How to deal with someone who self-harms
The challenges for an individual who is either self-harming or has an eating disorder such as anorexia or bulimia are similar, in that they are both coping strategies that overlay a deep psychological trauma. For the sake of clarity throughout this article I will be discussing those problems around self-harm, although the principals equally apply to the issues arising with eating disorders.
Contrary to common belief, self-harmers rarely inflict pain in some kind of masochistic pleasure seeking behaviour, the harm they inflict on themselves provides them relief from some unresolved psychological pain. Therefore simply focusing on the self-harm behaviour, without exploring the underlying issues would be like putting a plaster over their wounds, it might bring temporarily relief, but the wound will not heal unless the psychological thorn that is causing the wound is addressed. Self-harm is a learned coping strategy that individuals have adopted to help them manage negative and overwhelming feelings.
Another misconception is that many self-harmers may end up as suicides. Although some self-harmers may also struggle with suicidal thoughts, the act of self-harming is general one that enables the person to manage life rather than end it. Where suicides do happen theses are generally inadvertent consequences of the self-harming. For most self-harmers their behavior is a way of preventing them from taking their own lives and is used as a coping strategy for relieving distress caused by internal or external factors . That said some self-harmers with a long history of depression or other mental illness may be a risk of committing suicide and you will need to be aware of these risks. If you are inexperienced in dealing with self-harming behavior in a deeply depressed individual, you should seek help yourself and consider referring the individual to an experienced professional .
Show that you care about the person in pain and show concern for the injuries themselves. A person who self-harms is usually deeply distressed, no matter what ‘front’ they may put on and offering compassion and respect, maybe something very different from what they are used to receiving. It needs to be made clear that it is all right to talk about the self-harm and that this can be understood. Many people might find the injuries of self-harm to be an upsetting and it would be important to be honest if you find the injuries upsetting, whilst making it clear that you can deal with your own feelings and don’t blame them for them. Conveying your respect for their efforts to survive, even though this involves hurting themselves and acknowledging how frightening it may be to think of living without self-injury by reassuring them that you will not try to ‘steal’ their way of coping. (You will also need to reassure yourself that you are not responsible for what they do, seeking therapy yourself to deal with difficult issues.) Longer-term objectives should focus on helping them make sense of their her self-harming, through sensitive questions around when the self-injury started, and what was happening then and explore how the client has used the self-harming behaviour to help them survive both in the past and now. Once they can identify the reasons that they self-injure they by understanding the circumstances that lead to their self-harming - the events, thoughts and feelings will help the them to use the urge to self-injure as a signal of important but buried experiences, feelings and needs so that they can they can start to create other coping skills that are less harmful. When the they are ready, they can be helped to learn to express these things in other ways, such as through talking, writing, drawing, shouting, hitting something, etc. They should be supported in learning to keep themselves safe and to reduce their self-injury. (Adapted from: Anon, Bristol Crisis Service for Women, 1998)
However you feel about self-harming and what you see as successful outcomes, the wishes and goals of the self-harmer are always to be respected. Stopping the self-harm may not be the only or most important goal, instead perhaps all you will be able to achieve is to reduce the more harmful aspects of the self-harm for example by encouraging the them to take fewer risks such as washing implements used to cut, taking better care of injuries and reducing severity or frequency of injuries even if by only a little. In all these cases more choice and control is being exercised by the individual and should lead them in the direction of recovery. Reliving many of the issues that lead to the self-harming, will undoubtedly cause them stress and for a time the need to self-harm, as a way of coping, may actually increase. The road to recovery might be long and difficult before the self-harmer is ready to give up self-harm. However each small steep is an achievement and you should encourage them (and yourself) for the progress that is made.
Self-harm is often a way for individuals to maintain control so it is important that you allow them alternative options remaining in control. We all have our own ways of coping, you included, and removing these without them finding alternative ways to cope whilst allowing them control of their means of distress management, including self-injury, can be very challenging.
It will also be challenging for you as well, there maybe the fear that bringing up the issue of self-harm, might encourage the behaviour, however, avoiding the issue of self-harm would mean loosing the opportunity of learning about it. Whereas asking about self-harm gives them the opportunity to talk openly about it. Only when the self-harm is revealed, can you begin to understand. It is therefore important to understand ones own reactions to self-harm and to be honest about your reactions. To try and hide ones feelings from the self-harmer risks losing their trust in you. People who self-harm often have many reasons to distrust others and will have learned to recognise when people are not honest with them. They will have learned to expect reactions of disappoint and possibly don’t feel they deserve to be treated well. You will need to develop a trusting relationship by maintaining clear boundaries and by being consistent with them. If you are inconsistent they may feel they are being rejected, rejection often being a motivation to self-harm.
One of the mistakes of many caregivers is to pay too much attention to the self-harmer. For example hospitals may assess the self-harmer as ‘at risk’, providing them with their own personal staff, to watch them and talk, until they feel the risk of self-harm has passed. Although well meaning, this attention serves to reinforce the self-harming behaviour through positive reinforcement. Instead what might be more helpful would be to reinforce the behaviour prior to the act of self-harming injury, such as by encouraging the client to call when the feelings of self-harming first arise so that the positive behaviour of calling is reinforced.
It is also important for you to understand what is not helpful in helping someone who self-harms. Although you may feel that you should stop self-harming, ‘no self-harm contracts’ would only serve to set the client up to fail. When a client feels they have reach the point of wanting to self-harm, they need to have the choice and control over their behaviour, no-self-harm contracts take choice away choice. A better strategy would be to work with them in developing options to what they have prior to self-harming. Encouraging them to try other behaviour prior to self-harming still allows choice, control, and the ultimate decision to self-harm so that the come to understand that they have other coping skills that could be utilised during difficult moments. Likewise hospitalisation again only serves to take choice away, in fact could leave them feeling totally powerless, the very feeling that is possibly causing the self-harming behaviour, so that hospitalisation might have the effect of increasing the incidence of self-harming.
Perhaps the biggest challenge is how the self-harming behaviour effects your own feelings. The stories of suffering and trauma that they may relate to you will be undoubtly be disturbing, even therapists cannot totally isolate themselves from theses feelings. Dealing with these intense emotions can lead to compassion fatigue or secondary stress disorder (The transformation of the caregiver’s inner experience due to the work done with someone who has survived traumatic life events. (Alderman and Marshall 2006) Dealing with the trauma typically experienced by those who self-harm makes vicarious traumatisation a real risk, the effects of which can impact on both the personal and professional functioning. The effects of this secondary stress on the personal functioning may include diminished concentration; forgetfulness; confusion; disorientation; apathy; preoccupation; dissociation; hypervigilance; lack of purpose; depression; helplessness; impatience; irritability; anger; distrust; overly needy of others; guilt (particularly if they go on to more serious self-harming) withdrawal; isolation; loneliness; preoccupation with the self-harmer; adopting negative coping strategies; anxiety and stress.
When dealing with someone who self-harms, it is essential for you to be aware of and check your own levels of mental health and ensure that you maintain a healthy balance of work, rest and play. After all how can a you be of help to anybody else if you fail to take care of yourself? It is therefore of the utmost importance that you are aware of your own feelings so that when feeling frustrated you are able to step back and examine the issues of why you are feeling frustrated. It is essential for any regularly dealing with someone who self-harms to seek regular therapy for themselves in order to deal with the feelings bought up by dealing with a self-harmer and to have someone act as an impartial early warning for when you are taking on too much of their issues.
N Wood-Gaiger 2010
N Wood-Gaiger, 2014
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