Managing Self-Harm

Psychological Perspectives

Anna Motz

• Publisher: Routledge
• Year: 2009
• eBook ISBN: 9781135450045
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

Self-harm often arises at moments of despair or emotional intensity, and its reasons are not necessarily available to the conscious mind. Managing Self-Harm explores the meaning and impact of self-harm, and the sense in which it is a language of the body. It is designed to help clinicians, people who self-harm and their families and carers to understand its causes, meaning and treatment.

Each chapter integrates theory with clinical illustration, enabling the direct experiences of those who self-harm to be heard and reflecting the populations that are most likely to self-harm. The contributors are drawn from a wide range of backgrounds, including clinical psychology, psychotherapy, group analysis and psychiatric nursing.

Areas of discussion include:

• self-harm and young people in foster care and residential settings
• self-harm in women's secure services
• self-harm in people diagnosed with personality disorder

This book does not offer a prescription for self-harm cessation but rather describes therapeutic approaches to working with self-harm, and outlines the complex, subtle and meaningful interactions between those who engage in self-harm and those who seek to understand it. With a specialist interest in women's self-harm, Managing Self-Harm will be essential reading for all mental health professionals, including clinical psychologists, psychotherapists, psychiatrists, psychiatric nurses and social workers.

Part 1
Understanding self-harm

Chapter 1
Self-harm as a sign of hope

Anna Motz

INTRODUCTION

In contrast to the view that it is a pathological expression of underlying distress, without meaning, reason or hope, I argue that self-harm is a powerful, silent language. It communicates states of mind to others, inscribing a narrative on the body itself. Self-harm embodies unbearable feelings and memories of trauma; it expresses the hope of being understood and cared for.

In this chapter, I present my model for understanding self-harm as an expression of hope in an environment that can respond to this communication and bear its meaning, acting as a call to a longed-for other to see, hear and respond to distress. This model of self-harm does not ignore the fact that it is a serious and potentially life-threatening activity.¹ In this chapter I focus on self-harm as distinct from suicidal behaviour, because, with the former, the intention is not death, but self-preservation. Despite its horror, violence and the genuine despair it expresses, there are other aspects of self-harm that contain within them the hope of meaningful relationships with others, and with oneself. The most commonly seen forms of self-harm are cutting, burning and head-banging while other types of self-injury may be less visible—for example, picking at wounds or tearing or biting at the skin.

Members of the public and psychotherapists alike view self-harm as an attempt to connect with others, commonly considered ‘a cry

1 It is on a continuum with suicidal behaviour and has the potential to lead to death, whether accidental or deliberate. There is an association between self-harm and suicide such that episodes of self-harm increase the risk of completed suicide in the following year.

for help’, rather than a suicidal expression of isolation, desperation and anger. Throughout this chapter I will present arguments for the understanding of self-harm as a choice to preserve life. I suggest that its central purpose is to escape unbearable pain and establish a private, internal relationship with the self that can nonetheless relate to another person in a profound way. It is both retreat and approach, and is essentially paradoxical, using injury to create healing and withdrawal into the self as an attempt to make contact with others. Despite its conflicts, it is ultimately meaningful.²

I consider self-harm to be consciously chosen and, in this sense, deliberate, although there may also be unconscious motivations and meanings of which the individual is unaware. It is behaviour that is without conscious suicidal intent but which harms parts of the individual’s own body, with the potential to destroy or damage body tissue; common acts of self-harm include cutting, burning, head-banging and inserting objects into the body. I accept Favazza’s (1996: xviii) definition of self-injury as ‘the deliberate destruction or alteration of one’s body tissue without conscious suicidal intent’. Some authors within this volume argue that self-harm is not deliberately chosen, but rather a forced choice, an involuntary evacuation of a violent state of mind (Scanlon and Adlam, this volume) but I disagree. In my view, the conscious as well as unconscious meaning self-harm has for the individual is central. To deny this is to disregard its communicative function and its role as an expression of hope, not simply despair.

