to encountering deliberate self-harm is to recommend individual therapy, my experience is that this is frequently unsuccessful. Is it possible to predict who is most likely to benefit from individual therapy, and what should be offered if individual therapy seems unlikely to be appropriate?
Who will benefit from therapy?
There are a number of criteria which, in my experience, make a referral for psychological therapy likely to be fruitful. Those referred need to be able to take responsibility for making and keeping appointments; being brought by a family member or key-worker rarely predicts a good outcome. Similarly, if they themselves are not particularly distressed by the self-harm, individual psychological therapy may not be the most appropriate intervention. If they have some experience of controlling their behaviour, for example if they sometimes feel the urge to harm themselves without acting on it, or have been successful in reducing self-harm using practical advice from the referrer, then their optimism about the usefulness of psychological approaches is likely to be greater. Finally, it is difficult to engage anyone in psychological therapy unless they have some interest in their thoughts and feelings, and some ability to reflect on and discuss these.
It may seem that these criteria for individual therapy are rather high. However, it is important to emphasise two further points. First, there is a great deal that can be offered to help people stop or reduce self-harm in addition to, or instead of, individual psychological therapy. Second, the attributes discussed above are by no means fixed. 'Readiness to Change' Prochaska & DiClemente, 1983) is a continuum along which we move throughout our lives, and timing is crucial. Any therapist who regularly tries to help clients tackle deliberate self-harm will be familiar with a situation in which someone who has repeatedly, and frustratingly, engaged with their service and dropped out, often with much mutual acrimony, returns to work determinedly on a chronic and entrenched difficulty. That said, access to skilled and experienced psychological therapists within the Health Service is very limited, and it seems legitimate to focus those resources on those who are ready to change.
What else can we do to help?
Requests for psychological therapy for people who harm themselves may often be seen as requests for help from others who are trying to care for vulnerable people in the community, for example, staff in services for the homeless. If one investigates the referral further, one often discovers a subsidiary message: 'We are committed to working with this person, but their behaviour is scaring us to death. What can we do?'
The analysis above of the nature and functions of self-harm makes it clear that there are a wide range of strategies that can help.
First, if self-harm can be seen as a way of expressing and communicating distress or anger, then it is vital that healthy and appropriately assertive expression of negative feelings is encouraged and rewarded. This may be difficult for carers, particularly if anger is felt towards them, or towards other service providers. However, as I argued earlier, people who harm themselves have often received poor services, and realistic causes for anger should be addressed.
Second, if self-harm is used to help people manage their mood, 'get a buzz' or feel in control, then it is useful to help them think about other ways of dealing with unpleasant mood changes, build in exciting, relaxing and pleasurable activities, and offer opportunities for success and control. One housing worker who worked with me to develop a plan for a resident who harmed himself regularly found that getting her hands on a couple of bicycles and pedalling furiously into the country with her client had a dramatic effect on his urges to cut himself.
Finally, if self-harm is being maintained partly by carers' responses, basic behavioural techniques are relevant. An incident of self-harm often produces a flurry of intense activity and interaction around the self-harmer, and this may be unavoidable. However, if carets ensure that they make time to be with the person when self-harm is not an immediate issue, if they can provide some space to encourage the person to talk about their self-harm in a practical, problem-solving way, and keep their responses to each episode of self-harm as low-key, matter-of-fact and unpunitive as possible, they are reducing the risk to their client.
These strategies may sound straightforward, but they depend heavily on carers' ability to develop and implement a 'team plan'. Self-harm is a problem with an unparalleled ability to evoke rage, terror, punitive feelings and disagreement in teams, perhaps because it is seen as both dangerous and wilful. The distress that can be elicited in helpers may be extreme, and must be addressed. However, it may help to keep two important facts in mind. First, self-harm is not primarily intended to 'manipulate' or upset helpers. It must be seen as part of a desperate struggle to cope with something. Second, it is normal for staff to disagree about how to handle situations involving self-harm, but vital to get beyond this to an agreed response to a particular individual. Finally, although deliberate self-harm may appear particularly difficult to understand, it 'is best thought of as a purposeful, if morbid, act of self-help' (Favazza, 1989). It has much in common with many of the other difficulties with which our clients struggle, and many of our everyday helping skills are relevant to it.
