In this blog post we’re going to talk about people who self-harm. It is becoming an epidemic and we need to understand how to support people who do it. We will look at what self-harm is, identify types of self-harm and the reasons for it, and explore how to work with people who self-harm.
The NHS in the UK says that, ‘Self-harm is when someone intentionally damages or injures their body. It’s usually a way of coping with or expressing overwhelming emotional distress’. According to mentalhealth.org, ‘The UK has the highest self-harm rate of any country in Europe with the estimates of 400 in 100,000 people self-harming. These figures are likely to be higher. Many people who self-harm do not tell anyone about it. Self-harm can affect anyone. However, the majority of people who report self-harm are between the ages of 11 and 25.’ Other research says that self-harm amongst young people is going to become an epidemic.
The reasons why people self-harm can include:
- pressures at school or work: people feel that they’re not good enough or they’re under a great deal of pressure.
- bullying: especially in schools or with young people, but with adults it can be a trigger for self-harming.
- money worries.
- sexual, physical or emotional abuse: it’s not unusual for someone who’s being abused to try and disfigure themselves to make the abuser find them unattractive, for example, cutting, not washing, or over-eating, so that the abuser leaves them alone.
- loss and bereavement: sometimes, the pain of self-harm is preferable to the pain of engaging with loss.
- confusion about sexuality: sometimes people feel isolated or that they’re out of the mainstream.
- breakdown of a relationship.
- loss of a job.
- illness or a health problem.
- low self-esteem.
- an increase in stress.
- feelings such as depression and anxiety.
- anger or numbness.
Self-harm can be a way of masking the emotional pain with a physical one. It’s just easier for someone to feel physical pain rather than engage with the emotional things that are going on with them because it’s too hard.
Types of self-harm in children include:
- taking too many tablets (an overdose). Sometimes when people take an overdose, it can be self-harm that’s gone wrong.
- cutting yourself (using instruments to cut yourself)
- burning yourself.
- banging your head or throwing yourself against something hard.
- punching yourself.
- sticking things into your body: pins, your own nails.
- swallowing things, sometimes known as pica, involves swallowing objects that are not food and are not good for you: broken glass etc.
- hair or eyelash pulling, otherwise known as trichotillomania or trich. People
who do this call it trich.
Adults have the same ways of self-harming, plus:
- some forms of tattoos: such as homemade tattoos (a stick man or which have demeaning things written on them). Some people tattoo onto themselves how they feel about themselves, which can be an ugly image.
- putting yourself in harm’s way: for instance, deliberately getting injured on the sport’s pitch.
- sadomasochistic practices: people who put themselves into relationships in order to get physically harmed.
- substance misuse: alcohol or drugs.
- food misuse: over-eating, bulimia and anorexia nervosa.
The cycle of self-harm may start off with shame or grief. Sometimes the shame and the sadness of self-harming can trigger emotional suffering. When someone’s suffering emotionally, they become overloaded, they panic, and because they don’t want that feeling, they self-harm. The self-harm brings temporary relief, but then the cycle starts again.
According to the Royal College of Psychiatrists, self-harm is more prevalent in groups such as:
- young women
- prisoners
- asylum seekers
- veterans of the armed forces
- LGBTQIA+: in part due to the stress of prejudice and discrimination.
- a group of young people who self-harm together: having a friend who self-harms may increase your chances of doing it as well.
- people who have experienced physical, emotional, or sexual abuse during childhood.
All behaviour is goal-directed and there’s a trigger for all behaviours. If someone’s self-harming, there’s a reason why they’re doing it, even if they won’t or can’t say what that is. Maybe they’re not conscious of it, but there will be a reason for it.
There are some common misconceptions and truths about self-harm.
- It isn’t attention-seeking as many people self-harm in areas of their bodies that cannot be seen, such as the stomach or thighs. Some people take poisons which we can’t see at all, but that doesn’t mean that self-harm is not a cry for help. So, the act itself is rather an external manifestation of what’s going on internally for somebody. Some people talk about how they’re feeling in words, but others, especially younger people, don’t have the vocabulary to be able to do that. So, it’s easier to demonstrate what’s happening to them through self-harm.