In this chapter, I focus on self-harm as intentional, sometimes an expression of murderousness, at other times an attempt to create order and meaning in the face of confusion and turmoil, and to demarcate an important boundary between self and other, between internal and external and to give shape, colour and texture to overwhelming feelings. Blood is an important symbol in self-harm and connotes purification, liquid containment, warmth, fluidity, sensation and the exposure of what lies within, hidden under the skin, to the outside world. Not all forms of self-harm involve blood-letting, but all have their own private and public symbolism

2 Favazza distinguishes between culturally sanctioned acts of self-mutilation, and those that constitute self-harm, making the important statement that ‘self-mutilation is distinct from suicide. Major reviews have upheld this distinction…. A basic understanding is that a person who truly attempts suicide seeks to end all feelings whereas a person who self-mutilates seeks to feel better’ (Favazza, 1996:262).

that needs to be understood and responded to. The objects used in the injury, the parts of the body that are hurt and the ways in which the wounds are tended to, and by whom, have unconscious meaning as well as overt meaning, accessible to the self-harmer. Fantasies of self-harm, whether acted on or not, also play a significant role and can offer solace, imagined revenge, and release.

BORDER CONTROL: SELF-HARM AND THE CREATION OF BOUNDARIES

Self-cutting is the most common form of self-harm, and appears to serve a variety of functions, including that of creating an immediate sense of order, sensation and release in what was a state of pure distress and anxiety. The slicing of the skin can be precisely and delicately performed as an attempt to delineate and demarcate boundaries on the surface of the skin. This also symbolises the creation of an internal boundary between difficult psychic states and the creation of a sense of order. Caroline Kettlewell’s memoir describes the fascination with seeing how the inside comes out, how the self is constituted internally and the release that this provides, both psychically and physically, as she first uses a razor to cut herself:

In the razor’s wake, the skin melted away, parted to show briefly the milky white subcutaneous layers before a thin beaded line of rich crimson blood seeped through the inch-long divide. Then the blood welled up and began to distort the pure, stark edges of my delicately wrought wound.

The chaos in my head spun itself into a silk of silence. I had distilled myself to the immediacy of hand, blade, blood, flesh.

(Kettlewell, 2000:27)

It is clear from the above account, frequently echoed by self-harmers, that it serves a powerful function, which enables a kind of purity, focus and order to return to a restless mind. The body survives the assault.

SELF-HARM AS A SIGN OF HOPE

Donald Winnicott’s (1956:314) description of the hope in the antisocial act applies equally to self-harm: ‘In the hopeful moment …the environment must be tested and re-tested in its capacity to stand the aggression, to prevent or repair the destruction, to tolerate the nuisance, to recognize the positive element in the antisocial tendency’. In self-harm, the holding environment is the body itself. Self-harm offers the possibility of testing the body to see whether it is an object that can be relied on to withstand and survive assault. It also acts as a test of the mind and its strengths, to defeat the fear of pain and its consequences. I consider the main function of self-harm to be self-preservative rather than death-driven action although, of course, the possibility of death is often present.³

As well as being an attack on an individual’s own body, self-harm can also attack the minds of others (Campbell and Hale, 1991) who may desperately attempt to stop or prevent it, fearing that suicide or other destruction is the ultimate outcome. Managing self-harm requires the capacity to live with it, as carer, friend or therapist, in order to enable the self-harmer to find other ways to communicate unbearable states of mind.

My central hypothesis is that self-harm is a communication to oneself and others that serves several functions for the individual by offering them a variety of ways of relating to themselves and enacting certain essential roles. In this sense, self-harm reflects a split and divided self, and its enactment offers a sequential series of rewards and compensations. There are a series of splits, both psychic and physical, underlying self-harm; these splits require integration before a self-harmer can give up what has been an effective strategy for survival.

