Hidden Self-Harm

Narratives from Psychotherapy

Maggie Turp

• Publisher: Jessica Kingsley Publishers
• Year: 2002
• Print ISBN: 9781853029011
• eBook ISBN: 9781846423642
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

This practical and accessible book of case studies takes a new look at self-harm, focusing particularly on the under-explored area of `hidden' self-harming behaviour. These behaviours may not be immediately identifiable as self-harm by counsellors, therapists or their clients, but Maggie Turp shows how recognition and understanding of hidden self-harm can improve practice with those affected.

The author begins by discussing extracts from infant observation studies that reflect on the role of maternal care in encouraging the tendency towards self-care. A series of detailed case studies follows, including a client who has a serious eating disorder, a client who abuses recreational drugs, works excessively to the detriment of his mental and physical health and sustains a series of unconsciously invited 'accidents', and one caught up in 'self-harm by omission', who fails to 'take care' and delays seeking vital medical care. The clinical accounts highlight the importance of attending to the client as a whole person and of building on the self-caring tendency that has prompted him or her to seek help in the form of counselling or psychotherapy.

Written from a psychoanalytic perspective, but using straightforward language, Hidden Self-Harm is a valuable resource for social workers, psychologists, teachers, nurses and lay helpers as well as for counsellors and psychotherapists.

1

Introduction

For many people, the term ‘self-harm’ conjures up an image of violent self-cutting, self-scalding or overdosing. These ‘high visibility’ manifestations of self-harm are those most often highlighted in the literature, both popular and professional. In this book, I suggest that this characterisation of self-harm is too narrow in its scope. It seems to me that self-harming tendencies find expression in many different ways, ranging from the highly dramatic to the virtually invisible. A wide variety of self-injurious or health-impairing behaviours can perhaps be best understood if we think in terms of broadly similar underlying states of mind. In the chapters that follow, the reader is invited to consider this proposition through his or her imaginative interaction with a series of detailed case study examples.

I wish to suggest also that we all know something of the states of mind in question, through our personal acquaintance with entirely normal behaviours which I refer to as ‘cashas’ – an acronym for culturally acceptable self-harming acts or activities. Some ‘cashas’ have a specific role and meaning, serving as a rite of passage or signifying identification with a particular tribe. Such rituals are not limited to geographically remote parts of the world; scarifying, tattooing and body piercing, for example, are highly valued signatures of group belonging in some British and American youth sub-cultures. ‘Cashas’ can also be associated with religious practices, as for example with self-flagellation or pilgrimages that involve covering long distances over stony ground, barefoot or on bended knee. Favazza’s work (1989a, 1989b) offers extensive and fascinating accounts of such phenomena.

The ‘cashas’ that are of most interest in relation to the question of the relationship between normal, flawed self-care and actual self-harm fall into a third category. They consist of everyday, low-key actions and behaviours, which are nevertheless associated with injury or ill-health. Smoking offers an obvious example. Its physically harmful consequences are well documented but (except possibly in California) smoking is not generally seen as an example of self-harm. In a similar vein, chronic overwork is a major source of ‘stress’ and is known to be a factor in many mental and physical health problems. The Japanese, perhaps taking matters to their logical conclusion, have coined a new term, ‘karoshi’:

Talk about a bad day at work. Nobuo Miuro was simply getting on with his job, when he keeled over and died. It had been a busy few weeks for the interiors fitter from Tokyo; he was struggling to get a new restaurant ready for its launch and had been putting in a fair bit of overtime. The day before he collapsed he had worked from 11am until 4.30am the next morning, but had managed to snatch a few hours’ sleep before starting again. But when Miuro, 47, tried to pick up his hammer and nails again, he suddenly took ill. He died a week later. Last week a coroner returned a verdict of ‘karoshi’: death by overwork. (Addley and Barton in The Guardian, 13 March 2001)

Large numbers of civil lawsuits have apparently now been filed in Japan by relatives of those believed or found by the coroner to have died from karoshi. Nevertheless, in the United Kingdom as well as in Japan, over-working remains culturally acceptable. One might even say that it is widely encouraged.

The ‘continuum model’ of self-harm and self-care, set out and discussed in Chapter 2, brings into view an area of experience that lies between, and so connects, the ‘abnormal’ phenomenon of self-harm and the ‘normal’ phenomenon of the ‘casha’. My suggestion is that internal dramas that fuel behaviour conventionally recognised as self-harm are broadly similar to those that underpin ‘cashas’. There is a difference but it is a difference of intensity rather than one of kind. In other words, the difference resides in the level of desperation and emotional distress involved.

