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Treatment of self-harmers
SELF-HARMING
Introduction
Over the past five to ten years, research and clinical practice have led to a change in our understanding of self-harming. Regrettably, this has happened without a simultaneous change in how the specialists offer treatment to self-harmers; and without “most people” being given access to this knowledge. This is regrettable precisely because there are effective treatments now, and because self-harming is still perceived by many to be due to individuals craving attention or wanting to manipulate others.
In the past, self-harming was understood to be a phenomenon among patients suffering from psychoses, serious mental impairment or serious personality disorders. Self-harming still occurs among these groups as well, and when individuals are diagnosed with other disorders – but new knowledge also shows that this is a phenomenon which occurs among individuals with no mental issues. There is much to indicate that many young people and young adults are harming themselves without being discovered, that they are avoiding treatment, and that they are using self-harming as an attempt to control a silent, taboo desperation.
There are as many reasons for self-harming as there are self-harmers. The risk with having met someone who self-harms is that people believe that all other self-harmers are in some way comparable. This is a misleading and dangerous notion, in particular among people working at child welfare or psychiatric health care institutions. But the same is true for teachers or others working in the municipal health service. People working with young people or adults with superficial scratches could easily believe that self-harming is not harmful or linked with a risk of suicide.
Therefore, anyone dealing with people who self-harm should acquaint themselves with the knowledge on the phenomenon by actively seeking new literature on the subject (at www.helsebiblioteket.no or www.selvmord.info , for example) and attempting to persuade the self-harmer to describe as much as possible of their own perceptions. But general knowledge is not sufficient when it comes to dealing with people who self-harm. To help them constructively and effectively, you have to take a step further on from general knowledge, diagnoses and case descriptions. The objective is to work together with the patient to find a system: to identify which situations trigger a sense of powerlessness leading to self-harming, and what abilities individuals can apply to exercise greater control over their own lives.
Perception of powerlessness
It is easy for helpers to be overwhelmed by the expressions of anxiety and – occasionally – desperation which self-harming engenders. People who self-harm often are unaware themselves of why they cut themselves, whether or not they want help, or what it is they need. They experience shame more readily than other people, and often suffer from mood swings. This means that self-harmers, their families and the people helping them often feel a sense of powerlessness. This powerlessness is paralysing. It makes the people helping feel defensive, or leads to them not wanting or daring to help self-harmers. And this powerlessness makes the patient feel a sense of hopelessness, again laying the foundation for self-harming as the only solution they can think of. In other words: the typical vicious circle.
This sense of powerlessness can easily lead to the person helping being persuaded that there is something special about self-harming; something that requires special skills not available to the helper, or a sense that self-harming is, by its very nature, impossible to treat. Even experienced helpers who have treated a lot of patients with serious disorders can be convinced that self-harming is something essentially different to other disorders, requiring other treatments.
Self-harming and mental disorders
As mentioned, self-harming is something which occurs throughout all sectors of the population. In other words, self-harming occurs in school pupils who are apparently doing well, and in patients suffering from serious mental disorders. But once self-harming has been revealed, it is often the case that other symptoms are revealed as well. It is not uncommon to encounter self-harming patients suffering also from bulimia, PTSD, dissociative attacks and other symptoms. It then becomes difficult to diagnose and classify what is the most important, what is leading to what, and how to organise treatment. Therefore, treating self-harming patients requires the therapist him/herself to be aware of which of these symptoms are clinically valuable and which are due to stigmatising processes. Diagnosis is very important, but on occasion it can be easy to “go astray” in the hunt for a diagnosis.
Regardless of the diagnosis, patients who self-harm can be perceived in some cases to be acutely suicidal or psychotic. This may in particular be the case if they also report dissociative symptoms and hallucinations. Dissociation refers to a perceived feeling of unreality or impaired awareness of parts of the body. Dissociation is relatively common, either acutely or following major trauma: a major accident, for example, or a rape. Thus dissociation can be understood either as an attempt of the conscious mind to distance itself from or shatter the knowledge of the dreadful thing that has just happened. Dissociation can come on quickly following rape, and affect the person raped for years to come if he/she does not receive help. Self-harming is associated both with trauma in general and with the after-effects of rape in particular. This appears to be the case with sexual abuse, to a particular extent.
This has led – among other things – to individuals being sceptical about explaining self-harming using diagnostic categories. Rather, they understand the symptoms as being an expression of a chromic reaction following traumatic events.
