Understanding and Working with Self-Harm
Understanding and Working with Self-Harm
Issue 19 – November 2009Author: Gareth Foote (firstname.lastname@example.org)
- Self-harm is a way of coping with difficult feelings and situations and is therefore considered a survival strategy
- People who use self-harm often report being stigmatised and labelled in unhelpful ways by health services. Paradoxically this maintains self-harm as it reinforces their negative view of themselves and the belief that they are unworthy of the support of others, or that others cannot or will not help them, and ultimately will reject them
Implications for practice
- People who work with people who self-harm can experience emotions including frustration, anger, hostility and other negative responses
- By tuning in to the survivalist nature of self-harm, practitioners can accept self-harming behaviour and create a basis for help and support.
- Staff need clinical supervision, and organisational and peer support to work successfully with self-harm
Understanding Self Harm 1, 2Self-harm has been described as a scream without a sound. The term self-harm describes a range of behaviours including cutting, biting, picking at wounds, burning, banging or hitting body parts, insertion of objects into the body (including into prior wounds), hair pulling, or ingestion of objects or toxins. Not all people who use self-harm do so repeatedly. Self-harm can also occur in the context of hearing commanding or persecutory voices. However, the following will focus on people who use self-harm repeatedly to cope with distress. The UK has one of the highest rates of self-harm in Europe, particularly among adolescents and young adults. Self-harm is not necessarily indicative of suicidal intent, but it is associated with a higher risk of completed suicide. It is perhaps most helpful to consider self-harm as a means to cope with or survive intolerably distressing emotional states. Many individuals report that they have used self-harm to regain or take control of their feelings. Some may use it to numb themselves to such feelings, while others who feel numb, empty or unreal may use it in order to feel something. Each episode of self-harm represents a unique response to a particular life situation and we should seek to understand it as such. While there appear to be some common pathways to self-harm, including abuse in childhood or adulthood, bullying at school, and/or living in environments in which it is not safe to express emotions, each act of self-harm must be considered in relation to the individual experience and history of the client. The reasons that an individual first self-harms are not necessarily the same as the reasons for continuing to self-harm.
Working with Self Harm 3, 4, 5People who self-harm can encounter invalidating, negative and hostile responses from health workers. Such responses confirm the individual’s view of themselves, e.g. perhaps as bad and deserving of punishment, or as unworthy of and beyond the help and care of others. This also perpetuates experiences of others as hostile and unhelpful. It is common for self-harm to be seen by health workers as attention seeking and/or manipulative. Service users who use self-harm often report that being perceived in this manner is stigmatising and unhelpful. This terminology serves to reinforce their negative views of themselves and affirms overwhelming feelings of guilt and can therefore maintain urges and acts of self-harm. An alternative perspective is to see self-harm as a form of communication of emotions and states of mind that cannot adequately be put into words. Indeed, recognising and resolving problems and painful emotions are sometimes key difficulties faced by individuals who self-harm. Specific psychological therapies have been developed for working with self-harm. However, it is possible for all mental health workers who have contact with people who self-harm to provide useful help and support. Key features of effective relationships for people who self-harm involve: offering acceptance and validation of the emotional and social difficulties they face, and acknowledging self-harm as the best the individual could do at the time to cope. The absence of judgemental statements or attitudes is also crucial to such relationships. By sensitively exploring the meaning of acts of self harm, we are likely to identify ways that the individual’s needs are not being met by themselves or others. This may help to suggest possible ways forward. This needs to be done within the context of a supportive and accepting professional relationship. People who use self-harm are often sensitive to non-verbal communication. Because of their self-view from life experiences (including contact with health services) people who use self-harm can be prone to sensing and interpreting others’ actions as hostile or rejecting. Mental health workers need to be alert to this and clarify such potential misunderstandings. When working with people who use self-harm it is likely that some staff will feel overwhelmed by the emotions being directly or indirectly communicated. Some may seek to immediately challenge or propose ways to change such feelings in the client. This can be experienced by the client as invalidating and rejecting. It is instead helpful to simply reflect back to the client what we think they might be feeling and being curious enough to clarify this, e.g. “you seem angry, have I got that right?” or “you seem lonely, that must be very difficult at the moment”. This communicates to the client that we hold them in our mind and can tolerate their difficulties without the client being perceived as bad or wrong. Acceptance and validation should not equate to indifference; as the relationship develops the person can be supported to consider alternatives. Discussing ways that the individual copes when they do not use self-harm can help us to think about supporting them to tolerate distress and regulate emotions in other ways.
Supervision and Support 6, 7, 8Working with an individual who uses self-harm triggers a variety of powerful reactions and feelings in staff, ranging from anger and hostility to wanting to ‘save’ them. Literature now recognises the impact of working with self-harm on front-line staff and the corresponding need for training and support in order to understand and work with people who have self-harmed. This requires a safe reflective space in which to express and reflect upon our responses and reactions, and work beyond them if necessary. Similarly, it should be safe to question the use of stigmatising or judgemental language and attitudes, and challenge behaviour that might be perceived as rejecting. Whether we accept it or not, historically self-harm has been one of the greatest challenges faced by mental health services; it will not go away simply because we reject it or wish it to be so.
- Klonsky, E. D. (2007). The functions of deliberate self-injury: A review of the evidence. Clinical Psychology Review, 27, 226–239.
- Nathan, J. (2006). Self-harm: A strategy for survival and nodal point of change. Advances in Psychiatric Treatment, 12, 329–337.
- Linehan, M. M. (1993). Skills Training Manual for Treating Borderline Personality Disorder. New York: Guilford Press.
- Thompson, A. R., Powis, J. & Carradice, A. (2008). Community psychiatric nurses’ experience of working with people who engage in deliberate self-harm. International Journal of Mental Health Nursing, 17, 153-161.
- Fagin, L. (2006) Repeated self-injury: perspectives from general psychiatry. Advances in Psychiatric Treatment, 12, 193–201.
- Department of Health. (1999). A National Service Framework for Mental Health. London: Department of Health.
- National Institute for Clinical Excellence (2004). Self-harm: The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care. London: National Institute for Clinical Excellence.
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