When the emotional pain is > the physical pain.

 1.  Introduction:

Would you carry a razor, in case, just in case of depression – David Bowie, 1975.

 

The aim of this article is to reflect upon the coping mechanism of self-harm (SH), a prevalent practice issue in counselling. While this article mainly discusses self-harm, it is important to cast a light on how the terms committed suicide and deliberate self-harm are still widely stated across all socio-demographics of society. Unfortunately, by unknowingly stating these stigmatising terms, it creates an unintended negative effect on eliciting help-seeking behaviour and/or alleviating the shame many people have a tendency to feel when coping with this type of loss. Moreover, in a recent correspondence with the author, Cindy O' Connor (personal communication, June 17, 2019) stated "Nav Kapur has advocated for the prefix deliberate to be dropped. It is hoped that by removing the word deliberate it will reduce stigma ... The National Suicide Research Foundation (NSRF) have also dropped the prefix deliberate from reports (https://www.nsrf.ie)."

We as therapists and indeed, our society as a whole need to recognise how the value-laden language we use in describing issues or mental health terms can have positive or negative connotations in encouraging people in reaching out for support . As a therapist, in Ireland or internationally, depression is one of the biggest dilemmas facing society, contributing to early mortality (Polednak, 2012). Depression and self-harm are often linked in the extant literature (Andover et al, 2005; Sho et al., 2009; Moller et al., 2013; Subica et al., 2016). This article attempts to distinguish if self-harm like suicide, is rooted solely in depression.

A further aim of the article is to examine how it is managed and responded to within a practice setting. It is a stipulation of Village Counselling Service, one of Ireland’s largest community counselling agencies, that every volunteer therapist must complete the Applied Suicide Intervention Skills Training (ASIST) prior to commencing student hours. This indicates the high prevalence of this cohort of clients in agency settings and additionally, the high risk involved in working with these clients. The level of complexity evident in such settings suggests it is imperative for therapists to source evidence-based methods for counselling clients who self-harm in addition to ASIST. Noteworthy too, is that services using suicide contracts with clients to do no harm in-between sessions, has been shown to have no effect on preventing harm. Furthermore, Range et al (2002) state, "they can anger or inhibit the client, introduce coercion into therapy, be used disingenuously, and induce false security in the clinician"

This article is intended as a resource piece, to aid therapists in their understanding of self-harm symptomology, aetiology and how we, as therapists, effectively treat this issue. Moreover, this article will explore the relationship dilemmas that present when working with this client group, including discourse related to when and if liaising with psychiatrists and mental health services is necessary. However, before we begin, the author must acknowledge that we may all be on the continuum of self-harm. In its broadest sense, self-harm can include a lack of a healthy lifestyle, smoking, drinking excessively, exercising too much or not at all and the basic lack of self-care in our professional and personal lives.

 

2.   Self-Harm:

I hurt myself today to see if I can still feel, I focus on the pain the only thing that is real – Trent Reznnor (1994)/ Johnny Cash (2002). 

2.1.        Defining Self-Harm:

There are a few terms to describe clients who hurt themselves. Kitchener, Jorm, Kelly (2013, p.80) define it as non-suicidal self-injury (NSSI) however other terms are “self-injury, including self-harm, self-mutilation, cutting and parasuicide.” Additionally, the term trichotillomania, which refers to hair pulling and other repetitive self-harmful behaviours, has been linked with self-harm (Woods & Twohig, 2008, p.9). 

Anecdotally, we hear that self-harm is “manipulative attention seeking, but not as attention-needing” (Iwaniec, 2006, p.37). Klonsky et al (2013, p.231) define self-injury as “the intentional and direct injuring of one’s body tissue without suicidal intent and for purposes not socially sanctioned.” However, for the practicing therapist, it is not always easy to differentiate between self-harm and a suicide attempt. It is incumbent for therapists to ask the person the question ‘do they plan to end their life?’ Notably, Brausch and Gutierrez (2010, p.233) indicate clients that self-harm can actually present with lower suicidal ideation and less depressive symptoms than those who have a history of suicide attempts.

While people who have SH behaviour do not always go on to engage in suicidal behaviour, it is worth noting that Gask (2015) maintains that those who utilise self-harming behaviours are more likely to attempt suicide at some point in their lives.

