Self-Harm

A Psychotherapeutic Approach

Fiona Gardner

• Publisher: Routledge
• Year: 2013
• Print ISBN:
  9780415233033
• eBook ISBN:
  9781134570393
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Self-harm is worryingly common in young women, and is often used as a way of easing emotional suffering. Self-Harm: A Psychotherapeutic Approach explores the issues involved from the perspective of a psychoanalytical psychotherapist. Fiona Gardner examines these issues through extensive clinical material and an analysis of the social and cultural influences behind self-harm. This book will be of interest to all those working with those who are harming themselves, including psychotherapists, school counsellors, social workers and mental health clinicians.

Chapter 1

Introduction

One comes to see that it is not so much the nature of the act that counts but its meaning.

(Chasseguet-Smirgel 1990: 77)

This book is about uncovering the different meanings behind self-harm – a term used to describe self-inflicted physical attacks on the body. The central focus in this book is on cutting the surface of the skin, but there is also some reference to attacks such as burning and hitting the body. Implicit in the definition is an understanding that the body is going to be deliberately, and usually habitually, harmed rather than destroyed or killed, and that it is also a harming of the self. So why would people turn on their bodies in this way, repeatedly inflicting such painful damage on themselves?

Feeling unreal and distant disconnected with life,

I pick up my razor blades,

Relieved at the sight of them I cry,

Not totally aware I cut into the skin,

Jolted back into reality by the act,

Checking that I’m still alive that I’m still real,

For a short while I am in control, for a short while I am at peace.

This poem was written by one of the young women with whom I worked. She knew why, as she writes, she had to cut herself – it helped her to know that she was alive, real and in control. I was concerned and affected by such actions, and needed to understand their impact and unconscious meanings. It was from this concern, and the relative lack of analytic literature on the subject, that the idea of this book arose. From the young woman who wrote the poem and others like her, it seemed that attacks on the body were felt to be attempts at coping and even at self-healing. Such an attack on the self was also clearly a gesture, albeit a paradoxical one, in that feelings of relief and of being alive came from inflicting pain on the body. From my psychotherapeutic practice I understood that the attacks were a metaphoric representation for earlier psychic wounds and internalised processes derived from early object relationships. Object relations is a key concept in psychoanalytic psychotherapy. It means that both our real experiences of and our fantasies about parental and other figures (objects) are internalised, and become embedded in the way we cope with life. These inner objects then pattern our psyches and influence other relationships and the way we behave. In that sense self-harm can be seen as a system of signs marking statements about the self, and past relationships and previous experiences.

However, it is not just a private matter. Generally in the social field and in the collective consciousness there is a powerful symbolism attached to drawing blood and marking the body, which can link to healing, salvation, social identity and order. Attacking the body is then a gesture, a representation and an action, involving paradox, metaphor and symbol.

Through psychoanalytic thinking and the practice of psychoanalytic psychotherapy, we can gain access to the unconscious mind and to the underlying function and motivations for our actions. With this perspective the conscious meaning has its counterpart of unconscious meaning – in other words, the deeper meaning which is underneath that which is knowingly meant. An analytic approach reveals the power and extent of the unconscious and our inner individual conflicts and needs, but analytic thinking also helps with an understanding of the family, the way groups function, the wider social field and our cultural heritage. In this book cutting is explored primarily from the perspective of the individual, but is also considered as a behaviour particularly found in adolescents, and with significance as part of a wider social and cultural context. All these aspects are fully explored and discussed.

Generally people feel that psychoanalytic psychotherapy is only for those who can afford it, or who are already articulate or psychologically minded. What I aim to show in this exploration of self-harm is that psychoanalytic thinking can influence the way we reflect about our work and the way we listen to patients, whatever the context, and whatever their or our background. In that way, this book is aimed at the broad sweep of those who are working and involved with people who harm themselves.

