What are the challenges that face a psychotherapist working with self harm or eating disorders. “She cuts herself. Never too deep, never enough to die. But enough to feel the pain. Enough to feel the scream inside. The lines I wear around my wrist are there to prove that I exist. A broken mirror, a bleeding fist, a silver blade against a wrist, tears falling down to lips unkissed, she’s not the kind you’ll come to miss. ” (http://xxdailydreamxx. tripod. com/id16. html) I took this poem from an internet site that encourages people who self harm to express themselves creatively or make themselves heard.
It helped me to understand the emotions and thoughts behind self harm. Self harm is considered to be a deliberate attempt at causing physical harm. As you can imagine there a number of different ways and methods to do this. Cutting the skin, burning, hitting yourself, some even argue excessive drinking, over eating, under eating, over exercising can be considered self harm. All these actions have a way of distracting us from being alone with our fears, feelings and thoughts. Self harm can be looked at as a self defeating behaviour.
Which means that at one time this behaviour was used as a successful coping strategy and now it has become a maladapted coping strategy for an individual. And for them it works, albeit temporarily. Kahan and Pattison, (1983, 1984). identified three components of self-harming acts: Directness relates to whether the injury was intentional or not. Was the injury procured with awareness and was the intention of the individual. Lethality refers to the likelihood of death resulting from the act in the immediate or near future. Repetition, is the action repeatitive or a one off.
There are many different definitions and extensive lists of what constitutes self harming behaviour. All of which provide further insight into the behaviour. Self harming is a very private act and is shrouded with shame and guilt. It can often go undetected for many years. Each client will have different idiosyncratic ways of relieving the pain they are carrying. Often the act will have a ritualistic manner and will be very private to the individual. Malon and Berardi (1987) explain the process behind self harm: “Investigators have discovered a common pattern in the cutting behavior.
The stimulus… appears to be a threat of separation, rejection, or disappointment. A feeling of overwhelming tension and isolation deriving from fear of abandonment, self-hatred, and apprehension about being unable to control one’s own aggression seems to take hold. The anxiety increases and culminates in a sense of unreality and emptiness that produces an emotional numbness or depersonalization. The cutting is a primitive means for combating the frightening depersonalization. ” In my research I have read a number of blogs by individuals who self harm and found a few common sentiments.
Firstly many individuals claim to feel numb, have no enjoyment, to feel nothing, like they are walking through life in autopilot and the action of cutting and feeling the pain makes them feel alive. This depersonalisation is perhaps something that could be looked at in therapy. Detachment is a defence mechanism normally applied when something very traumatic has happened and the mind is in essence trying to protect itself. Often when the mind suffers a trauma the person will go into shock which also creates a feeling of numbness and a sensation of not being there at the moment.
Perhaps the body continues to experience this after the trauma which leaves the individual feeling numb and disconnected for a long time without really understanding why. I will talk more about this idea later when I look at treatment for self harm. Another aspect that I found repeated in the blogs was the feeling of control. The individuals felt scared and alone and this one action was something that they felt they could control, so no matter how bad things were in their lives they had this one thing that they could do.
As I read their accounts it dawned on me to some extent this action gave them some power where in the outside world they felt really powerless and insignificant. This perhaps would be something that could be worked on in therapy. It was also suggested that some people self harm as a way of communicating or expressing things they cannot speak. It is suggested when self abuse is used in this mannor it is considered manipulative an attempt at getting a need met or to influence another.
If this is the case it is important for the therapist to listen to what that need is and to help the individual satisfy that need in a constructive and effective manner I imagine the therapists first challenge when presented with an individual who self harms is creating a space where the client can trust the therapist. I can imagine an individual who self harms will carry a large level of guilt and shame at the behaviour and it is as always vital to move at a pace the client is comfortable with.
If I am aware of marks or cuts before the client has disclosed to me I will wait until the client feels safe or I feel is ready to talk about the behaviour. Often the client will not have appropriate support systems for whatever reason which puts them in a very vulnerable position. I would never suggest a no self harm contract as I feel that would create too much pressure. It is important to remember that the behaviour is the adapted coping strategy for this individual and on some level it provides some release or comfort and the idea of removing this would be very stressful if it was made an absolute.