 

2.2.        Aetiology of Self-Harm:

The world breaks every one and afterward many are strong at the broken places -Ernest Hemingway, A Farewell to Arms

2.2.1. Emotional Regulation: 

Individuals experiencing symptoms characterized by high levels of arousal (e.g., anxiety, panic) may engage in NSSI more frequently as a means of regulating intense emotions, while individuals suffering from … depression may experience lower levels of arousal, and thus may be less inclined to engage in the behaviour… (Zielinskia, Hill, & Veilleux, 2018, p.395).

As therapists, we are required to consider the purpose of any given behaviour. Why do clients choose the behaviours they use, despite painful consequences? However, there is evidence to suggest, there is a pleasurable element to SH behaviour, through the brain releasing endorphins. This may be why “many people who engage in self-harm indicate they feel little” or any pain at all (NOSP, 2014, p.13). Perhaps, this contributes to the strong urge cycle of self-harm and possibly creates calmness in chaos, for a moment. Some research (McKenzie & Gross, 2014; Mikolajczak, Petrides & Hurry, 2009) suggests that self-harm is an attempt to regulate painful emotions. Rees et al (2015, p.2) maintain that adolescents that DSH struggle with “adaptive emotional regulatory responses.”

Chapman, Gratz & Brown (2006, pp.373-374) state, “Despite differing theoretical perspectives, these theories are bound together by the notion that SH somehow helps the individual escape, manage, or regulate emotions.”

Additionally, it is important to note that there is an overwhelming issue of shame that emerges consequently from non-suicidal self-injury and Gilbert et al (2010) maintain it can be used in the counselling space to promote change in behaviour. Furthermore, Amoss, Lynch & Bratley (2016, p.198) posit, “both blame and shame are potential steps towards transformative actions. The next step usually involves the capacity to tolerate emotions and consider alternative responses.” As therapists we must face our own shame so that we can work effectively with the shame-based issues that a self-harming client may have. Johnson (2006, p.234) highlights;

“Shame, like pride, is woven into the fabric of our being. It is a part of us that cannot be cut out; we must accept shame to transform it.”

However, due to the complexity and commonality of self-harm, it cannot be generalised to one cause, as Sim et al’s (2009, p.75) study hypothesised that “self-harm may be an outcome associated with poor emotion regulation as well as an invalidating family environment.”

2.2.2. Social and Environment:

There is some evidence to suggest that clients from socio-economically disadvantaged areas are more likely to engage in self-harming behaviours (Kokkevi et al, 2012; Hill, 2011). Naicker et al (2016, p.1), maintain that low-income countries “bear the majority burden of self-harm.” Although, Page et al (2014) argue that people from such areas are less likely to engage in research and subsequent help for incidents of self-harm, which suggests that issues of generalisability may be at play. Moreover, due to the mass influence of social media on people’s lives, it pivotal to delve deeper into the conceivable correlations between Internet usage and self-harm. Marchant et al (2017, p.2) maintain that “Clinicians working with young people who self-harm or have mental health issues should engage in discussion about internet use. This should be a standard item during assessment.” Furthermore, several studies confirm correlations between excessive Internet usage and self-harm behaviour (Pan & Yeh, 2018; Dyson et al, 2016; Hawton, Saunders, & O’Connor, 2012; Marchant et al, 2017; Jacob, Evans, & Scourfield, 2017). Although, the aforementioned studies also mention the positive effects of the Internet as a support to help people who self-harm.

 An extensive international research by Ystgaard et al (2009, p.888) indicate that “Problems in the relationship with parents are considered one of the strongest risk factors” and “the family situation of those receiving help from health services was characterised by parents who were separated or divorced (only significant for girls).” Bailey et al (2018, p.501) suggest “Online interventions may also present a low-cost or free alternative for those who are unable to access services due to financial or practical constraints.” Additionally, Lodebo et al (2017, p.8) study concludes “that low parental socioeconomic position is associated with self-harm in adolescence, predominantly among girls.” This also suggests gender factors should be further explored.