A word about the terms being used: ‘self-harming behaviour’, which is also sometimes referred to as self-injury, is different from self-mutilation, in that the term ‘self-mutilation’ tends to be used both in psychiatric and psychoanalytic writings to refer to serious and sometimes lethal body mutilations where the aim is often to actually cut off an offending body part. This is relatively rare in comparison to self-harming. An estimate about the known frequency of self-harm is generally quoted as one in 600 adults who harm themselves sufficiently to require hospital treatment, although this figure is acknowledged as probably an underestimate (Tantam and Whittaker 1992). A recent United States study (Strong 2000) gives a prevalence of one in eight students who had deliberately cut or burnt themselves. People who harm themselves will be found on the caseload of virtually every community-based professional. Interestingly there is a greater incidence in British social services and probation departments than the high-profile work with child neglect and abuse (Pritchard 1995). The extent of the behaviour creates great demand, leads to considerable unhappiness for all those involved, and results in high levels of attendance at accident and emergency departments. It is especially prevalent among adolescent girls and women, and there is a clear gender dimension that has to be considered in uncovering meaning. This is one of the central themes in the book.

This book draws on my experience of working first as a social worker in social services and child and family guidance for fourteen years, and second as a psychoanalytic psychotherapist for over twelve years, working initially for a voluntary organisation, and then in a public sector clinic for young people, as well as in private practice. The clinical work described in this book is taken mainly from my work in the clinic, but also from my private practice. The clinic was established on a tertiary referral basis – in other words, the young people who were seen had already been assessed either by a child and family psychiatry department or an adult mental health team, and then referred on to the clinic team. The rationale for establishing the specialist service was that it was hoped that more intensive work in the community would prevent admission to an adolescent residential unit or adult psychiatric ward. The young people referred were all showing serious signs of emotional disturbance and were often at risk. Many more females were referred – after eighteen months in operation the ratio was one-third young men to two-thirds young women, and the symptoms varied between the sexes. By far the largest group attending was of young women attacking their bodies – usually by a combination of methods which invariably included cutting.

Over a four-year period at the clinic, fifty-one young people were assessed with a view to psychotherapy, and of these I took on thirty-three for individual work. The remainder were offered another form of treatment within the clinic such as family work, cognitive therapy, or some joint therapeutic work between psychiatrist and psychiatric nurse involving close monitoring of the young person’s weight or level of mental disturbance, others were referred on to another service, or dropped out. Out of the thirty-three seen for psychoanalytic psychotherapy, six were young men, only one of whom described suicidal thoughts; the others were referred with a variety of phobic and depressive symptoms. None of the young men were cutting themselves. Out of the twenty-seven young women taken on for individual psychotherapy, fifteen presented with symptoms that included cutting, although two of these hit themselves and another inflicted small burns on her body. Many cut alongside repeated overdosing, and some also had an eating disorder. Out of the remainder of the twenty-seven, six were referred for depression, three for drug use and three solely with an eating disorder. Such rough statistics do not of course constitute a valid scientific survey, so the grouping can in no way be seen as representative, but the preponderance of those who deliberately harmed themselves seemed to be significant and was a concern to myself and my colleagues.

The symptoms were repeated, and frequently included several other self-destructive behaviours alongside the cutting. Often the self-harm followed on from an earlier problem behaviour. There was clearly an addictive quality to the damaging actions, and, as mentioned, for some of the young women there was a well-established link both with overdosing and eating disorders. Out of those whose symptomatology included harming themselves, only one was cutting as the sole way of expressing her distress. Six were cutting and/or hitting themselves and had taken an overdose. One was cutting alongside her depression, and another burning herself and depressed, and four had an eating disorder alongside cutting. The two remaining had previously cut and then taken several overdoses, one also drank heavily and another misused drugs. Some of the young women also told of repeatedly putting themselves in dangerous situations, sometimes sexually and sometimes physically. While risk-taking behaviour is characteristic of the adolescent state of mind it is usually done in groups, and these young women tended to try things alone with minimum protection. Cutting was often one symptom among a chain of disorders, sometimes with one stopping and then being replaced by another.