SELF-HARM AS DIALECTIC

The notion of the divided self is central to my conception of self-harm. It relies on a primitive defence mechanism—splitting—as

3 Glasser’s (1979) notion of the difference between sado-masochistic and self-preservative violence is relevant here. In sado-masochistic aggression, of the kind found in core complex phenomena, the object is kept alive to be tortured. In self-preservative aggression, the object is considered a threat to survival and must be annihilated. Self-harm can express both types of aggression; at times the intention is to eliminate the badness, through a kind of self-murder, to be allowed to live. At other times it has a more perverse, sado-masochistic quality in that the body becomes the object tortured by the part of the self that identifies with an aggressor. The body in pain is the victim, which is, in turn, tended to.

described by Klein (1946) in her account of how a preverbal infant develops a means of protecting good internal objects from the perceived threat of bad ones. The mother is not viewed as a unitary creature capable of both feeding and depriving the baby, but as either Good Breast or Bad Breast.⁴ In crisis, facing psychic threat, an adult individual reverts to using this defence mechanism and divides the world into good and bad. In self-harm, this type of dichotomy is expressed when the toxic contents of the mind are violently discharged onto the body. One part of the self can become calm, purified and released, while another is violated and intruded upon. The movement does not end here though: the body that has been injured, and thus the victim of a savage attack, is then tended to and cared for. The attacking self then becomes the caring, nursing self.⁵ The movement from thesis to antithesis and finally to synthesis can be identified in self-harm in that the ultimate aim for the self-harmer is to develop an integrated sense of herself, and to recognise that she is the containing receptacle in which both good and bad impulses inhere. She is both savage aggressor and wounded victim. She is also finally the nurse who can facilitate recovery and act as witness to the violence and its aftermath. The individual moments of contradictory impulses seem altogether disconnected, which I suggest is the function of dissociative mechanisms, preventing the sense of a continuous, remembering self that performs the various actions. Instead, the person who self-harms experiences themselves as wholly aggressor, or pure victim. These discordant states of mind appear to have no sense of continuity.

It follows from this model that one of the aims of the therapy is for the therapist to act as container of both toxic and good feelings, to enable the self-harmer to integrate both sets of feelings into themselves without needing to take violent action to discharge

4 In Klein’s (1946) view, the infant evolves from merging with the mother to becoming a separate and integrated self by moving through two positions: first, the paranoid-schizoid position, characterised by splitting (i.e. the satisfying part of the mother and the frustrating part are seen as two distinct entities, the ‘good mother’ or ‘good breast’ versus the ‘bad mother’ or ‘bad breast’); and second, the depressive position, which entails an integrative experience of both the mother and the infant himself/herself as a whole person, both good and bad at the same time.

5 This fits the notion of a dialectic movement as first described by Hegel (1979) in Phenomenology of Spirit and later adopted by Marx in an understanding of political and economic developments in history.

angry, anxious or shameful states of mind. This mirrors the development of the depressive position in Kleinian terms, in that there is the gradual evolution of a capacity to tolerate ambivalence rather than to function in a state of rigid splitting in which the external world is terrifying—what she calls the paranoid-schizoid position. The self-harmer acts as Other to herself, and what is urgently required is for a re-integration to end this self-alienation; otherwise it becomes increasingly frightening, creating a sense of profound isolation and loss of contact with reality.⁶

When someone penetrates their skin, defaces it, marks it or bruises it, there is a violent intrusion from the external world onto the point of contact with the internal world and the harmed person is left damaged, disfigured and filled with impinging sensations. To do this to one’s own body is essentially to become Other to oneself, to enact a split and an attack that could come from an alien outsider. Penetrating the skin thus reflects a divided self and can be a violent replication of the earliest relationship between self and Other. After the penetration and intrusion, the person who has been perpetrator to themselves can now become nurse, tending to the injured body. Nursing the self-inflicted wounds can also be seen as a re-enactment of the early infantile experience of being tended to and cared for by another, usually, though not always, by the mother. This is the other side of the divided self, the caring, nurturing and attentive aspect. It can also be a vital communication to oneself as well as to others; it is a request for a healthy, nurturing part of the self to attend to the injured aspect with care, respect and understanding. Nursing the wounds often plays an important part in the ritual of self-harm.

We can therefore see that there are a series of roles, taken on and played out sequentially, all of which serve important psychic functions for the self-harmer. At the moment of self-h...

Table of contents

• Contents
• Contributors
• Acknowledgements
• Introduction
• Part 1 Understanding self-harm
• Part 2 The wider context
• Part 3 Women and self-harm
• Further reading
• Index