“What are the challenges that face a psychotherapist working with self-harm or eating disorders?”
Self-harm can be said to be the act of self-inflicting physical attacks on the body (Gardner, 2001). In self-harming, the client aims to deliberately, and usually habitually harm their body but not to destroy or kill it. Levitt et al (2004) also says that the act of self-harming is an attempt to draw attention to one’s plight or to scream for help rather than an attempt to achieve death. Self-mutilation and self-starvation are said to be pleas for recognition (Hewitt, 1997 cited in Levitt et al,). Gardner reiterates that self-harming is a metaphoric representation of earlier psychic wounds and also internalised processes obtained from early object relationships (Gardner, 2001). She sees both our real experiences of and our fantasies about parental and other figures/objects as internalised and being embedded in the way we cope with life. I agree with the theorist as it is a fact that the inner objects shape our psyche and influence other relationships and also how we behave. Engaging in self-harm can therefore be perceived as a way of making statements about ourselves, our past relationships and also our previous experiences.
Clients can engage in self-harming behaviours in so many different ways, such as: smoking, drinking or abusing any substances, comfort eating, existing in abusive relationships, denying needs in areas of their lives, doing excessive exercises or hard manual labour. Most of these activities are done unconsciously by people (Chrysalis notes, module 5). The body can also be harmed in a number of ways such as, through eating disorders, frequent and often unnecessary cosmetic surgeries and excessive dieting and many other such ways (Miller, 2005). The most common type of self-harm is cutting of the skin. People who are likely to engage in self-harming are; those who already are into drug and alcohol abuse, have signs and symptoms of depression, those with eating disorders, those who felt unloved as children, those with difficulty to express their feelings and in most cases, those with a history of childhood abuse. (Alderman 1997).
The deliberate self-harm without the intent to die, is generally characterised by unbearable emotional pain coupled with periodic strong and persistent urges to physically hurt oneself. Thus, it is important in any therapeutic approach to acknowledge that self-harm is a way of coping with the pain. The urges may be resisted for a short time, but ultimately the individual becomes overwhelmed with negative emotion and engages in self-harming, often resulting in tissue damage (Simeon & Favazza, 2001; Stanley, Gameroff, Michalsen, & Mann, 2001). In a sense, self-harm is a coping mechanism similar to overeating, excessive drinking and drug abuse.
The danger of self-harm, of course, is in its most extreme forms it may cause accidental death. Furthermore, non-suicidal self-harm is one of the strongest risk factors for suicidal behaviour (Muehlenkamp, Gutierrez, 2007). It is fair to say those who self-harm offer a variety of reasons for their behaviour some of the reasons are to experience relief from unbearable tension and upset, to distract themselves from intolerable feelings, to communicate distress, to improve their mood, to self-punish, to restore a sense of equilibrium, to provide proof to themselves that they are, in fact, suffering, and to achieve a sense of control (Brown, Comtois, & Linehan, 2002; Klonsky, 2007; Nixon, Cloutier, &Aggarwal, 2002).
A number of studies reviewed in Landecker (1992), cited in Miller, (2005) found a high correlation between severe childhood abuse or neglect and adult self-destructive behaviour. The adult behaviour patterns are linked to a lack of secure attachments in childhood and leads to the victim to dissociate. In that respect, self-harm can be done to escape feelings of emptiness, depersonalization, to express emotional pain and to punish the body as a way of expressing responsibility for the abuse. In literature it is suggested that following the act, individuals generally report feeling better, and thus the behaviour continues as a viable solution to their problems. Self-injury is explained as functional rather than manipulative behaviour and detailed clinical guidelines and examples are provided to better illustrate approaches that will improve the therapeutic alliance. Past traumatised clients seem to be the most common in self-harming, however, not all abused people engage in self-harm and not all self-harming people were abused.
Some clients engage in self-harm because they perceive it as a way of escaping from feelings of depression and emptiness. Some feel that by self-harming, their anger or aggression is relieved and some feel that it eases the pain within them as the act eases their anxiety and tension. A person centred approach (Carl Rogers), would be ideal to use for the first few sessions with clients who self-harm. This approach focuses more on the “here and now” issues. In this treatment the quality of the therapist and the client relationship is considered paramount. Rogers believed that to build a therapeutic alliance and growth promoting climate, three core conditions must be demonstrated by the therapist. 1) Unconditional positive regard (UPR). The therapist believes that people are essentially good and displays this conviction to the client. Accepting the client as intrinsically worthwhile however does not mean that the therapist necessarily agrees with all aspects of the client’s behaviour rather the client is respected for the person they are, not judged by what they do.
Acceptance recognises the potential of the client for self-help and encourages promotion of growth in the client. 2) Congruence, also known as genuineness, transparency and authenticity, meaning not hiding behind a façade acting out a role, putting up front or trying to make a good impression. The congruent therapist strives to be “real” and fully involved in the relationship. Congruence by the therapist encourages genuineness, openness and realism from the client. 3) Empathic understanding. The empathic therapist strives to enter the client’s world by communicating that understanding cautiously, demonstrating an empathic understanding, while standing back far enough to remain objective . This will then minimise the risk of becoming too enmeshed in the client’s world and losing the therapist’s objectivity. The theory commonly used for clients who engage in self-harm is Cognitive Behaviour Therapy (CBT).