The focus of this study is an exploration of the conscious and unconscious meanings that lay behind the self-cutting by the young women with whom I worked. Most people who harm themselves begin to do so in adolescence – a time of transition – and the focus of the clinical material used in this book is primarily, though not exclusively, based on psychotherapy with those aged between 15 and 21 years. Some of the clinical accounts involve older women who had begun harming themselves in adolescence. Cutting is in some ways seen as a particular characteristic of young adolescent females, and this aspect is explored here. All those who I saw were white, apart from one who was from the Far East.

A word about the actual injuries. When they cut themselves the young women created a wound using a sharp instrument, usually razors, sometimes knives. The areas they commonly cut were their arms and legs (usually their thighs), but some sometimes cut their stomach or breasts. The cutting made superficial, delicate and sometimes carefully designed incisions. Once the wound had healed, often no visible scar remained, but most of the young women tended to repeat the behaviour over and over again. Some cut more deeply, so unsightly scars were left or lumpy flesh formed around and over the wound. This sort of cutting is clearly different from making a single very deep wound around a jugular vein or radial artery. Burning was with cigarettes or cigarette lighters, and those who hit themselves either banged their heads or their hands, usually against walls – one so fiercely that her knuckles were bruised and damaged.

The frequency seemed periodic and sometimes even random, as the young women attacked themselves when they felt they needed to, and when they were upset and could not manage their feelings. Thus there were sometimes gaps of weeks, and sometimes months between incidents, while others reported cutting several times on a certain day, but were then able to have a space of several weeks before feeling that they needed to hurt themselves again. Generally the young women spoke of a sense of tension present immediately before they harmed themselves, and then different feelings either of numbness and/or gratification alongside the physical pain. There was normally a sense of shame and secrecy so that the scars were hidden under clothing. Mostly there were feelings of defeat, not self-possession or triumph, about what they had done.

As this book is an exploration of the conscious and unconscious meanings of attacking the body, it is not an outcome study. However, out of the fifteen young women with symptoms that included cutting, hitting and burning themselves, eight had stopped those symptoms by the time the psychotherapy ended, while with one it was not really clear. Three were unfortunately left with their long-established eating disorder, although the other forms of self-harm had stopped. Three left the area, so the treatment ended prematurely, and I later learned that one of these then took a serious, though not fatal, overdose.

Professionals in mental health – social workers, counsellors, teachers, families and friends, and by extrapolation the general public – seem to have a similar response to people who harm themselves, as was prevalent towards anorexics more than twenty years ago. This is generally one of shock, fear, anger, disgust and revulsion, which may lead to hostility and anxiety. Families and friends of those who are harming themselves are often deeply upset, and shocked by the behaviour. Sometimes this leads to denial – the idea that it is just a phase, something that will be grown out of – or sometimes parents may be too upset or angry to see beyond their own hurt feelings. Among professionals, such patients are seen as difficult, frustrating, and demanding of enormous amounts of professional attention. Why is the reaction so negative? There are obvious reasons, such as: the behaviour does not seem to make sense; it goes against current notions of health and attractiveness especially among young women; patients do not respond to drug treatment, or quick-fix psychological treatments; they demand time-consuming physical care for mental illness in contrast to those who are straightforwardly physically ill; they often do not know why they did it, or why they repeatedly do it, or seem to care about it, and so on.

What does this behaviour of attacking the body stir up within us? It may be that feelings of judgement and punishment which are evoked by such behaviour can serve as a defence against other upsetting feelings of horror, sadness, fear and responsibility for the person’s well-being. Such feelings can be especially powerful if the professional lacks support or supervision of the work. Turp reminds us that the ‘shocking’ quality is an essential aspect of the behaviour, which communicates the rawness and unprocessed quality of the emotions and impulses (1999: 309).

Such feelings do not necessarily go away with familiarity, but over time they can become blunted and so easier to handle. Immediate feelings of shock are often followed by incomprehension and a search for direct meaning – if the injury can be explained, and a clear, obvious reason found for it, it becomes easier to cope with and understand. There can also be worries and fear about what the person might do next, and upset and distress at the pain the patient is causing to themselves. A common response is anger and frustration, particularly when the person continues to harm themselves during treatment, and such frustration leads to feelings of powerlessness and inadequacy in the therapist. If success is measured by symptoms, this can be problematic in situations where people continue to harm themselves, even though other changes have been made, and there is improvement.