2.2.3. Gender:

A Kidger et al survey questionnaire shown the “prevalence of lifetime self-harm was higher in females (25.6%) than males (9.1%).” Likewise, McMahon et al’s (2014, p.1929) extensive Irish study discovered that “The rate of self-harm in the community was 5,551/100,000, and girls were almost four times more likely to report self-harm.” These findings are echoed by Geulayou et al’s (2018, p.168) extensive retrospective study, which indicated a high percentage of “self-harm, especially in females.” Contrariwise, Sanderson (2006, p.270) argues that “the incidence of self-harm may not differ between males and females but rather manifest in different forms” with men likely to engage in more overt risk-taking behaviour.

2.2.4. Trauma:

Unexpressed emotions will never die. They are buried alive and will come forth later in uglier ways (Freud as citied by Quish, 2015, p.13).

Trauma and abuse have been positively correlated with self-harming behaviour. Iwaniec (1995) suggests that emotional abuse is linked to increased rates of self-harm. Likewise, there is a body of literature that infers a history of childhood sexual abuse may be linked to self-harming in later life (Romans et al, 2005; Noll et al, 2003;). Notably, Kilic et al. (2017) maintain that disassociation is positively correlated with self-harm. Gender issues may also be at play when considering trauma as an etiological factor. One study (Vaughn et al, 2015) indicated that links between sexual abuse and self-harming were far more prevalent in female than male respondents. As Inckle (2010a, p.365) proposes “Self-injury provides people with a degree of control, relief, and self-comforting that is absent in their life-situation.”

3.   Prevalence rates:

In Ireland in 2014 there were 8,708 individuals treated for 11,126 self-harm incidents in accident and emergency’s services, these figures suggest that one in five of these episodes were recurring acts, with young people making up the largest population in these figures (Griffin et al, 2014). From a practice perspective in Ireland, it is important to note that the highest prevalence of self-harm occurs in 15-19 year old female (Griffin et al, 2014). This has a serious implication for therapists, as not only should the practitioner understand the issue at hand, but should also be competent to work with younger clients.

Interestingly, when considering prevalence rates amongst young people, one study by Doyle, Treacy & Sheridan, (2015, p.489) found that only “a small minority of young people presented to hospital as a result of their last attempt to harm themselves (6.9%, n=7) or any previous attempt to harm themselves (11.8%, n=12).” This suggests that the figures for youth self-harm may in fact be much higher than those proposed by Griffin et al.

In the UK, in secondary schools, there has been an estimated surge of 70,000 cases in the past year alone and “NHS England figures show that the number of girls treated as hospital inpatients after cutting themselves quadrupled between 2005 and 2015, while the number of boys admitted had more than doubled” (Weinstock, 2018, n/p). When considering epidemiology, adolescents who self harm are “at increased risk of developing mental health problems, future self-harm, and problem substance misuse” (Mars et al, 2014, p.349). This implies that therapy and treatment of the issue is important. Nevertheless, therapy and treatment can only occur if those who opt to work with this client group have the necessary knowledge and competencies to intervene.

 

4.   Relationship Dilemmas Specific to Self-Harm:

Attachment does not exist in the parent or the child [nor in the therapist or the client], just as music is not contained in the fiddle or the bow but rather in the interaction between the two (Zanetti et al, 2011, p.130).

Whisenhunt, Stargell and Perjessy (2016) argue that therapists can have intense, visceral reactions to clients who self-harms. They go on to posit that “the therapeutic relationship can be damaged beyond repair if the clients feel judged.” Fleet and Mintz (2011, p.44) found that, despite a desire to remain person-centred, many therapists who work with self-harming clients have “an explicit or implicit agenda for change.” This implies that it is vital to work hard at suspending one’s value judgments and agendas. Research into client’s views echoes the importance of the relationship in working with this issue. For instance, self-harming participants in a recent study (Long, Manktelow & Tracey, 2016) indicate that clients will withhold information if they do not trust the therapist, particularly with regard to confidentiality.

Self-harming clients may be under the care of Adult Mental Health Services (AMHS). Ethically, in our professional training we are informed that we are not medical professionals and the consequences of working with a client that may need medication or may want to come off their medication can present a major dilemma. Not only does this infer a high level of complexity, and potential co-morbidity (Haw et al, 2001), medication tends to be a controversial issue in psychotherapy circles. In a recent article, Gallagher (2017, p. 28) cites Brogan (2016) who argued “antidepressants have repeatedly been shown in long-term scientific studies to worsen the course of mental illness.” There is some evidence to suggest that SSRI use with adolescents (a group who are more like to self-harm) can increase the risk of self-harm in depressed youth (Martinez et al, 2005). However, other studies (Henriksson et al, 2003; IsHak et al, 2014;) indicate that SSRIs can have a positive impact. Therapists who work with this population must be mindful of the limits of their competencies and act only within such limits (IACP, 2018). 