References
Carroll, J., Schaffer, C., Spensley, J. & Abramowitz, S. I. (1980) Family experiences of self-mutilating patients. American Journal of Psychiatry, 137, 852-853.
Cauwells, J.M. (1993) Imbroglio: Rising to the Challenge of Borderline Personality Disorder. New York, Norton.
Favazza, A.R. (1989) Why patients mutilate themselves. Hospital and Community Psychiatry, 40, 137-145.
Feldman, M.D. (1988) The challenge of self-mutilation: a review. Comprehensive Psychiatry, 29, 252-269.
Fennell M. (1989) Depression. In: K. Hawton, P. M. Salkovkis, J. Kirk & D. M. Clark (Eds.), Cognitive-Behaviour Therapy for Psychiatric Problems. Oxford, Oxford University Press.
Lambert, M.J. & Bergin, A.E. (1994) The effectiveness of psychotherapy. In: A. E. Bergin & S. L. Garfield (Eds.) Handbook of Psychotherapy and Behavior Change (4th Edn) Chicrester, Wiley.
Lewis, G. & Appleby, L. (1988) Personality disorder: the patients psychiatrists dislike. British Journal of Psychiatry, 153, 44-49.
Linehan, M.M. (1993) Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York, Guilford Press.
Prochaska, J.O. & DiClemente, C.C. (1983) Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research and Practice, 20, 161-173.
Rachman, S.J. & Hodgson, R. (1980) Obsessions and Compulsions. Englewood Cliffs N J, Prentice Hall.
Ryle, A. (1990) Cognitive-Analytic Therapy: Active Participation in Change. Chichester, Wiley.
Sachs, J.S. (1983) Negative factors in brief psychotherapy: an empirical assessment. Journal of Consulting and Clinical Psychology, 56, 681-688.
Salkovskis, P.M., Atha, C. & Storer, D. (1990) Cognitive-behavioural problem solving in the treatment of patients who repeatedly attempt suicide: a controlled trial. British Journal of Psychiatry, 157, 871-876.
Shapiro, S. (1987) Self-mutilation and self-blame in incest victims. American Journal of Psychotherapy, 41,46-54.
Stevenson, J. & Meares, R. (1991) An outcome study of psychotherapy for patients with borderline personality disorder. American Journal of Psychiatry, 149, 358-362.
Tantam, D. & Whittaker J. (1992) Personality disorder and self-wounding. British Journal of Psychiatry, 161,451-464.
"I need to see blood, and for other people to see me bleed. That's my way of showing that I'm trying to get rid of the badness in me." "I hate my body, and don't feel as if it belongs to me. When one person had finished using it another took over. I hurt my body because I hate it." Statements like these, from people who deliberately harm themselves, go some way towards explaining why this problem is so often met with intense emotional reactions from others, whether professionals, families or other carers. The range of emotions evoked, including panic, hopelessness, anger and even hate, makes a consistent, therapeutic response very difficult to achieve. As a result, people who harm themselves often receive a poor service when they turn to professional systems for help.
When providers of mental health services turn to the literature for guidance, they face a number of difficulties. First, although deliberate self-harm is not uncommon amongst people referred to their services, basic texts are unlikely to be of much use. Psychiatric texts focus on the diagnostic status of patients who harm themselves, and the poor prognosis associated with the likely diagnoses, while a scan of basic psychological therapy textbooks is unlikely to produce any mention of this problem at all. The literature focusing on clients with severe learning disabilities makes many suggestions that are relevant to others who harm themselves, particularly those living in institutional contexts, but often assumes an intensively staffed environment.
