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...
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