Self-harm and self-injury are not uncommon presentations in further and higher education (FE and HE) counselling and psychotherapy and therapists are, on the whole, reasonably at ease in talking to clients about this. That is not to say talking about self-harm and self-injury is not in itself a difficult conversation, but it is one that most of us acknowledge is an important one to have.
Most often we will explore the possibility of self-harm and self-injury during the early stages of therapy, most typically in an assessment session. However, clients may or may not disclose their harm at this stage and, instead, it emerges as therapy commences or continues. It can be an important part of a client’s process and one better to know about so that clients can be supported to move to more self-caring coping strategies. Some clients may wish to use the therapeutic encounter to explore their self-harm or self-injury as a means of changing the behaviours. Others will acknowledge its presence, but not see it as a priority for discussion, instead preferring to focus on what they consider to be the underlying, and thus more pressing, issues.
In this article I wish to explore a less considered aspect of self-harm and self-injury: one that is less written about, less acknowledged and therefore more hidden. It doesn’t appear in the very well-researched treatment guidelines, in assessment protocols, in the academic literature or in many of the textbooks. And indeed why should it? Much that is written about self-harm and self-injury positions ‘us’ in a healthy, emotionally articulate and, well… generally quite got-it-together sort of place, while the client – the ‘them’ – is chaotic, acting out and presenting with a behaviour that is best seen as speaking of underlying pathology. That’s the ‘them’ and ‘us’ of self-harm and self-injury: there are those people who harm themselves, and then there’s the rest of us. Phew, isn’t it such a relief to be in the ‘us’ category rather than the ‘them’ one? It means we can understand, empathise, support, challenge and help change the client’s process, without spending too much time dwelling on our own self-harming one. While it is OK to be alongside our client, it can be such a relief to know that while we might walk in their moccasins, so to speak, the shoes ultimately belong to them, not us. Yet the really difficult conversation, about working with self-harm and self-injury is often one we need to begin with ourselves. Then, and arguably only then, can we really achieve the relational depth we might seek with our client. This article, therefore, is about our own self-harming and self-injuring process and the importance of recognising and reflecting on it for the sake of our clients. That can be a more difficult conversation.
A matter of definitions
I don’t intend to spend many words here looking at the much written-about definitions of self-harm and self-injury, assuming that readers will be quite familiar with them. Instead, I want to explain why I persist on laboriously writing out self-harm and self-injury, instead of just writing ‘self-harm’, like everyone else, and having done with it. For me, a differentiation between the terms ‘self-harm’ and ‘self-injury’ goes beyond the semantic and has helpful implications for the inter- and intrapersonal discourse that can take place in therapy. When looking at a number of key definitions previously, I have provided a generalised summary of what they essentially say:1
Self-harm and self-injury can:
- Be directed against the body (for example, cutting, burning), which might be termed as self-injury
- Include behaviours without immediate impact, (such as eating disorders, risky sexual behaviour)
- Be planned and form part of a habitual pattern, or may be unplanned and spontaneous
- Be about coping, living, surviving and self-worth
- Have a relationship with suicide potential, particularly in the context of other risk factors.
In looking at the specifics of behaviours, I would differentiate self-harm and self-injury using the following concepts:
- Self-injury includes behaviours with immediate and direct consequence, such as cutting, burning etc. They are typically apparent to the individual inflicting the injury on themselves and are likely to have a quality of communication (to self or others) that is more immediate, if not apparent.
- Self-harm includes an indirect and generally deferred consequence, such as eating disorders, overexercise or overwork, or sexual risk taking, and is likely to have a quality of communication (to self and others) that is less accessible and clear.
Finding a ‘way in’ to self-harm
While it may be helpful to deconstruct these definitions and terms with our clients, if it is important for them to do so, the point of the differentiation here is to help us begin to think about our own behaviour and actions more closely. There will, without doubt, be many of you who readily identify with the concept of self-injury, and reflect on times in your life historically, or in the present, where self-injury has been a mechanism through which you have coped with, or expressed, unbearable pain. We know through statistics, which I will not burden you with here, the extent of self-injury and how the statistics themselves significantly under-report the true extent of the number of people who self-injure. There is an interesting parallel here: the statistics of self-injury are not too dissimilar from self-injury itself – hard to reach; hard to determine; and ultimately what we see is only the very tip of the iceberg.