It was with these thoughts in mind that I responded to a recent call by NICE (National Institute for Clinical Excellence) for suggestions and evidence relevant to the question of services for individuals who self-harm. I argued in favour of the establishment of an early intervention unit, to provide a clinical service for people who were beginning to be concerned about the intensity of their self-destructive thinking or behaviour and to serve as an educational resource for the practitioners in many different professions whose work brings them into contact with self-harming behaviour. As things stand, the term ‘self-harm’ is widely associated with florid and dramatic behaviour and carries a certain stigma. Individuals are unlikely to seek help at an early stage, while it is still possible for them to keep their self-harm hidden. Disclosure eventually becomes inevitable but by this time self-harm has become an entrenched coping strategy, and therapeutic intervention, while by no means impossible, is that much more difficult. An early intervention unit could begin to address some of these issues.

As a psychotherapist based in the community, I work from time to time with clients who harm themselves, by which I mean that their behaviour on the one hand leads to injury or ill-health, and on the other goes beyond the limits of cultural acceptability. Much of the behaviour I encounter lies close to the border area between ‘cashas’ and self-harm proper. In contrast to the florid and dramatic examples more frequently referred to, it has a low-key or ‘hidden’ quality. This kind of low-key self-harm is seldom described. In the literature, as in life, it is not in the limelight. It seems to me that the focus on high visibility self-harm results in the loss of a valuable opportunity, the opportunity to enter into the client’s frame of reference. While we may be unwilling or unable to enter imaginatively into the world of a client who is engaged in violent and repetitive self-cutting or self-scalding, the task is less daunting when the self-harm in question is low-key and hence closer to behaviour that we already recognise and acknowledge as part of our own repertoire.

In some cases, the self-harm described in the book falls within conventionally recognised parameters, involving episodes of self-cutting or self-hitting and in one case a very serious eating disorder. In other cases, the self-harm in question is hidden and falls outside conventionally recognised parameters. Partly for this reason, it passes unnoticed, or is noticed but not seen for what it is. Some individuals are themselves blind to the self-injurious or health-damaging nature of their actions. Others recognise that they are harming themselves but keep this knowledge to themselves, fearing, not unreasonably, that disclosure may meet with an unsympathetic response.

Over ten years of practice as a social worker and a further fifteen years as a psychotherapist, I have learned to appreciate the multifaceted and subtly shaded nature of self-harming behaviour. I know that ‘high visibility’ self-harm – whether witnessed or recounted – is the cause of a great deal of shock and dismay. Maintaining a compassionate and ethical stance in the face of disturbing and distressing behaviour is not easy and the particular issues raised merit ongoing discussion. At the same time, we will wish to ensure that our thinking about self-harm is based on the consideration of a representative range of examples. It is a matter of concern therefore that there is so little reference in the literature to hidden self-harm, although it is a part of the day-to-day experience of many counsellors, psychotherapists, social workers, youth workers, nurses and practitioners in other professions.

Sarah’s story

The following vignette offers a first example of the kind of scenario I have in mind. I have called the client in question ‘Sarah’.

About three months into our work together, Sarah tells me about a period of her life, shortly after she finished university, when she became very depressed and retreated from the world. She did not seek work and became more and more isolated as, one by one, her friends left the university town. She made no contact with her family, who lived over a hundred miles away.

In therapy, Sarah describes various symptoms she experienced at that time – a buzzing in her head, a feeling of being cut off and unreal and an all-encompassing ‘mental blankness’. She tells me that she also developed very bad eczema. We talk about this and share an understanding that this symptom represented some kind of eruption into the outside world of a disturbed inner state. There is a tense silence as Sarah struggles to tell me the next part of her story. Then she describes how she neglected her eczema to the point where she developed secondary infections and her body was covered in sores. It became difficult to move around. Dressing and undressing were acutely painful, as her clothes repeatedly adhered to her weeping skin.

I feel dismayed when Sarah tells me that she remained in this state for more than six months. Finally, at Christmas, she went home to her family. Her mother became aware of the state of her skin and ‘marched her off’ to the local doctor. The doctor was profoundly shocked and shouted at Sarah in the surgery. Subsequently, he apologised, adding that it was the worst case of eczema and skin infection he had ever seen.

I ask Sarah what help she was offered and she tells me that the doctor prescribed antibiotics and steroid creams. There was no suggestion of counselling or any other kind of psychological help.

I undertook some preliminary research for the book, which will be described in more detail in Chapter 2. As part of this research, the vignette of ‘Sarah’ was presented to a gathering of seventy practitioners at a conference at the University of Hertfordshire (2001). All but three of them expressed the view that what was described was a clear case of self-harm.

Theory and practice

All kinds of practitioners – nurses, social workers, doctors, teachers and youth workers as well as counsellors and psychotherapists – are familiar with this kind of low-visibility self-harm. I would go as far as to say that for many practitioners working in the community, ‘high visibility’ examples of self-harm are only the tip of the iceberg. Perhaps (as with an iceberg) 10 per cent of the phenomenon of self-harm is clearly visible, another 20 per cent is ‘low visibility’ – submerged but vaguely discernible – and the remaining 70 per cent is entirely hidden from view. Sometimes a change of circumstances leads to a degree of thawing as when, in the context of a good therapeutic relationship, the client begins to let go of frozen defences. Then that which was entirely hidden may move closer to the surface, where its contours can begin to be traced and explored.

