Early cartographers placed the words ‘Here be Dragons’ at the edges of their known world to admit to themselves and to travellers the limitations of their knowledge. Working in therapeutic alliance with clients who self-harm, I have sometimes experienced a feeling similar to those of the pioneering mapmakers.
I am aware of my limitations and constantly working hard to keep young clients safe from harm, whilst paying attention to our professional ethical framework. When I was approached to deliver a workshop on self-harm at the recent CYP conference, I was again struck by my desire to try and open up new ways of understanding and supporting these young clients.
I told workshop participants at the outset that I was shamelessly standing on the shoulders of the therapeutic giants who have gone before and laid the foundations of our profession. This means that I borrow the wisdom of other psychological passage makers and integrate it, particularly in the fields of NLP, CBT and play therapy. I love NLP because it’s metaphor-laden, making big concepts really accessible to CYPs and to therapists. I have often used it with CYP clients because it lends itself to visual and kinaesthetic work as well. I love CBT too, because it has so helpfully articulated useful ways for clients to exercise control over their own cognitive, affective and behavioural processes. And I love play therapy because who doesn’t love to play? Particularly when it can provide a medium for life changes.
There were three key principles that I wanted participants to understand as we undertook a workshop journey together exploring the terra incognita of self-harm.1
1. The first key principle was that if you’re working with self-harmers, the map is most certainly not the territory for the client or the counsellor.
Territory is best understood by on-the-ground exploration. Therapists naturally rely to some extent on internal schemas that we hold and that hold us as we approach working with our clients. These can be either more or less helpful to our work. However, schemas are only dim reflections of the richness, complexity and elaboration of client experience. As therapists, our cognitive maps of self-harm can limit our effectiveness. They are also affected implicitly and explicitly by our own experiences, fears, hopes and aspirations. But the very act of owning our stuff enables us to sense our limits and barriers and to ask powerful questions about risk and reality in working with our young clients. The therapists in the workshop spent time bravely exposing some of these often ignored neural pathways. As we did so, it was interesting to see how new understanding and knowledge began to emerge and flow – including the idea that some therapists might have a blood phobia that would require treatment before working with self-harming clients. 2
2. The second principle was that all behaviour is goal directed and has a positive intent.
Self-harm is a genuine attempt by CYPs to meaningfully cope with life. The statistics around self-harm aren’t ivory-towered facts. On the contrary, they are really useful therapeutic compass points for defining the implicit and explicit meaning of self-harm, assessing risk and identifying key resources for helping clients and therapists understand the nature of an individual’s self-harming behaviours. How often have you drifted off mentally as a trainer expounded on the statistics around a certain issue? Yet, to quote Mick Cooper, ‘the facts are friendly’. Therapists should warmly embrace statistical research to inform practice and to empower clients within the therapeutic alliance to understand the meaning behind the numbers. The impulse to self-harm can leave clients feeling that they are trapped in a terrifying and hopeless place. The message of statistics can be a support and inspire both us and our clients, if we use them sensitively. They tell us that CYPs use self-harm as a direct result of meaningfully and actively trying to cope with distress. They remind us that the issue is not the client, but the limited repertoire of destressing behaviours. They also encourage us by showing that 90 per cent of all self-harmers will develop alternative ways of dealing with that distress over the course of their development into adulthood. These statistics will build hope if we use them wisely. They also tell us about resourcing factors in a client’s life, and provide clues as to when systemic issues might lead a client to increase or decrease self-harming behaviours. Creatively shared, these statistical facts can provide clients with better ways to understand and cope with their own lives.
3. The third and final principle we explored was that human beings have all the resources that they need (they just haven’t fully discovered them yet!).
I admit that I added the bit in parenthesis, but when working with CYPs I am always struck by the third active element in the therapeutic alliance, and that is the power of a young, developing human being to learn and change. So the end section of the workshop was dedicated to play and resourcing clients through resourcing therapists.
Play and resourcing therapists
Self-harm can be a hidden, shame-laden, guilt-inducing experience for many young people. And therapeutic work with self-harmers can often feel challenging for clients and therapists because it is affect laden. For this reason, clients often feel relieved when we allow them to lighten the load by using play-based skills in a therapeutic setting. The use of play allows for a form of reciprocal inhibition, where two opposite emotional states can’t co-exist, and the positive one wins out. Fun can be enormously resourcing for CYPs and play allows for visual and experiential learning. It opens up new neural pathways that go beyond words into experience, allowing new connections to be activated.