Both national and international studies have shown that self-harming is not merely a phenomenon among individuals suffering from mental disorders. The CASE study (Child and Adolescent Self Harm in Europe) was an extensive survey into self-harming in Europe in which
Manipulation and attention
There are individuals who self-harm because they are driven by a desire for attention, who manipulate others and who demonstrate serious personality disorders or psychotic episodes. But these people are not representative. Such descriptions are easy to find in the literature, and in the field of psychiatric health care for adults. But it is important to remember that these are the extreme variants, and that these patients have experienced several years of feeling powerless, along with an aid system that takes responsibility only once the situation has become critical. Most people who have experience of self-harming patients with personality disorders also learn fairly quickly that they are not really such good manipulators. They often use methods which are easy to see through, and are exposed relatively quickly. Their desperation is probably the reason why they plan for the short term – again, this is something which should confirm to us just how enormous their aversion is to what they experience in their everyday lives.
But surveys into self-harming among young people and young adults has shown that most of them have not been in contact with the specialist health service, and that they often conceal their self-harming. Very few young people who self-harm are suffering from serious mental disorders, but they claim to be intensely uneasy and occasionally wish themselves dead. Despite this, they rarely talk about it and seldom get in touch with the health system. Surveys have shown that the average time from beginning to self-harm to being discovered to self-harm is eighteen months. Furthermore, very few people self-harm merely to garner attention. Nor is wanting attention abnormal in itself. The problem is often that individuals who self-harm receive no attention as a result of positive behaviour. This may be due to the fact that the people around them are not good at giving positive attention, that the self-harmer is not good enough at accepting positive attention, or – quite simply – that they are not good at communicating difficult emotions. Regardless, the desire to receive attention does not mean that they are not hurting. It is more an effect of normal psychology, equivalent to most people with stomach-ache “embellishing” a little to make sure that everyone else understands just how painful it is.
Social abilities
Surveys show that many self-harmers state that they do so in conflict situations, or when they are overwhelmed by highly unpleasant thoughts or emotions. A typical scenario of this type is when they find out that a friend or lover has let them down or failed them. Instead of communicating this directly by describing their own reactions, they keep quiet about it. They pretend nothing has happened, mull it over and over in their minds, and then allow a dreadful pressure to build up. Such mental self-poisoning is difficult to understand for anyone who has not suffered it. Self-harming becomes a consequence of a process, triggered quite possibly by a new, minor issue.
At the same time, we know that many of the friends of self-harmers know all about the self-harming. Some try to help, others feel afraid. Unclear communication between the self-harmer and their friends often lead to negative circles in their friendship which take their toll on both parties. Viewed in this manner, self-harming is not merely a problem for the self-harmer. Many people go round being afraid of their friends. Maybe they have promised not to say anything about it to anyone, particularly parents or other adults.
What does this mean in practice, in relation to treatment of self-harming?
These are just a few elements from new research into self-harming. What does this mean in practice?
Given what has been stated above, I would like to point out that it is necessary to take into account four situations in particular. This will apply regardless of the theoretical foundation of any helper.
A relationship that can withstand problems
Initially, the same strategies and techniques can be used when treating self-harming as when treating other disorders. But self-harmers are often more affected by feelings of shame, hopelessness and intense, negative emotions. Helpers also encounter other negative attitudes towards “self-harmers”. Statements such as “she’s only doing it to get attention” “she’s only manipulating you” and “you’re probably not helping, anyway” are common. Of course, patients are also aware of these attitudes. They are aware that their behaviour is upsetting and distressing others, but the extent to which they are affected by this varies. Sometimes, they will perceive these attitudes to be incredibly unfair, with accompanying anger, while other times they will concur and experience a sense of shame and a bad conscience.