If I had a client who self harmed I would indeed ask whether the individual felt suicidal or had ever attempted suicide. However as the Chrysalis notes aptly suggest, self harm is one of lifes paradoxes as the act serves as a life sustaining behaviour rather than a life destroying one. A further challenge perhaps presented by a self harming client would be the issue of contact. How much contact is sufficient, how much can the therapist support the client, what about out of hours support. I think it is important to establish within the contract these issues to ensure boundaries are maintained.
This is to protect both client and therapist. For example if a client calls in an highly emotive state and is just about to self harm and is calling you to stop or protect her/him. What is the ethical thing to do. Bare in mind the individual is in a very vulnerable state and to completely dismiss her/him could be very rejecting and further traumatise the individual. However on the other hand if you make yourself available all hours and every time the individual is distressed you receive a highly charged emotional phone call in which you have to reassure and talk the individual down.
The therapist can easily get caught up in the drama triangle rescuing the individual who becomes quickly the victim. And what happens if for whatever reason you are not available, the therapist quickly becomes the persecutor. I imagine this can be a very difficult situation for both parties and to maintain an ethical stance throughout therapy it is important for both parties to agree and form a written contract that can be referred to and adapted throughout therapy. If I was the therapist I would ensure my client had access to some sort of support network, a friend, family member, support group or even help phone lines.
I would imagine a therapist and client should have an agreed upon procedure that could be looked upon if the client feels he/she needed to self harm. I would have it written in the contract that phone calls to the therapist could be made to make appointments but that it would be unethical and not keeping to our confidentiality agreement to discuss outside of sessions. I would also explain that this policy is for the benefit of the client as it encourages her/him to be responsible for his/her actions and gives him/her back a little bit of the power.
I would explain one of the goals or aims of therapy is to for the individual to be autonomous and to feel powerful and in control. The last thing wanted within the relationship is dependency on the therapist as this devalues the capability of the client to cope themselves. As for the therapist it prevents therapist burn out. The treatment of self harm can be a long process with quite a few set backs. The relationship between client and therapist should be the corner stone of therapy and the therapist should be in tune with the capabilities of the client. Not pushing them but going along with them.
Also it will be important for the therapist to be aware of their own reactions to the client, being aware of the drama triangle and when they are going into the rescuer role. It is not always the case but often self harm is a sign of past trauma or abuse, therefore the therapist should go at the pace of the client to avoid retraumatising him/her. Another challenge that a therapist might face is a reluctance of the client to address the issue, this might be experienced by missing sessions or perhaps a client will jump from one therapist to another without ever really facing these issues.
This I imagine is a delicate problem as the client is in therapy because he/she wants to change some part of their life, however if they are not ready to address the behaviour or have trouble trusting or relating to another person it could take a long time with many set backs to build up a relationship. Therefore I imagine it would be important to build up a very trusting relationship between client and therapist. And it would demand that the therapist maintains very clear boundaries on time and missing sessions and that this is discussed in an open and supportive manner.
Encouraging the client to be responsible for his/her responses and therapy outcome. Treatment plans should be tailor made to suit an individuals needs and capabilities and the way forward should be discussed together and decided on together with both parties putting input into the treatment. If we are to look at the person centred approach in the intial stages, establishing an environment where the client feels unconditional positive regard and doesn’t feel judged. I imagine the individual will have very low feelings of self worth and self esteem. With low conditions of worth, where they don’t feel worthy of love or respect.
Again this needs to be done sensitively and not in a rescuing manner. Perhaps beginning to identify feelings that surround the self harming. I would be reluctant to force psychodynamic techniques too early in therapy as it can sometimes be too much for the client and actually increase the self harming behaviour or retraumatise the client. This is a fundamental challenge faced by therapist to be very congruent and in tune with the client and trying to see past the mask they put up. Getting past the secrecy, the shame and the guilt will be an important part of the intial therapy.
Using person centred techniques of non judging, and unconditional positive regard to encourage the client to accept themselves and the behaviour. To help them understand that the self harming is not their fault and is in fact a coping mechanism and therefore dealing with the shame or whatever feelings surround them. Initially I imagine focus would be on the present and whatever is happening in the life of the individual at the time, together looking at emotions experienced and thought patterns in an attempt to identify the triggers for the self harm behaviour.