Once we bring hidden self-harm into the equation, we find that, in many cases, widely familiar theories are of limited relevance. For example, the theory of secondary gain, which suggests that self-harm is primarily a bid for love and attention (Feldman 1988), seems irrelevant in a case like Sarah’s, where the difficulty has remained undisclosed for such a very long time. The gradual nature of Sarah’s self-harm conflicts with the idea that self-harm indicates a ‘disorder of impulse control’ (Pattison and Kahan 1983) or a ‘multi-impulsive personality disorder’ (Lacey and Evans 1986). Having worked with Sarah for two years, I can state with confidence that she was not suffering from a ‘borderline personality disorder’ (Walsh and Rosen 1988). Welldon (1988) has drawn attention to the element of perverse pleasure often associated with self-harm. In Sarah’s case, however, there was little evidence of this autoerotic element. Sarah’s self-harm was not linked to childhood sexual abuse (Wise 1989) or to adult experiences of rape or trauma (Greenspan and Samuel 1989).

In introducing their work on children’s literature, Michael and Margaret Rustin write: ‘Our method is to provide a number of detailed readings of stories, not an encyclopaedic review or general history’ (Rustin and Rustin 2001, p.1).

My own method is similar, although the ‘stories’ in question are real-life rather than fictional accounts. My aim is to describe and reflect on individual encounters and individual narratives. While I will endeavour to identify such themes as suggest themselves, it is not my intention to put forward a new ‘meta-narrative’ or to attempt to decide between the various competing theories already in existence. The theories referred to above – and the list I have given is far from complete – may be relevant in certain cases of self-harm but it is clear that none of them applies across the board. At best, they provide a backdrop, a context for our one-to-one encounters with individual clients. At worst, they create the illusion that every case will fit into one of the existing scenarios.

With these thoughts in mind I have chosen to devote a considerable amount of space to sequences of dialogue, as they come into being between client and psychotherapist at particular moments in time. Given the vagaries of memory and the inevitability of narrative smoothing, I do not claim to be presenting the ‘real thing’ in an unadulterated form. I have, however, endeavoured to ensure that theory is brought into play in a sensitive and respectful way.

Psychoanalytic understandings

I have long thought that a holistic perspective on the human subject is in the true spirit of psychoanalytic thinking. As practitioners, we rely on our experience of being with the whole person – feeling, thinking, always embodied, always in relationship – to help us in the search for meaning that is the essence of the psychoanalytic endeavour. Together with the client, we seek out ways of making sense of initially incomprehensible eruptions of thought, feeling and action. We rely on our awareness of our own physical responses, as well as on intellectual effort, as we tune in to unconscious aspects of client communications. Past experiences find active expression in the therapeutic relationship, shaping the client’s experience of the present and colouring his or her expectations of the future.

The therapeutic encounters described in the book take place in the context of weekly or twice-weekly psychoanalytic psychotherapy or psychodynamic counselling. A search for the meaning behind the distress, rather than an exclusive concern with the symptom, is a hallmark of all psychoanalytic practice. More specifically, the body of theory called into play in this book derives from a contemporary ‘object relations’ approach. Bollas writes about relations between ‘internal objects’ in terms of what it means to be oneself, to be a ‘character’:

To be a character is to gain a history of internal objects, inner presences that are the trace of our encounters, but not intelligible, or even clearly knowable: just intense ghosts who do not populate the machine but inhabit the human mind. (Bollas 1993, p.59)

Gardner offers a description of an object relations approach, which she then links to the subject of self-harm:

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 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. (Gardner 2001, p.4)

My aim is to render object relations theory accessible to as wide range of readers as possible, given that counselling and psychotherapy are by no means the only useful resources for people who harm themselves. Lay helpers and many different professional practitioners also have an interest in reflecting on the sense of self-harm. Object relations theory offers a valuable way of thinking about what is going on. It sets out a general understanding of the dynamics in play in the internal world of the human subject, while at the same time respecting the uniqueness of each individual and his or her experience.

One of the many strengths of a psychoanalytic perspective is its continuing insistence on the mixed nat...

Table of contents

• Cover Page
• Of Related Interest
• Title Page
• Copyright
• Contents
• Acknowledgements
• Dedication
• 1. Introduction
• 2. What Do We Mean by ‘Self-Harm’?
• 3. The Capacity for Self-Care: Observations of Esther
• 4. Bodily Integrity and Psychic Skin: Observations of Esther
• 5. Themes and Theoretical Frameworks
• 6. Trauma and Dramatic Repetition: Working with Lorraine
• 7. The Skin in Question: Working with Ellen May
• 8. Acting, Feeling and Thinking: Working with Tracey
• 9. A Body in Pieces: Working with Peter
• 10. Self-Harm by Omission: Working with Kate
• 11. Reflections on Case Study Themes
• 12. The Self-Harming Individual and ‘The System’
• Bibliography
• Subject Index
• Author Index