Self-harm, however, is even harder to understand. It represents not only a set of behaviours that are more measurable, such as eating disorders, sexual risk taking etc, but also ways of being that become so embedded in the very ‘self’ that they are camouflaged against the external routines of reality. For example, when does working hard become overwork? At what point does exercise become physically and emotionally damaging? These are particularly difficult parameters to pin down and can serve to become unconscious – or ‘out of our awareness’ – ways of being, which are more about ways in which we punish or harm ourselves, than ways of living our life self-respectfully. Many factors will influence the answers to these questions, such as what is socially acceptable for different groups of people at different times.
For many ‘behaviours’ it is very difficult to differentiate between self-care and self-harm. For example, I might return home from work and open a bottle of wine, perhaps sitting by the fire, enjoying a peaceful and relaxing evening. This experience will turn out to be restorative and fulfilling and play an important part of my self-care, so that I can return to work refreshed. I might also return from work, perhaps after a particularly challenging, difficult or upsetting day, and open a bottle of wine and use it as a means of anaesthetising difficult feelings that I might not want to experience. It could be that I feel angry, hurt or attacked by my clients – or colleagues – but that I personally find these feelings difficult to reconcile with being a caring, nurturing therapist, so I blot them out with alcohol. The bottle of wine might be the same bottle, but the intention behind my action is very different. One is about connecting and restoring, while the other is about blanking and dissociating.
The nature of the intention
We are prompted to look beyond the behaviour and instead explore the intention of the behaviour. This is always a challenge, and much that is written about self-injury, for example, is behaviour orientated. That is, we can too often be drawn into trying to eradicate the behaviour, perhaps because we or our institutions find it too difficult to tolerate, rather than being with the behaviour and really helping the client focus on the intention, meaning or communication of what is happening for them. The same is true for self-harm, in that we might want to help the person battling with anorexia to eat again, whereas almost always it is the meaning of the not-eating where the individual’s truth lies.
If we return to the example of the bottle of wine, if I tell myself that it is always about self-care and relaxing, I also miss an important insight: that sometimes it isn’t. Instead, on occasions, it is more about how I might struggle to articulate challenging or distressing feelings and instead dissociate from them. If I do this in this instance, I will do it in other instances too. But if I can begin to be open to the times in my life when I might revert to actions that are more self-harming than self-fulfilling, then I gain precious insight into my own process. This might, in turn, help me connect with it in others. We will probably all agree on the importance of helping our clients understand the meaning behind their thoughts, feelings and behaviours, and will willingly apply the same principle to ourselves. Yet it is fascinating that much of the literature looking at self-injury and self-harm does not encourage us to do so. Instead we are encouraged to think about the ‘them’ of self-harm, and we are allowed to sit outside of that very human process.
What does this mean for practice?
The points I make here are not modality-specific or aimed at one particular group of therapists. Instead, I am attempting (in what might be a rambling and garbled way) to challenge the idea of pathology of self-injury and self-harm and bring it back to a human process. Without doubt, and from my own practice experience, self-injury and self-harm can be very intense, chaotic, out of control and even life threatening. The points I make here are not to diminish the seriousness or importance of meeting with the risk in the ‘other’, and I have discussed this very point extensively elsewhere.1,2 Rather, it is my assertion that we can only truly connect with another’s harming process if we are open to it in ourselves.
We do not all self-harm all of the time, but there are times in all of our lives when something can become too painful, too immediate or too overwhelming for us to really engage with. Having worked for many years in a mental health crisis team, one of my personal and professional learnings is that no matter how settled and safe our lives might be, we are all just one heartbeat away from a crisis. With those experiences, and at those times, we can all have the propensity to ‘behave’ our feelings, rather than really connect with them. A willingness to accept that in ourselves, to be open to its possibility, to really go there and consider what happens to our psyche in those moments – how it can be for us to sidestep the emotionally threatening – can provide more insight than almost any other experiential opportunity.
Professionally, really bringing the ‘self’ into self-harm can provide the mechanism through which we can really begin to connect with our clients and, in doing so, provide them with invaluable opportunities to move beyond their own sense of ‘stuckness’ and shame. Philosophically it moves us from a ‘them’ and ‘us’, simply to a place of ‘us’ where we all have something to learn and contribute.
Dr Andrew Reeves is a Senior University Counsellor at the University of Liverpool; a BACP senior accredited counsellor/psychotherapist and Fellow of the British Association for Counselling and Psychotherapy.
01. Reeves A. Challenges in counselling: self-harm. London: Hodder Education; 2013.
02. Reeves A. Working with risk in counselling and psychotherapy. London: Sage; 2015 – forthcoming.