Problems of definition
In addition, there are problems of definition. Deliberate self-harm may be equated with suicidal intention. Many people who harm themselves do also experience suicidal wishes, and may have attempted suicide. However, most self-harmers can make a clear distinction in their own minds between behaviours which are suicidal in nature, and other self-harming actions which may be much more frequent and serve other functions. For example, one young woman said: "I didn't want to die this time, I just needed to hurt". There may also be confusion with the much more rarely seen problem of intentional self-mutilation. Tantam & Whittaker (1992) review the literature on what they describe as self-wounding and self-poisoning, distinguishing these behaviours from suicide attempts and from intentional self-mutilation, where the aim is 'to rid oneself of an offending organ or body part'. They also distinguish between self-wounding and self-poisoning. I have chosen to retain the term 'deliberate self-harm', as many people who poison themselves without suicidal intent also wound themselves. The clients described here use a very wide range of methods to hurt themselves, including scratching, cutting, stabbing, scalding or burning themselves, use of caustic substances on the skin or on cuts or scratches, and over-use of prescribed -- or other -- medication. This last may be intended to be sedating, to make the person feel sick or poisoned, or to induce non-fatal physical harm. One young man, knowing that paracetamol in overdose could produce liver damage, routinely took small overdoses of paracetamol, with the expressed intention, not of dying, but of damaging his liver. The medical consequences range from the slight to the severe: one client of mine had severed his Achilles tendon, another spent a prolonged period in hospital having perforated her bowel. The behaviours described, and their functions as understood by sufferers, closely resemble the patterns described by Cauwells (1993), who also makes the point that self-harming behaviours are often mistakenly assumed to be impulsive in nature, an assumption many of my clients would challenge.
This paper does not aim to be a comprehensive review of the literature on deliberate self-harm. Reviews are available by Feldman (1988) and by Tantam & Whittaker (1992). The aim is rather to empower helpers effectively to work with this challenging and needy population, by describing the reasons people give for hurting themselves, looking at a case example where a relatively straightforward psychological intervention yielded very positive results, and reviewing some of the issues around the provision of services to this client group.
Why do people harm themselves?
When one asks people about their reasons for harming themselves, their explanations fall into three main categories:
- 1. To manage moods or feelings: Self-harm is associated with a range of mood states. Some people describe their typical mood preceding self-harm as one of intense anger and distress. They may see the self-harm as a release of pent-up emotion, a strategy to contain distress or anger, or as a way of reducing tension. Others see self-harm as a way of coping with a state of emotional numbness, saying things like 'at least this way I feel something', or 'I get a buzz from it'. Favazza (1989) comments on the use of self-harm to end feelings of depersonalisation, and to bring relief from a sense of alienation from the world. One of his patients says: 'Sometimes I think a dose of the good things loving, hugging -- would do it, but it's simpler to reach for a razor blade'. The process itself is often experienced in a dreamlike or trance-like state, which may be seen as pleasant, and people frequently report feeling no, or very little, pain at the time (Feldman 1988). Episodes of self harm may be impulsive, but are often carefully premeditated, and many clients describe carrying the means for self-harm around with them, as a way of feeling safe or in control.
2. As a response to beliefs or habitual thoughts: Common themes include self-punishment for intrinsic 'badness', hurting one-self to pre-empt inevitable hurt from other people and channelling aggression that the person fears may result in harm to others. Self-injury causing bleeding, in particular, is often described as a way of 'getting rid of bad blood', with all the possible symbolic functions that this phrase might imply. Thoughts and beliefs may be related to painful early experiences. For example, clients who harm themselves frequently describe a history of physical or sexual abuse in childhood (Carroll et al., 1980). In fact, only one of the last ten people I have worked with on deliberate self-harm did not describe such a history, and she had experienced extreme and prolonged adversity of another kind. Sometimes the links may be quite clear and direct: one woman who regularly scalded herself with boiling water remembered being forced to scald herself as a punishment, another identified self-blame for sexual abuse as a regular trigger for episodes of self-harm. Shapiro (1987) proposes that ideas about self-blame and self-punishment are the mediating processes between early abuse and deliberate self-harm, and suggests that violent sexual abuse in particular 'increases the potential for self-destructive activity'.