One counsellor wrote:

When I first began to work with people who harmed themselves, I was shocked and frightened. I also felt I should be able to stop them, at least once we had established a therapeutic rapport. Surely they should not need to do this to themselves when support and opportunities to talk about things were on offer?

(Self-Injury Forum Newsletter 1999: 2)

So is self-harm a form of mental illness? The psychiatric literature certainly includes it in a variety of diagnoses and classifications. Self-harm is often linked to a manifestation of borderline personality disorder, or to other ‘multi-impulsive behaviours’. It is judged to be part of a pathology found in patients who have difficulty in controlling their impulses and coping with depressive feelings and anxiety. Histrionic, narcissistic, schizotypal or antisocial personality disorder are all labels that have been used, as has the more recent multi-impulsive personality disorder. Self-harming behaviour is also said to be a possible symptom of schizophrenia, major depression, mania, obsessive-compulsive disorder and hypochondriasis. It is also recognised that cutting can occur in the context of neurosis, and in response to situational crises, such as being imprisoned or isolated.

All these various possibilities lead to a lack of coherence, and an illusion that the behaviour is explained or even understood by the label. A further problem is that by using such diagnoses the patient can become reduced to her symptom. There is a tendency in some settings for clinicians – as one way of coping with the patient’s behaviour, and the unwelcome effect on themselves – to use alternative descriptive labels such as ‘cutter’, ‘slasher’ or ‘scratcher’, often alongside the defensive reasoning that all such behaviour is merely ‘attention seeking’.

Psychoanalytic descriptions and labels such as destructive, narcissistic or perverse have also been used in connection with cutting and can help position the behaviour, but again do not necessarily lead to understanding the meanings behind it for the individual patient. Certainly understanding the behaviour in terms of direct historical life events carries a certain validity and indeed attraction, and the link with trauma is explored in this book. If the behaviour is caused by childhood sexual or physical abuse or neglect, perhaps we can make sense of it. However, not all those who cut themselves have experienced obvious past trauma, and this suggests other dynamics are involved. In recent years psychoanalytic psychotherapy has tended to move from attributions of cause and direct historical explanations to an exploration of how the person is in themselves. In this book I suggest that the origin and meanings of the symptom are to be found in the internalised processes derived from object relations (cf. Bateman and Holmes 1995). Although this will of course be different for each individual, I am suggesting a particular aspect of early inner object relations, resulting from a combination of the instinctual processes and the environmental that in my experience is common in those attacking their bodies.

This suggestion is central to my exploration of the meaning of self-harm, and is fully illustrated in the more detailed clinical material included later in this book. The development of my understanding of the dynamics involved in self-harm emerged from appreciation of a well-established theoretical concept. This is Glasser’s (1992) ‘core complex’. In this he describes a universal complex which he places as central to the structure of the psyche. In summary, it has a number of elements, which are outlined here in detail using Glasser’s sequence and descriptive terms.

1 The first is the fantasy of fusion with the idealised mother who satisfies the person’s (originally the infant’s) basic need and longing for security. Glasser describes this as the fantasy of ultimate narcissistic fulfilment, or the fantasy of primary narcissism.

2 However, the mother is a split figure, for she is also envisaged as relating entirely narcissistically to the subject, and seen as being both (a) avaricious – so that the fusion involves incorporation with a mother who threatens to annihilate the self – this emerges in ideas of engulfment, possession, intrusion and so on; and also (b) indifferent – paying insufficient attention or not unde...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Contents
• Acknowledgements
• 1. Introduction
• 2. Meanings – conscious reasoning and unconscious motivation
• 3. Turning the Anger inwards: Masochism and mastery
• 4. Predisposing factors in adolescence linked to self-harm
• 5. Reversing the process: From action to articulation
• 6. The psychodynamics of the psychotherapeutic process with patients who are harming themselves
• 7. Speculations on historical, cultural and social aspects
• 8. Concluding thoughts
• References
• Index