Shame is the evil twin of self-harming. Self-harming often takes place as a reaction to a strong sense of shame, and feeling dependent upon self-harming often leads to feelings of shame whereby the self-harmer considers him/herself to be mentally weak. Therefore, helpers should not be surprised to discover that anyone experiencing shame and hopelessness, and who has experienced being let down, will also have a low threshold for being affronted or despised in a therapeutic relationship. Regardless of how much empathy a helper expresses, he/she has to expect the patient to feel affronted at some point during the treatment. For example, an automatic reaction of disgust from the helper when shown a cut can be interpreted as disgust for the patient as a whole. Shame is also an emotion without words. It often comes as a physical feeling and is difficult for others to discover. Anyone who is experiencing a sense of shame will attempt to avoid drawing attention to what they feel is the cause of their shame, and have a desire to make themselves invisible. Unless the helper is aware of this, the consultation will end without the helper really understanding the patient’s sense of shame and embarrassment. Following the consultation, the mental self-poisoning mentioned previously can gradually lead to an increase in the shame felt. This can lead to a greater need to self-harm, and to the patient failing to turn up for the next consultation. In other words, the patient may feel that the help offered makes the need to self-harm even greater, or the patient
It is the responsibility of the helper to do something about this. The helper should plan a strategy based on the premise that things will not happen “if they happen”, but “when they happen”. The easiest thing to do will be to realise that it is normal for shame, with the subsequent avoidance, is a common reaction to treatment, and that both parties should be aware of how to react when this occurs. Discovering, putting into words and reflecting upon such situations should be part of the treatment, and may form a basis for how the patient can transfer this to other relationships and situations in his/her life as well.
Focus on overcoming unpleasant emotions
As mentioned, self-harming is often a reaction to an intense negative emotion or thought, such as strong memories or situations which remind the patient of earlier negative experiences such as sexual abuse or bullying. Many people describe an almost ecstatic experience when they discovered that there was something that could help them to fight this feeling. Self-harming is perceived by many as the first really effective protection against “the bad thing”. People who self-harm are not stupid. They behave the way they do on the basis of previous experiences indicating that their behaviour has been effective or that they have no other way out regardless. When asked directly what they really want – whether they want to take their own lives, whether they want their lovers back, whether they can promise not to self-harm – they will most commonly reply that they do not know. They just want to escape from the difficult situation. All they know is that things are not good for them right now, and that something has to be done to change the situation.
Thus the aim of treatment is to focus on how to prevent the dreadful emotions from crowding in, how to discover these before they become strong enough to make resistance futile, and how to overcome the bad feelings by means of other methods. Many creative – and often directly stupid – solutions have been presented to self-harmers over the years. Telling self-harmers to draw red lines on their skin, or to try to think of something else, says more about the helpers’ lack of understanding than about their creativity. Instead of gazing obsessively at the wound or focusing on the moment prior to self-harming taking place, they should focus instead on situations, thoughts and interpretations before that bad feeling built up which again would lead to a need to self-harm. Reviewing situations which led to self-harming do, of course, form a good starting point for this, but it requires the emphasis to be on the psychology prior to the self-harming rather than on the crisis itself. In addition, actually talking about the self-harming is a must, as is reviewing together with the patient his/her behaviour and thoughts instead of allowing the helper to speculate on these independently.
Focus on overcoming unpleasant social situations
The “unpleasantness” linked with self-harming affects relationships with friends and social relationships in general. Self-harmers will often misinterpret social situations along the lines of “I knew it! She said she cared about me, but she didn’t mean it. I’ll never learn. I’m just a fat, disgusting bastard. I don’t deserve anything else”. Such negative self-instructions build up a feeling of disgust and can lead to the patient reacting with anger or shame in situations where it is simply unjustified, or to him/her reacting much more violently than is necessary. This can result in a self-fulfilling prophecy; the patient behaving in a way which ensures they make a fool of themselves, and then actually causing the situation which they thought was applicable right from the start. This often leads to the self-harmer feeling lonely, angry and bitter; a situation that causes friendship to deteriorate, increases the feeling that they have nothing to lose, and makes them think that self-harming is their only friend.
Therefore, treatment should focus on friendships in particular and social interaction in general, and actively use situations from day-to-day life to improve the patient’s skills regarding interpretation and how to act in social relationships. Again, this should be normalised. It is necessary to talk about vicious circles and the consequences of previous bad experiences, not about mental weakness or personal failings. In this respect, group therapy and use of “homework” can provide a good foundation for active treatment. With young people in particular, suicide attempts and serious self-harming are often linked with a combination of problems in their love lives and the use of drugs on weekends. Therefore, helpers should not have a bad conscience about talking to self-harmers about problems in their love lives. This subject is right on target, and is often perceived by patients to be extremely meaningful.