3. To manage interactions with others: It is this function of self-harm which is most often assumed by those working with the client, and tends to be labelled as 'just attention-seeking'. It is mentioned less often by clients themselves. However, self-harm seems to develop in a context where more ordinary strategies for communicating needs and feelings have been unsuccessful, and some people do describe using self-harm to let others know just how bad things are, or to obtain a sympathetic hearing that seems un-obtainable in any other way. Favazza (1989) makes a link between beliefs related to early abuse, and efforts to control interactions in the present: "Self-mutilators who received nurturance after enduring the pain of physical abuse as youngsters may harm themselves as a repetition of their childhood experiences because they believe that 'after the suffering there is forgiveness and protection'".
How do services respond?
Service responses range along a continuum, from 'the Counsel of Despair' to 'naive therapeutic optimism'. Though services rarely respond with the extreme versions given below, readers may recognise elements of their own or other services in the following caricatures.
Proponents of the Counsel of Despair argue that these are clients with personality disorders, that they are therefore incurable, and that they will only be reinforced in their self-harming behaviour if anyone indulges them by listening sympathetically and trying to help. The naive therapeutic optimist, on the other hand, believes that this is someone who desperately needs therapy, and that, once the person's appalling early history has been properly 'talked through', the problem will go away.
Each of these positions inevitably leads to the provision of an inappropriate service. The Counsel of Despair ignores the fact that people who engage in serious deliberate self-harm rarely disappear; in fact they frequently make contact with a whole range of different services, none of which is very willing to take them on, and they often have a long mental health career. The choice may well be between providing a well-planned therapeutic service or a chaotic one driven by crises. The concept of personality disorder as a global 'illness entity' is of course open to much debate, which is beyond the scope of this paper. The argument that a diagnosis of personality disorder is much more likely if a psychiatrist dislikes a particular patient, or finds him or her a nuisance (Lewis & Appleby, 1988), is, however, highly relevant to people who harm themselves. It is also important to note that the Counsel of Despair ignores recent developments in using a wide range of different psychological approaches with clients who would usually be labelled 'borderline' or 'personality disordered'. These include specialised forms of psychodynamic psychotherapy (e.g. Stevenson & Meares, 1991), cognitive therapies (e.g. Linehan 1993), problem-solving training (Salkovskis, Ather & Storer, 1990), and integrative approaches such as Cognitive-Analytic Therapy (Ryle, 1990).
Naive therapeutic optimism can be equally damaging to people who harm themselves. There is a tendency to believe that any kind of counselling, even from an untrained, inexperienced helper, is better than none. Unstructured, unfocused counselling always has the potential to be harmful (Sachs, 1983), and more severely disturbed or impulsive clients are most at risk of suffering negative effects, especially if faced with 'therapeutic techniques aimed at breaking down, challenging or undermining habitual coping strategies or defenses' (Lambert & Bergin, 1994). Many of my self-harming clients have experienced unstructured, unfocused or confrontational counselling', often from relatively inexperienced or untrained helpers, and describe two main difficulties with it. The first is the degree of ambiguity they experience about what they are supposed to be doing and why; for people who have often experienced horrifying punishments in childhood for 'getting things wrong' this can be a paralysing difficulty. The second is that in an unstructured setting they are more likely to be overwhelmed by a flood of painful feelings and memories, returning in an uncontrollable way. One recent client was referred to me after this process triggered her only serious suicide attempt, and her only psychiatric hospitalisation. Individual psychotherapy for people who harm themselves is, therefore, a task for the trained and experienced therapist. However, as this paper will argue, there is much that the competent helper, whatever his or her background, can do to help.
A case example: Tony
Tony first came to the attention of mental health services at the age of twenty-nine, when an acute episode of depression precipitated by a family crisis led to a brief admission to psychiatric hospital. Whilst in hospital, he disclosed that the catalogue of injuries described in his medical notes were self-inflicted, and he was referred for psychological help.
During our initial meetings, he told me that he had been harming himself since childhood, the earliest episode he could remember being an eye injury at the age of eight or nine. Despite frequent and severe self-harm, and repeated treatment in casualty departments, he had managed to keep the cause of his injuries completely secret. Although he had taken considerable pains to maintain this secrecy, he also had a strong dislike and distrust of doctors, and health service workers in general, which he attributed to their failure to realise what was happening and confront him. He expressed great relief that this problem was now out in the open, but initially found it quite difficult to discuss.