Once the client has identified the emotions and triggers a treatment plan could be devised to find healthy alternative coping mechanisms. Reminding the client that they have a choice in their reponses and aiding them in taking back the control and power over their options. As each client will be individual a variety of approaches could be applied now at the stage. If the client is experiencing feelings of anger finding a way of releasing the anger in a safe way, this will be a very individual task and the client may have to try a few different approaches to find a way that works for them.
A potential challenge at this stage would be lack of motivation or interest in therapy, for example using a CBT approach and the client has some form work to do between sessions but doesn’t get involved. Here the therapist has to avoid getting into a tennis match of, “have you tried this,,, yes but.. ”. From an ethical stance the client must feel autonomous and any setting of task need to be created together and as always the therapist must be flexible and aware of over challenging the client.
This leads me to the problem of relapse which can happen at any stage of therapy particulary as the relationship starts to look at the deeper issues. This should be discussed in a very clear and supportive manner so that relapse is not portrayed as failure or shame, instead as a learning experience where we can identify the triggers and reasons for relapse. An interesting idea to consider when looking at self harming behaviour is shadow work. Carl Jung used the archetype of the shadow to refer to all negative aspects of our character, our dark side if you like.
Author Connie Zweig suggests unless we face up to and accept our shadow we are forever victims to it. Jung describes the shadow as having severals layers, the first layer is our personal shadow which is comprised of all our early experiences and learning and is made up of the things we consider unacceptable, these notions often come from the adults around us and are our guidelines of what is good and bad. Another level is what Jung called the collective unconscious or archetypal shadow and this connects us all in knowing the dark from the light.
The personal shadow is of interest to us when we look at self harming. It is the personal shadow “that erupts spontaneously and unexpectedly when we do something self destructive, or something that is hurtful to someone else. Afterwards, we know it’s been around because we feel humiliated, ashamed and guilty. ” Connie Zweig describes the personal shadow as a part of us that cannot be tamed or controlled. This all sounds very familiar to the experiences of an individual who self harms. Perhaps the very act of self harming is the shadow turned inwards.
Carl Jung felt we could learn a lot from our shadows and that to fully develop we had to accept and acknowledge it. This could be done in therapy as often our shadow self is trying to tell us something. For example if we feel powerless and worthless in our shadow could be great strength and purpose. The shadow can also be likened to the Johari window as our blindspot or unknown to self aspects. [pic] Working with the shadow and trying to find the underlying denied aspects of self can be a frightening undertaking for anyone, and I imagine it would be particulary daunting to an individual who self harms.
However I believe if approached in a gentle and supporting manner, using techniques such as anchoring and being aware of how the individual is reacting it can be very empowering. I almost imagine when I think of shadow work a fairy tale where the scared little girl or boy finally turns round to the dark looming figure that is always behind and finds something valuable, something they need. Another way of using the shadow in therapy is to examine triggers to self harming behaviour, for example if the individual really hates their boss and feels so stressed and angry after a meeting he/ she feels the need to self harm.
We could look at what it is about the boss that causes such strong feels, or what it is about the whole situation that causes such distress and then try and relate that to the individuals shadow. Again a challenge to met by the counsellor may be resistance. A possible solution would be to encourage the client to be aware of the bodily reactions and try to focus on what is happening in the body rather than intellectualising the behaviour. Then the reaction becomes about the individual and not the exterior situation or person.
With more and more practice and awareness a client might be able to feel when he or she is resisting or to understand further how he/she reacts bodily and thus emotionally to situations and feelings. Trying to reduce feelings of anxiety or to understand why and how the body reacts to certain experiences. The end result is to give the individual a deeper understanding of their body and emotions and then to gain control and power over them. When it comes to self harm there are many challenges that face the therapist and many more that face the client.
The most important aspect of the therapeutic relationship is that the client does not feel alone. In the therapist there is a support system, in the therapy there is a process and the client has the power or responsibility within themselves to move forward. The therapist is not there to rescue or to make it all better, because no one else can do that but the client. I imagine when a client successfully faces the self harming behaviour and its darker parts they experience a liberation from fear and isolation.