Focus on the patient’s own good solutions
Many people who self-harm could have harmed themselves to a much greater extent. There is a great likelihood of patients already having some techniques or an understanding of their problems which they already apply without their helper being aware. It may also be the case that the patient him/herself is unaware of this, or that he/she plays down the significance of these techniques. Remember that many self-harmers have a poor self image and are not used to receiving positive feedback. As a consequence, the helper should put into words the fact that together they will be focusing not only on when the patient self-harms, but also on when he/she does not. Discovering such situations and putting them into words can teach both parties just as much as maintaining a negative focus. In addition, this gives the patient attention for a good reason for once. The aim in this case is to make more of whatever it is that is good, and to extend this to other areas in the patient’s life.
In this respect, it is important to remember that a lack of symptoms in patients is otherwise linked with the end of the treatment. The termination phase is always difficult for patients who are easily offended and have had bad experiences of other relationships. Treatment of self-harmers should continue for a reasonable time once the self-harming has ceased. This is because the emphasis them should be on stabilisation, focusing on what the patient is continuing to do to prevent self-harming, with such good results.
Forms of treatment
As mentioned, a number of forms of treatment have been developed over the past few years which have been created especially for self-harming patients. Some of these patients have personality disorders and self-harm, while others self-harm “alone”. One thing some of them have in common is that fact that their cases are documented effectively, or that the results of their treatment are promising. The most renowned forms of treatment are Schema Focused Therapy (SFT), Dialectical Behaviour Therapy (DBT), Mentalisation-based Therapy (MBT), Manual Assisted Cognitive Behaviour Therapy (MACT) and Transference Focused Therapy (TFT).
Dialectical Behaviour Therapy
In
DBT was originally developed as a treatment for suicidal and self-destructive women suffering from borderline personality disorder. DBT has gradually been adapted for other diagnoses and problem areas, such as self-harming young people, elderly people suffering from depression, men who abuse family members, patients who abuse drugs, and psychiatric patients suffering from antisocial personality disorder.
Within the field of DBT, learning and the use of various skills are central to the treatment. DBT requires an undertaking on the part of the patient to acquire skills through both training in a group and as part of one-on-one therapy. This is interlinked with the fact that with DBT, the cause of the patient’s problems is perceived to be difficulties with controlling their own strong feelings and reactions. The patient has to learn; and many self-harmers have ended up in vicious circles, so impeding this process. In DBT, it is explained that you cannot expect a child to learn to ride a bicycle completely alone, or without sufficient assistance. We would react with disbelief and alarm if a parent were to accuse a child of not doing their best in such a situation, but in the field of psychotherapy such attitudes are not uncommon.
In the field of DBT, there is emphasis on the fact that patients have problems in five central areas of their lives. A lack of control over their feelings is expressed by anger and mood swings. Interpersonal problems are expressed by a fear of rejection and intense reactions. Negative perception of the self is expressed through self-reproach and feelings of shame and emptiness. A lack of control over their own behaviour is expressed by impulsiveness, self-harming and suicidal behaviour.
Mentalisation-based Therapy
Mentalisation-based Therapy (MBT) is a recently developed, psychoanalytically oriented treatment for patients suffering from borderline personality disorder. MBT is based on modern development theory and attachment therapy. MBT has proven effective in the treatment of individuals suffering from borderline personality disorder through randomised, controlled clinical trials. It appears to produce good results when treating self-harming patients, but as yet no documentation has been compiled relating to its effects when treating self-harming young people.
The expression “mentalisation” refers to a mental process whereby individuals interpret their own behaviour and the behaviour of others on the basis of their own personal perspective. In the field of MBT, it is asserted that patients suffering from borderline personality disorder are unable to handle this as well as other people. Incorrect interpretations are manifested in strong mood swings and intense reactions. The aim of this treatment is to teach the patient how to discover their own mental state and requirements and those of others, and through this to place the patient in a better position to control their own feelings and interactions. Putting into words current events, previous experiences and interaction with the helper are all ways of achieving this.
Conclusion
Initially, there is no reason to adopt a negative attitude towards treating self-harming patients. We now know a lot more than we used to about both self-harming and treatment. Yet still “most people” hold on to knowledge which has not been brought up to date. Nevertheless, I would like to assert that a lot of progress can be made on the treatment of self-harming without mastering the forms of treatment outlined in the previous section. However, to do this the helper has to absorb what knowledge is available and devise the treatment accordingly.
REFERENCES
References are available upon application to the author: arkimedes.svein@gmail.com