Understanding self-harm

Before I started working with people who self-harm I could not reconcile in me the possibility that someone who already suffers greatly emotionally could add to their suffering so directly and physically.

I now work privately with this group of people and I also co-facilitate a self-harm support group in Brighton. These experiences have helped me make sense of this complex and challenging behaviour. I have outlined here some of the thoughts that help me create the kind of therapeutic relationship that a person who self-harms may benefit from.

However people define their self-injury is what matters. This can involve (but not only):

•  cutting (arms, legs)

• burning/scalding (arms/ legs)

• picking and scratching wounds

• overdosing

• inflicting blows

• pulling hair and biting

• swallowing or inserting objects

• jumping from a height

• food related self-harming behaviours.

There are many myths which contribute to an interpretation of self-harm as primarily attention seeking, tyrannical to others and self-destructive. Other myths include the assumption that only young people self-harm, mainly young women, but in fact men and older women also do; they are perhaps a more invisible population. With their family, this older group of people tend to protect their relatives from their behaviour, often intensifying feelings of self-blame and loneliness. A concerning fact is that although many people stop self-harming when they are ready, many continue for decades.

People who self-injure often report feeling misunderstood, making it very difficult for them to seek help, even in the midst of a very hard time. The great majority don't attend emergency services, and if they do many report feeling a negative and dismissive attitude from some of the staff.

In the groups that I have co-facilitated most of the participants have shared that when they tend to seek help from their GP or at A&E, they do not feel listened to, they are not given time to share their distress or helped to understand their experience. At its worst they find the care provided distressing. This is corroborated by an audit of hospital admissions following self-harm published by the Royal College of Psychiatry (2007).

Some of the things that have happened to people who self-harm include: childhood neglect, physical and sexual abuse, losing someone important, being seriously ill or disabled, being bullied or hated, not being loved enough, being put down and criticised. Often a combination of these things. In other words a great majority of these people have suffered some form of unbearable psychological and physical trauma and this makes daily life precarious.

Many people who self-harm have personal experience of the care and mental health systems. Some experience homelessness, or time in prison. They have difficulty finding and staying in a job and are in unstable relationships. Being a parent becomes an almost impossible task. Most often people are extremely isolated. These circumstances become maintaining factors in self-harm. However some people self-harm whilst holding a job and being in a long term relationship. Students who self-harm can go to great lengths hiding their behaviour and continue to study.

So what have I learned about self-harm?

The people I work with describe their actions as a way of coping with, or escaping hugely intense and unsurmountable mental distress. Often the words are difficult to find to describe what is felt, but it has a sense of being a threat to an already fragile mental equilibrium, it happens all of a sudden, with little or no recognisable trigger at the time.

Many share that in that moment they find no other way to release their pain. Self-harming can also be a way of feeling real, more alive, rather than feeling impossibly cut off from parts of themselves and from the world around them. For some, taking control of their body in that way helps alleviate a deep sense of powerlessness they experience in significant areas of their life. Most often it has to do with one or more relationships, in love, family, at home or at work. These feelings of powerlessness seem impossible to challenge in themselves and in relation to others.

Other people consciously or unconsciously punish themselves in their self-injury. For some of the young women I have worked with, self-harming has been a way of communicating their distress to a significant other or indeed to secretly punish them (as expressing aggressive feelings in any other way would be too dangerous or experienced as too damaging to themselves and others).

Caring for any wounds inflicted can be an act of self care, a moment also when the person recognises their pain in a very real way.

Most of the time, self-harm serves more than one function, and the stories attached to this kind of protective behaviour are diverse, complex and very sad.

I have learnt to listen to each person's relationship to their self-injury at a deeper level, to be alongside them through past and present experience, sometimes at a very fast and incomprehensible speed, at other times the silences and pauses are immense. I have learnt to come close but not too close to each person and their often very painful story. I am continuing to learn from the individuals I work with, so as to create a safe and sensitive therapeutic boundary to encourage reflection on the issues behind their self-injury, as little or as much as they need to at a given moment.

This is by no means an exhaustive article on self harm. There is some useful literature on the issue and organisations such as the National Self Harm Network, LifeSigns, and the Bristol Crisis Centre also provide good interactive websites and helpful resources. In Brighton following from NHS partnership, Southdown Housing offers one to one support to people who live with self harm. A new weekly support group may start again in the Autumn 2014.