CBT is a short term problem focused psychological treatment, the average number of sessions is normally 8-20. It deals with the “here and now” issues as opposed to the unconscious conflicts originating from childhood. The relationship between therapist and a client is similar to that of tutor and student. They should work collaboratively to identify thoughts and behaviour patterns that are causing difficulties and to plan a structured way ahead with agreed realistic goals. The therapist can then facilitate an environment and working practice for the client to identify their goal to overcome their situation. Homework tasks are formulated by the client with the therapist and they are a key component of the treatment. These may include challenging self-defeating beliefs, thought stopping, assertiveness training, social skills training and developing relaxation techniques. Some therapists may wish to use the psychodynamic approach which focuses mainly on identifying unconscious processes of the mind and bringing unconscious issues into the client’s awareness.
This enables the client to develop insight into how the past influences their actions in the present and to discover more effective ways of coping with present day reality. The therapist will need to be prepared to face some resistance from the client when unpleasant issues may be unearthed which the client can find difficult to examine. This type of therapy takes a long time for the client to begin to reach an understanding of their deeply buried issues. For the therapist to effectively use the mentioned theories, Carl Jung’s personality archetypes and the idea of the shadow has to be understood. According to Jung (1923) personality reflects both our conscious and unconscious minds. The conscious mind is what we are aware of regarding ourselves, the unconscious mind is what we are not aware of regarding ourselves. Jung concluded that there are a limited number of personality types and that each individual is born with preference for a certain type.
Jung argued that each of these personality types is equally valuable but our environment (eg parents, teachers, friends) either encourages or discourages the expression of our inborn personality type. Jung believed that our personalities are dynamic over our lives. The first half of the life should be dedicated to embracing our inborn personality types and the second half of life should be dedicated to embracing the polar opposites of our inborn personality types or our “shadow” personality. (Corlett, Millner 1993). Jung considered ‘the shadow’ to be like a foreign personality, a primitive, instinctual kind of being. He advised that moving the shadow from our unconscious into our conscious requires much courage and effort. The shadow is a moral problem that challenges the whole ego-personality, to become conscious of it involves recognising the darker aspects of the personality as present and real. Recognising the shadow is essential to achieve any kind of self-knowledge, therefore the therapist must expect that the client will strongly resist as uncomfortable things are revealed.
I think that some people resort to self-harm because they wish to have control over one part of their lives. The popular image of self- harming is usually cutting, and in this action the individual will use the action sometimes to reinforce their own individuality to themselves. However it must be remembered that self- harm takes many guises for example, over eating, excessive exercise, eating disorders or smoking; all of which are harmful to physical health as well as a psychological dependency. On the other hand there are behaviours which may at first seem incongruous such as hair twisting/chewing or getting several tattoos but which become a behaviour that the individual cannot break even though their appearance will change. The key factor that helps clients develop alternative coping strategies when self-harming has become an ingrained habitual behaviour is congruence and trust in the client/therapist relationship. At the beginning of therapy, a client may try to stop self-harming because of a promise made to the therapist.
A positive therapeutic relationship is not the solution to self-harm but it provides a context in which problem solving and behaviour change can take place. Because patients must be willing to endure urges to self-harm without engaging in the behaviour itself, having a therapist who provides support, encouragement, and validation for how difficult this is, becomes vital. Self-harm can elicit fear, blame, and disgust, although these emotions are understandable, as a therapist, I must effectively manage these feelings or they may otherwise interfere with the creation of a productive therapeutic relationship and jeopardise the client’s well-being. Also if the client is self-harming to validate their own existence care must be taken that they don’t replace one maladaptive behaviour with another. It can be a challenge for the therapist to maintain a compassionate attitude in the face of feeling frightened, frustrated, or ineffective when treating resistant individuals who self-harm. It is therefore important as a therapist to “validate the valid” in the client’s experiences.
Cooley et al suggests that not only does validation promote confidence and help clients learn to trust themselves, but it also strengthens the client/therapist alliance and is associated with effective psychotherapy (Norcross, 2002). Another common goal of self-harm is to avoid some feared emotion or interaction. Some clients describe self-harm as a useful coping mechanism that helps them feel better without having to confront their painful feelings or thoughts. Therefore these clients are unlikely to discuss their feelings and concerns openly with the therapist. Some clients may avoid confrontation, but instead they may become complimentary or apologetic towards the therapist. This strategy is used because they may be scared of rejection by the therapist. This will only be overcome by building a true rapport and trust in the client/therapist relationship. Also at the time of integrating the client and therapist goals, the therapist may be frightened to give direct advice to the client. Many teachings about therapy are that a client must come to their own insights for meaningful change to happen.
