To set the therapeutic context most widely regarded as integral to understanding and treating self-harm, one would consider the work of Melanie Klein (1882 – 1960). Melanie Klein is widely regarded for developing Object Relations Theory. An adult sufferer of depression herself and, through her work with one of Sigmund Freud’s (1856 – 1939)students; Sandor Ferenczi (1873 – 1933), she was encouraged to further her interest in psychoanalysis through her work with children; namely in ‘play’.
The term of ‘object’, in Object Relations Theory; developed by Klein, represents either a person; often the Mother or primary carer, or an object to which there is an attachment. The term, ‘part-object’, describes part of the object; for example parts of the Mother’s body. Other theorists, such as Winnicott (1896 – 1971), built on this to describe ‘transitional objects’; items the child uses as a substitute for their Mother / primary carer, as they develop independence. This suggests the child is learning to ‘relate’ to people and their world.
Klein suggested that the Mother / child relationship starts long before birth; becoming firmly imprinted on the psyche of the child; as the child goes on to create a sense of parts of their world into categories of ‘good’ or ‘bad’.
The sense of ‘good’ or ‘bad’ comes from the child’s experiences of having their needs met. Anxieties develop, in our present, where there is fear that needs will not be met. This suggests the experiences of the past become part of our present; our psyche is affected by past experiences and subsequent evaluation of whether experiences were ‘good’ or ‘bad’; which we learn through whether our needs were met.
Through considering and applying Object Relations Theory, the Counsellor or Psychotherapist may see patterns of how clients may respond to the experiences and challenges of life; both the environmental world, including other people, as well as thoughts, feelings and emotions that are triggered within us. If our experience has been negative, in our formative years, our response to situations, events, circumstances, people or to life may be negative, damaging or even harmful; triggering corresponding behaviours.
It is possible to consider that how a person develops and, within that process, how they relate to their world and the people within it, creates a value system and belief system that could either be healthy and helpful or unhealthy and unhelpful; possibly even traumatising. This, in turn, affects coping skills and behaviour.
Albert Ellis (1913 – 2007) developed Rational Emotive Behaviour Therapy (REBT) (please refer to my Blog post; entitled ‘Overcoming Negative Beliefs’, about Albert Ellis whose REBT theory suggests that behaviour is directly affected by thoughts, feelings and emotions, which are themselves affected by our belief and values systems.
It is also possible to conclude that, in line with recognising how Object Relations may well describe human development, a suitable way of treating self-harm may be through effective use of Rational Emotive Behaviour Therapy; empowering a person to challenge their own innate belief systems and the subsequent unhealthy or unhelpful behaviours that may develop as a consequence.
There are a number of methods known to be helpful for treating self-harming behaviours; in particular this may include the safe use of self-harming methods through a monitored regime of harm reduction. This is a controversial method in many countries but is a common practice within the UK. For example, in a Primary Care setting; such as the NHS, or within a residential treatment programme, a client may be encouraged to carry out their self-harming act while under the careful supervision of a clinical professional who would teach harm reduction initiatives to the client and whose treatment regime would involve mutually managed reduction of the self-harming behaviours. Other methods may include helping the client to develop self-awareness through self-monitoring tools; such as a journal and through developing skills of self-expression and communication. Also helpful are strategies for coping with the triggers of emotional, or behavioural, responses that contribute to the compulsion to self-harm. Such methods are varied and many and so I would recommend further reading on this subject, for this article is more of an overview.
Carl Jung (1875 – 1961); founder of Analytical Psychology, developed a technique known as The Shadow Archetype. This simple technique asks the client to list the characteristics and traits that the client most dislikes in another. The client is then asked to add a title to this list: ‘My Shadow Self’. The theory is that the listed characteristics and traits are a representation of the client’s own ‘darker side’; their repressed self. It is suggested that if the client learns to identify, own and accept that they, themselves, have some or all of these characteristics and traits, there is an opportunity to resolve inner conflict, to understand one’s self-defeating behaviours and to overcome unhelpful or unhealthy thoughts and behaviours.
This technique aims to bring such behaviours and thoughts to the surface, in order that they may be addressed, rather than for them to remain hidden and then to become triggers into unhelpful or unhealthy feelings and behaviours. For a client that self-harms, this can be a useful key to overcoming impulsive or compulsive tendencies.
I have described the basis for how self-harming is underpinned by the way in which a person develops. Self-harm, itself, can be a multitude of behaviours. Commonly recognised are cutting, scratching, picking, banging the head against a wall, violent acts against ones-self and other acts such as self-sabotage, self-poisoning or deliberate carelessness within high risk activities. There are too many variants for me to list but, again, I would recommend further reading and research here.