- It isn’t true that people who self-harm are trying to kill themselves, but rather that acts of poisoning and cutting can have unintended consequences which lead to death. For instance, using dirty razor blades, knives, or any sharp instruments can cause blood poisoning and death, or pass on diseases, such as HIV, hepatitis, and other blood-borne illnesses. The NHS says that more than half the people who die by suicide have a history of self-harm. So, self-harm is crossing the line as attacking your own body. We’re programmed as humans to protect our body. If you try to hold your breath for a few minutes to see what happens, your brain will eventually switch off the executive control of holding your breath and you will breathe again. So, when people cross the line, the risk becomes higher. For those who self-harm and then go on to commit suicide either what made them self-harm hasn’t been resolved or it hasn’t been worked on with some kind of therapeutic intervention.
- Self-harm can be addictive as it triggers endorphins, the body’s natural painkiller. These endorphins can become addictive, so those who self-harm can suffer withdrawal from it.
Carl Rogers wrote 19 statements (the 19 Propositions) of how humans experience the world. They’re based on phenomenology, the philosophy of perception (how we view the world and our unique view of the world). In proposition eight, Rogers says, ‘Behaviour is basically the goal-directed attempts of individuals to satisfy their needs as experienced in their phenomenal field as perceived’. Basically, this is saying that all behavior is goal-directed. If someone is behaving in a certain way, there’s a reason for it. This theory really fits self-harm because someone behaves and does the self-harm to meet their needs and also because it’s about how they’re experiencing their life and the reality of their life.
Proposition 17 sums up what we do and how we do it. Rogers says, ‘Under certain conditions involving primarily complete absence of threat to self-structure, experiences which are inconsistent with it may be perceived and examined, and the structure of self revised to assimilate and include such experiences’. Or in other words, ‘If I feel safe and treated in a non-judgmental way, I will be able to explore what is going on for me and make the changes in my life’. The ‘absence of threat’ is key, because if somebody feels unjudged and can talk about what’s going on for them, then there’s hope that they can examine and look at their behaviour and think of different ways of behaving or even find out why they’re behaving in such a way. For that to happen, we need to be non-judgmental, unalarmed by physical signs of self-harm and to engage with the person, accepting them as they are.
Some types of self-harm carry more risk than others. A person who is taking pills, poisons and cutting is exposed to more danger than if they were pulling their eyelashes out. So, confidentiality becomes an issue, and therapists need to move away from the modality they practise and move towards clinical thinking and question whether there is a risk to that person. Consequently, they may need to break confidentiality. Therapists and organisations need to have a contract in place with clients, a ‘harm to self and harm to others’ policy, so it is clear what measures they will take should those people show them or tell them about self-harm marks. They want help, so therapists should follow through on that.
There are different ways to intervene initially with people who self-harm. They are usually seen by specialists who try to assess their emotional and mental state and try to support them. They are used to people judging them, so respect for them is key. They will also feel bad about themselves, as self-hatred is part of self-harm in some cases. So, they need to receive an unconditional positive regard, and not to be seen as a label, ‘This is the person who self-harms’, but rather as ,’This is an individual human being.’
Distraction techniques are useful:
- punching a cushion: this is good for anger management, for self-harm and minimising risk. We can say to someone, ‘I know you’re going to hit something, but if you have to do it, do it safely’. Also, if you punch something, it absorbs energy, so punching cushions is good.
- going for a walk: just moving out of your environment into another one is enough of a change.
- doing exercise: when we exercise, our brains work more efficiently and we feel better. Going for a walk, going to the gym or going for a run may get rid of pent-up energy.
- talking to someone: people who feel that they don’t want to burden anybody else, build up their painful feelings and then explode, sometimes leading to self-harm. So, it’s better to talk to someone and release that energy.
- listening to music: it can be very useful and it blocks the world out. Someone who’s living in a very difficult household can put on their headphones and turn on their favourite tunes to take them to a different place.