This may be true with certain clients; however, I think that one of the most compassionate actions is to discuss with the client that they wil not to self-harm. By asserting the elimination of self-harm, I would not only help to protect the client from physical harm, but I also demonstrate genuine caring. In a world where they may rarely feel cared for, this directive may be a welcome change. It is one clear way to stand on the side of self-preservation and self-care and not been seen as approving of the self-destructiveness by ignoring or not addressing the behaviour. Many clients who are motivated to stop self-harming are aware of the negative consequences of self-harm, but they have not been able to develop effective alternatives to the behaviour. Alternatively some clients are unwilling to stop because they identify themselves through this behaviour.
They will feel that letting go of it means they will lose a part of themselves. This is a difficult position for the therapist. As a therapist, I don’t want to jeopardise the relationship with client by promoting my own agenda. On the other hand, I don’t want to provide poor client care to maintain a good alliance. Therefore when a therapist and their client differ in the priorities, collaboration and aims/goals will suffer as will the likelihood of a successful course of therapy (Tryon & Winograd, 2002). In such cases the sessions are likely to become more tense than therapeutic. If a therapist feels very strongly that a client’s behaviour or plan is life threatening or extremely self-destructive, then that therapist is obligated to act ethically and refer the client to the appropriate help and support. From the outset, therapist should collaborate toward a goal that is, first and foremost to preserve the client’s physical health. At this point, I would ask the client to generate a list of negative consequences of self-harm so that they do not view ceasing self-harm as solely the therapist’s goal, but rather as a joint objective.
Negative consequences will be different for each patient, and taking time to understand what is aversive about self-harm for a particular client will help personalise and focus treatment. A final approach is one of compromise. A therapist’s willingness to consider alternative objectives could promote greater cooperation on the part of client. Compromise also instils in patients a sense of control over their therapy. Negotiation can take the form of lessening the intensity of a request (e.g., rather than throwing the razor blade away, give it to someone to hold), the frequency of a request (e.g., write down your thoughts 3 days a week rather than 7 days a week), or the duration of a request (e.g., if you won’t promise not to cut yourself for the next 3 months, then promise not to cut yourself for the next month). Before agreeing on and designing a course of treatment with the client, the therapist must decide what is non-negotiable, based on research evidence, and their own limits of experience.
Therapists should never act against their better judgment because of demands made by patients or patients’ family members. Such actions have the potential to result in dire consequences (Hendin, Haas, Maltsberger, Koestner, & Szanto, 2006) and will not help patients progress. Using a “give and take” technique, therapists must strike the right balance between agreeing to the patients’ wishes, safeguarding their well-being, and observing their own limits. If self-harming does not make the client feel better in some way then they would not continue to hurt themselves. Therefore in the process of helping the client the therapist must avoid inadvertent reinforcement of the client’s actions when interacting with them (Walsh, 2006). Whereas demonstrative compassion and kindness will solidify a therapeutic relationship, the therapist must be aware of the detrimental outcomes that showing over concern may promote further self-harm. As the client may realise that if they self-harm, they will receive concern from others, which gives them positive reinforcement for their self-destructive behaviour.
Therefore as a therapist one should try to maintain a neutral response style and be dispassionate (Walsh, 2006). In the same vein, an extreme negative reaction can jeopardise the relationship and the client’s care. Self-harming is a socially unacceptable behaviour because it runs counter to the human instinct of self-preservation. As a therapist one may experience a range of emotions, including fear, panic, upset, and despair. These emotions may leave the therapist worrying about being blamed by the client or client’s family, or feeling guilt for having missed a sign that ultimately led to the client’s self-harm. In response to these intense negative emotions, therapists can sometimes resort to scolding the client, withdrawing, avoiding assessment, or minimising the problem. Whereas those responses are understandable, they are far from helpful. As a consequence, client may feel judged or embarrassed, may retreat, may avoid reporting any further self-harm, or, in contrast, may take some satisfaction in worrying their therapist.
To avoid alienating a client, the therapist can respond with non-judgmental compassion and calm curiosity that focuses on understanding the facts (Walsh, 2006). It must be realised that seeking therapy is a giant step for the self-harming client as they normally keep their act as a secret. The prospect of someone harming themselves will arouse strong emotions in most people including therapists (Sanders et al, 2009). The therapist therefore is challenged to listening to the client’s whole story and use the right psychotherapy approach at the right time. When listening to the client’s story, the therapist should take note of what is happening, who said what to who, what ideas they’ve got about it, how they felt then and how they are feeling now.
The therapist, on reflecting can only do so on what the client has shown without the need to go to the unconscious material. It will also help the relationship if the therapist mirrors and matches the clients terminology to establish a rapport. Reflecting and rephrasing the clients main points will also reinforce understanding of the clients’ point of view. It is a great challenge to maintain equilibrium and optimism when treating self-harming clients. The key to a successful outcome is learning how to adapt to the specific obstacles presented by those who self-harm. Validation, collaboration, and patience will enable therapists to establish and maintain a strong therapeutic relationship. Helping the client to conceptualise self-harm as functional, rather than manipulative, and avoiding common pitfalls will help maintain that working relationship. Thus it will assist the client in moving forward toward eliminating the self-harming behaviour.
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