What he told me about his early history was that his father had left when he was an infant, and relatives had told him that his mother had experienced great difficulty in providing basic care around that time. Although he was living with his mother at the time of referral, his relationship with her was poor, something which he attributed largely to her drinking.
Tony's account of his self-harm at the time of referral was that it occurred in response to difficult situations or experiences, was usually carefully planned and executed in a very controlled way and that he felt no pain at the time of the injuries, but began to feel pain up to two hours later. He described the functions as 'Being in control, being the only person who can hurt me', and 'Getting rid of the badness in me'. He could sometimes control the wish to harm himself by using distraction, but felt that this was a fragile coping strategy.
Psychological work with Tony had a number of distinct phases. The first priority was to establish a good relationship, as his experiences of professionals had left him suspicious and wary. The limits of confidentiality, my likely responses to future self-harm and his degree of control over the therapeutic process were made explicit and explored in detail.
The second phase involved the completion of a record form detailing the circumstances, thoughts and feelings around urges to harm himself, using a similar format to that used in the cognitive-behavioural treatment of any other difficulty (see, for example, Fennell, 1989). During this time, Tony was managing to resist most of his wishes to harm himself, but close examination of the record form enabled us to see that he was doing so by avoiding likely internal or external precipitants. This emphasised his feeling that his capacity to carry on coping was fragile, and it also suggested a line of intervention.
The third phase focused on an adaptation of the technique of exposure and response prevention used in the treatment of Obsessional-Compulsive Disorder (Rachman & Hodgson, 1980). Rather than blocking or avoiding his wishes to injure himself, Tony began to try and 'sit with' them, using deep breathing techniques to try to contain his agitation. He continued to record conscientiously, and we saw a steady diminution of both the strength and the frequency of the thoughts of self-harm. We also noticed two other phenomena. First, Tony began to have a series of nightmares and flashbacks. These related to his childhood, and included an image of being face down on a vomit-soaked pillow, unable to move. Once he had talked these through with me, he found that he could put them to one side, and was clear that he did not wish to discuss them in more detail. Second, he made a number of attempts to harm himself during this phase, in response to stressful events in his life. However, he reported that he had been unable to persevere with these beyond the level of superficial cuts because of an immediate awareness of pain.
The final phase of work with Tony is ongoing. His life circumstances have continued to be stressful and difficult. For a year after the end of regular treatment sessions he came to see me occasionally, using this appropriately as an alternative to acting on infrequent wishes to harm himself. At present, he comes very occasionally, for five minutes every four to six months. He manages very occasional wishes to harm himself without external help, but, perhaps because of his early history, we have agreed that he will not be 'abandoned' by our service before he feels ready.
It is important to note that the course of Tony's therapy went unusually smoothly. With such a long and serious history of self-harm, I would have expected the process to be much more difficult. I attribute this to his powerful motivation to improve his life, our shared model of his difficulties and perhaps to the fact that he was able to transfer to treatment the exceptional self-control that he had previously required for slow and calculated self-harm. However, the outcome of this intervention raises a number of more general issues. First, the success of the exposure and response prevention technique suggests that deliberate self-harm can be placed in the category of compulsive or addictive behaviours. This supports Tantam & Whittaker's (1992) view that self-wounding should be seen as an addictive behaviour. Second, the implementation of response-prevention seems to have precipitated both the retrieval of early, suppressed memories and the reduction of Tony's capacity to shut out sensations of pain. This suggests a link between early traumatic experiences, self-harm and strategies for managing pain, which merits exploration. Third, the sequence of events suggests that therapists working with this problem need a broad range of experience and competence, which can encompass cognitive and behavioural techniques, attention to the therapeutic relationship and boundary-setting, and skills to address the retrieval of traumatic early memories and other issues which arise in helping survivors of abuse.
The case above describes a situation in which individual psychological therapy had a dramatic effect on a long-standing and serious problem of self-harm. However, although the first reaction of many non-therapists to encountering deliberate self-harm is to recommend individual therapy, my experience is that this is frequently unsuccessful. Is it possible to predict who is most likely to benefit from individual therapy, and what should be offered if individual therapy seems unlikely to be appropriate?