How we develop in relation to ‘objects’, how we develop responses, values and belief systems is likely to have a direct influence on how we regard ourselves, others, society and the world. These factors may affect our ability to believe in our own potential, our ability to form or maintain positive relationships and our ability to cope with the world and life. When difficulties arise for the person whose responses are so affected, the ability to cope may be significantly impaired. The ability to understand, to rationalise and to communicate may also be adversely affected. This may render a person into feeling stuck, helpless, confused, fearful and hopeless; to name but a few possibilities. It is the sense of foreboding, imminent doom and defeat that I believe are key, at this point. This is precisely when the risk of self-harming behaviour is at its highest level.
The person who carries out an act of self-harm, is widely regarded as doing so due to their need; as a means of relief, a sense of empowerment, expression and control. When faced with the knowledge that a client is self-harming, or when faced with evidence; such as scars from cutting, one of the challenges a Counsellor or Psychotherapist faces is their own personal reaction. There may be a sense of apprehension, fear, shock, repulsion or even a fear that this is an issue that is ‘too serious’ to handle; rendering the Psychotherapists into lacking professional self-confidence. Here, the client needs to feel understood and they need to feel safe.
Conversely, there are instances when self-harming behaviour is a manifestation of a feeling of self-loathing. This is, in my experience of working with self-harming clients, more common in cases where a person may have been sexually abused or raped; due to self-blame or a sense of contamination; challenging the Counsellor or Psychotherapist with a different dynamic and root cause. Here, gentle but considered use of Socratic questioning can be most helpful to the client, along with reassurance.
Another challenge is that it may be easy for the Psychotherapist to see the self-harming as the problem and to try to focus on resolving, or ‘curing’ that, rather than focusing on the feelings and processes that underpin this behaviour; which is where, ultimately, the solution lies. In my own experience, it is rare for a client to come to see me to resolve self-harming behaviour. They usually come to see me about their feelings and later reveal the self-harming behaviour. With this in mind, it is useful for a Counsellor or Psychotherapists to consider the potential that any client may be concealing a self-harming behaviour and so gentle, explorative questioning early on can be helpful in identifying if such behaviours exist. Getting this explorative process right is another challenge for any Psychotherapist; for heavy, direct questioning could alienate a client who is not yet feeling ‘ready’ to reveal. This could damage or destroy the therapeutic relationship; the working alliance.
The Psychotherapist may also be challenged by a change in self-harming behaviour, once the client begins to explore and address the issues that underpin this behaviour. For example, I have had clients reveal to me that they cut themselves after a counselling session, or sometimes before, in response to the fact that their emotions, senses and feelings are becoming heightened as a direct result of therapy. This is where a coping strategy is helpful for a client. In all cases, the Counsellor or Psychotherapist must be clear that they have the skills, training and experience to work with self-harm. They should be supported by their own Clinical Supervisor and they should be ready to refer the client on to a suitably skilled Counsellor or Psychotherapist, if they do not possess the required skills.
From an ethical standpoint, it is essential that a Counsellor or Psychotherapist has a Clinical Supervisor to talk to; particularly where client’s self-harming behaviours or suicidal ideation manifest at increasing levels. Objectivity is essential and the guidance of a Clinical Supervisor can help maintain boundaries and ensure that medical, ethical and legal considerations are accounted for. This also helps address the potential for transference and collusion. I have a Clinical Supervisor that oversees my work and I, in turn, am also an Approved Clinical Supervisor and I oversee the work of other Counsellors and Psychotherapists. This ensures that the client will receive the best possible level of care and treatment from their Therapist.
A Counsellor or Psychotherapist must also consider that there may be differing legal requirements around confidentiality where a child or young person is concerned, just as if the client’s mental wellbeing is impaired and the Mental Capacity Act must be considered. Many clients will fear their self-harming behaviours may become known. Clearly explained boundaries and contractually agreed protocols should be established, from the outset. Here, the Data Protection Act and the Mental Capacity Act should be explained to the client or their legal Guardian and Safeguarding protocols must be considered.
As someone who has written and conducted many Group Therapy programmes over the years, I believe the considerations of a therapist that is working with groups are important. For example, the safety of the group is paramount and so one must assess the capability and readiness of participants, prior to entry to the group. Given that disclosures made within a group may trigger any one of the participant clients into high risk responses, the group facilitator may have to decide to refer a client to individual therapy instead of Group Therapy. Likewise, if a participant is known to be in the midst of self-harming behaviour, in their private time, it may be considered that a group setting is not appropriate for such a client, until the self-harming behaviours have eased down or ceased; for the client may be particularly vulnerable until the behaviours are ceased. Of course, this may also be determined by the treatment setting, as mentioned earlier.
Through therapy, the client may learn to replace existing belief systems, values and unhelpful or unhealthy thoughts, reactions and behaviours, with new positive alternatives. In gaining self-awareness and by developing improved self-esteem and a sense of empowerment, together with taught coping strategies and techniques, this may lead to the end of the self-harming behaviours.
As stated earlier, this is a broad subject and this article merely offers a brief overview and so I would recommend further reading on this subject. I would also recommend developing an understanding of how people of different cultures respond to the subject of self-harming and how this affects access to treatment for the person who is self-harming.
(C) Dean G. Parsons. 2016.