- writing about how you feel: Some people are very good at writing about how they feel (in a personal journal, a poem or a story).
- drawing: it engages the mind, as does colouring in.
- a long bath: relaxing in and enjoying the sensation of the water around you.
It helps to encourage the person to keep a diary of self-harm, when it happens and what the trigger is. The aim is to find out why people self-harm. If they can find the trigger, then they can start to engage in the process of unravelling what’s going on for them. They can also use the information to help them see when they’re most at risk. Sometimes people are blocked by the cycle of self-harm when they are harming themselves. They get emotional, they feel overload, they self-harm, they feel bad about it, they get some relief and then they feel bad about it. Identifying the trigger can help them to stop getting to that point.
There are some techniques which we can substitute for self-harm. The idea is that people will eventually stop, as they have an alternative in a supportive way:
- instead of cutting, a person can paint or draw a cut, for instance, using an eyebrow pencil, or with a felt-tip pen. Some people get relief from the pain of the cutting, while others get relief from seeing the blood. So, it can be helpful to explore this with the person and say, ‘Where does the big relief come from?’ If they answer that it’s the blood, that is a riskier situation because there’s a chance that they could get hurt, so we can suggest using a pen or a pencil so they can see the self-harm and acknowledge it, but without really hurting themselves.
- squeezing ice is painful if you hold it for long enough, but it doesn’t do the same amount of damage as cutting yourself.
- substituting blood with a red soft drink: for those people who like to see blood, they can put a red soft drink in a bowl with ice cubes. When they pick up the ice cubes they are red and they also feel pain, but there is no damage done.
- flicking an elastic band on your wrist: we can help people to practise this, as we help them initially to get the same emotional hit, without the chance that they may harm themselves.
- rubbing a toothbrush on your skin: for instance, rubbing your arm quite vigorously hurts a lot, but you’re not doing the same amount of damage as cutting.
- the five-minute technique: trying to encourage the person to wait for five minutes before they self-harm, saying, ‘Look. Use your watch or use your phone. Just try waiting for five minutes’. After that time, sometimes the urge just disappears as it gives a piece of space for the person so they’re able to take a breath before they self-harm. If that works, they can do another five minutes and then another five minutes.
Looking back at the cycle of self-harm, we can’t intervene in the moment people do it because we’re not there when it happens. We can’t help much with the temporary relief or with the panic, because if someone is in full panic mode, they’re going to be more difficult to regulate. However, we can intervene in some parts of the cycle.
- First, we can work with the shame of their self-harm. We can ask how the person feels about self-harming, while remembering to show them an unconditional positive regard, no judgment, in an absence of threat, so they can look at themselves, see what’s going on and make changes. We can ask them, ‘How much of your life, if you think of it as a clock or 100%, does self-harm take up?’ By using that idea, they can see how it reduces. The self-harm isn’t normalised, but we’re engaging with them about their experience. We’re validating who they are and maybe why they do it or how they feel about what they do.
- Second, we help therapeutically when they are in the emotional suffering stage. If we can find what the trigger is, almost certainly that’s where the healing process really begins, because that’s something that’s happening in their life that’s causing them great emotional pain where they have to self-harm. We’re helping them to let that energy out at their own pace, helping them explore it, and helping them to feel valid people in the world. This is going to have a big impact on how they feel on a day to day basis.
- Third, in the emotional overload stage, we can introduce safe strategy interventions, saying, ‘If you feel like you’re going to self-harm, then you can help yourself with this intervention’. We’re meeting the person where they are and helping them to break the cycle. If we can help them to break the cycle, then the self-harm will either slow down or be less intense, and eventually stop. However, if the person is dangerously self-harming, we should start here first.
Self-harm is becoming an epidemic. The more people there are who self-harm, the more people there are who are likely to go on to take their lives. So, we all need to help them and see if we can make a difference.
Source:
‘’Preparing to work with clients who self harm’ ’(Lees-Oakes 2018). Lees-Oakes R 2018, ‘’Preparing to work with clients who self harm’’, delivered 16th September 2018