Who will benefit from therapy?
There are a number of criteria which, in my experience, make a referral for psychological therapy likely to be fruitful. Those referred need to be able to take responsibility for making and keeping appointments; being brought by a family member or key-worker rarely predicts a good outcome. Similarly, if they themselves are not particularly distressed by the self-harm, individual psychological therapy may not be the most appropriate intervention. If they have some experience of controlling their behaviour, for example if they sometimes feel the urge to harm themselves without acting on it, or have been successful in reducing self-harm using practical advice from the referrer, then their optimism about the usefulness of psychological approaches is likely to be greater. Finally, it is difficult to engage anyone in psychological therapy unless they have some interest in their thoughts and feelings, and some ability to reflect on and discuss these.
It may seem that these criteria for individual therapy are rather high. However, it is important to emphasise two further points. First, there is a great deal that can be offered to help people stop or reduce self-harm in addition to, or instead of, individual psychological therapy. Second, the attributes discussed above are by no means fixed. 'Readiness to Change' Prochaska & DiClemente, 1983) is a continuum along which we move throughout our lives, and timing is crucial. Any therapist who regularly tries to help clients tackle deliberate self-harm will be familiar with a situation in which someone who has repeatedly, and frustratingly, engaged with their service and dropped out, often with much mutual acrimony, returns to work determinedly on a chronic and entrenched difficulty. That said, access to skilled and experienced psychological therapists within the Health Service is very limited, and it seems legitimate to focus those resources on those who are ready to change.
What else can we do to help?
Requests for psychological therapy for people who harm themselves may often be seen as requests for help from others who are trying to care for vulnerable people in the community, for example, staff in services for the homeless. If one investigates the referral further, one often discovers a subsidiary message: 'We are committed to working with this person, but their behaviour is scaring us to death. What can we do?'
The analysis above of the nature and functions of self-harm makes it clear that there are a wide range of strategies that can help.
First, if self-harm can be seen as a way of expressing and communicating distress or anger, then it is vital that healthy and appropriately assertive expression of negative feelings is encouraged and rewarded. This may be difficult for carers, particularly if anger is felt towards them, or towards other service providers. However, as I argued earlier, people who harm themselves have often received poor services, and realistic causes for anger should be addressed.
Second, if self-harm is used to help people manage their mood, 'get a buzz' or feel in control, then it is useful to help them think about other ways of dealing with unpleasant mood changes, build in exciting, relaxing and pleasurable activities, and offer opportunities for success and control. One housing worker who worked with me to develop a plan for a resident who harmed himself regularly found that getting her hands on a couple of bicycles and pedalling furiously into the country with her client had a dramatic effect on his urges to cut himself.
Finally, if self-harm is being maintained partly by carers' responses, basic behavioural techniques are relevant. An incident of self-harm often produces a flurry of intense activity and interaction around the self-harmer, and this may be unavoidable. However, if carets ensure that they make time to be with the person when self-harm is not an immediate issue, if they can provide some space to encourage the person to talk about their self-harm in a practical, problem-solving way, and keep their responses to each episode of self-harm as low-key, matter-of-fact and unpunitive as possible, they are reducing the risk to their client.
These strategies may sound straightforward, but they depend heavily on carers' ability to develop and implement a 'team plan'. Self-harm is a problem with an unparalleled ability to evoke rage, terror, punitive feelings and disagreement in teams, perhaps because it is seen as both dangerous and wilful. The distress that can be elicited in helpers may be extreme, and must be addressed. However, it may help to keep two important facts in mind. First, self-harm is not primarily intended to 'manipulate' or upset helpers. It must be seen as part of a desperate struggle to cope with something. Second, it is normal for staff to disagree about how to handle situations involving self-harm, but vital to get beyond this to an agreed response to a particular individual. Finally, although deliberate self-harm may appear particularly difficult to understand, it 'is best thought of as a purposeful, if morbid, act of self-help' (Favazza, 1989). It has much in common with many of the other difficulties with which our clients struggle, and many of our everyday helping skills are relevant to it.
References
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