 

5.   Professional Practice Considerations

 

5.1.        Therapy with Self-Harming Clients

Doyle et al states (2015, p.485) “seeking professional help is not a common phenomenon, and those who present to hospital represent the ‘tip of the iceberg’ of adolescent” self-harm. As specified throughout the extant literature, the main intervention for working with clients that disclose self-harm as their coping mechanism, from their perspective, is that someone listens and does not judge them (Inckle, 2010b). The Rogerian core conditions are the foundation to build a relationship with; however, other interventions have been shown to be beneficial.

5.1.1.    EMDR (Eye Movement Desensitisation & Reprocessing) with Self-Harm

McLaughlin et al (2008, p.1) case report showed EMDR as “an effective treatment option in reducing repeat self harm where traumatic events are noted to be the precursor to deliberate self harm.” From a practice development perspective this is where referral of a client to an EMDR specialist may be warranted, to ensure the client gets adequate assistance. More research is needed to show it efficacy.  

5.1.2.    Harm-Reduction with Self-Harm

By trying to prevent their injury we harm them, we may fail to help them. I conclude that healthcare professionals sometimes have an obligation to allow harm.  (Sullivan, 2017, p.322).

While harm-reduction has been utilised in sexual health and substance misuse through dispensing condemns and needle exchanges, there is substantial research that sees harm-reduction as an effective intervention for people that self-harm (Sullivan, 2018; Inckle, 2010b). Pembroke (2007, p.166) maintains that “harm-minimisation is about accepting the need to self-harm as a valid method of survival until survival is possible by other means.” This may be particularly challenging for therapists to consider and may raise ethical and legal requirement issues; however, Pembroke makes a valid point. Furthermore, Inckle (2010b, p.176) proposes that “providing reliable and accurate anatomical and first-aid information which enables people to reduce the lethality of their injuries and also to subsequently take care of their wound.” In openly discussing this with the client it relieves the taboo nature of self-harm and its association with shame and secrecy (Inckle, 2010a).

5.1.3.    Dialectical behaviour therapy (DBT) with Self-Harm

 Quish (2015, p. 63) maintains “the goal of this therapy is to teach coping skills, regulate emotions and improve relationships with others.” There have been a number of studies that have shown positive outcomes for non-suicidal self-injury using DBT (James et al, 2008; Booth et al, 2012; Carr, 2016; Haga et al 2018). However, a comprehensive comparison study by Andreasson et al (2016, p.524) “assessing the effect of DBT versus CAMS [collaborative assessment and management of suicidality] treatment on the individual components in the primary composite outcome (attempted suicide and NSSI) … did not observe any signi?cant difference between the two outcomes.”

6.   Conclusion:

The low level of professional help seeking for SH is a cause for concern. As therapists, we must be mindful of the importance of assessing the underlying reasons for self-harm and what is the meaning for the self-harm to the person. Also, that each event of SH requires an objective assessment (NICE, 2004).  Arguably, effective intervention is crucial to help reduce the repetition of self-harm. Perhaps, for all the negativity that surrounds the usage of the internet/social media, it may well be our best medium to help dissolve the barriers to seeking professional help. Therapists who work with this clinical cohort must be able and willing to suspend judgement, work creatively and ethically, while creating a therapeutic space of safety and support. It is paramount for therapists to recognise that SH incident may not be an attempted suicide but a maladaptive way to cope when the emotional pain is greater than the physical pain inflicted. Nevertheless, Fleet & Mintz (2013, p. 51) reflect that “the client who remains in therapy and continues to engage in self-harm provides an enormous challenge to any counsellor with an agenda for change.” In summation, therapists and clients alike may do well to remember:

What you can change lies within you. You can change your character and behaviour. You can change your way of "being in the world," and your interactions with persons and events. You only need the courage to pursue wisdom, and to face each new day with strength of character and fortitude. Serenity can be had.

(Ferraiolo, 2017, p.341).

 

 

 

 

 

 

 

 

 

 

 

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