So, as part of the workshop experience, we played with Jenga, Snap, bubbles, balloons and water pistols and lots more stuff – and not just because I like playing with them. We used Jenga to explore the many factors that have led a client to use self-harm as a coping mechanism. Blocks represent individual experiences like the loss of a parent, a sense of feeling isolated, the build-up of stress around exams, having no words to talk about feelings. Take some Jenga blocks away and suddenly things feel very wobbly with your life tower. In my work I use multicoloured post-it labels to tag the blocks with parts of the client’s life experience. Therapists can use this method to provide words for feelings and to stabilise and normalise the client’s responses to difficult situations. Playing Reverse Jenga means that, instead, resources can be identified and blocks can be put back in with resourcing labels to support the client’s life tower. It’s great to see clients re-label blocks with new resources as they construct other ways to cope as part of their therapeutic journey.
We looked at making a coping kit for the client using a recycled gift bag to include things that provide alternatives to self-harm for the client. My clients really like to use balloon bursting, British Sign Language ‘emotional signs’ cards, bubbles, music and play dough, and I always include ideas from the excellent National Self-Harm Network’s alternatives to self-harm leaflet1.
Self-harm isn’t just a cognitive or affective experience. It involves thoughts, feelings, behaviours and sensations. Often I will use Butt Head – the game with the very weird hat with Velcro strips and Velcro balls – to explore with clients how experiences stick. As we process our experiences, we interpret the meaning of that experience via the thoughts, feelings and sensations that attach themselves. I then get them to play with the different thoughts, feelings, behaviours and sensations to see if we can vary the outcome.
When a client is feeling safe, I will often support clients to move out of their heads and into their bodily sensations by playing Very Fast Snap. It was amazing to watch 26 therapists addictively trying to beat their opponents at a card game (perhaps we all need to get out more?). Apart from being a game that ends with a giggle, it engages clients in the kind of adrenalin rush/release that can often parallel aspects of the physical sensations experienced during the ritual of self-harming. From there, we explored questions to analyse the individual steps of the self-harming ritual. This helps clients to identify the primary and secondary gains from the experience. The question format we used was to go back in the client’s memory to the last time when they did not want to self-harm. We then moved forward in memory from there, thinking about the three Ws – where they were, who they were with, and what they were feeling? We also thought about helping clients work out why they began feeling like they did, by asking if self-harm gave a sense of escape, or relief or control. We ended with trying to support a client to work out something to do that might give the same result, but that doesn’t damage them.
In the workshop, we used Catchabubbles (a kind of bubble that doesn’t burst but goes hard – obtainable from joke shops and online) and ordinary bubbles to illustrate the difference between ordinary thoughts and the kind of self-harming thoughts that can become like sticky thinking. Then we played the ‘mindful thought game’ using bubble guns. This helps CYPs identify passing thoughts and acknowledge them as psychological ephemera drifting past, and can eventually help with understanding that a thought does not have to be followed by an action.
The Chinese finger trap – pulling at the problem
Everyone left the workshop with my favourite item – a Chinese finger trap – made famous in the Addams Family movie. It’s a woven straw cylinder that the unwary push their index fingers into. Once your fingers are in, escape can prove tricky. The more you pull, the tighter the cylinder becomes. To release yourself, you have to move your fingers together, not apart. In the workshop, we used them to explore how often therapists and self-harmers are so busy pulling at the problem of self-harm to escape it that they end up becoming more enmeshed and trapped in it. The trick is to relax, accept where you are at, let go, and suddenly the answer to your dilemma becomes apparent. The way to support clients to find their way through and out the other side of self-harm is to open their options. After all, another way to think of self-harm is as a one-option approach to problem solving and self-soothing. Development teaches us that no problem in life has only one solution.
I hope that workshop participants left with a renewed sense of encouragement that clients who self-harm are human beings we encounter at a particularly challenging point on their personal journey. They are extraordinary and valuable individuals who have shown considerable courage in coming to talk to a therapist and are capable of extraordinary change, given support and the freedom to explore and map their own territory. They are the experts on themselves. If we trust them, they will show us their own way through uncharted territory. They are our teachers, and walking with them changes us in ways that will enrich us as therapists and people. If we journey with them, the only dragons we encounter will be the ones we ourselves bring with us.
I haven’t room to cover here the many ethical dilemmas we discussed fully during the workshop. But the hidden wisdom for our journey can be summed up in three simple phrases, none of which I am clever enough to have penned myself.
‘The map is not the territory.’
‘Not all those who wander are lost.’ – JRR Tolkien
‘No man steps into the same river twice; for it is not the same river and he is not the same man.’ – Heraclitus
Edith Bell is an accredited counsellor with BACP, and the Director of Familyworks – an organisation that provides a school and community-based counselling service to children, young people and adults in North Down, Ards and Belfast. She trained originally in person-centred counselling and subsequently in CBT and NLP.
1 www.nshn.co.uk/downloads/ Distractions.pdf