Self-Harm

A child or adolescent who deliberately harms themselves is one of the most distressing and disturbing symptoms that present in therapy. This may take the form of cutting, hitting oneself, burning, abuse of medication, restrictive eating, punishing exercise regimes and other forms of harm. While death may not be the intent, there is a higher risk of this outcome than in a non-self-harming population. A common set of strategies to protect a person from acting on these thoughts are distraction techniques which can be categorized according to the feeling that has become intolerable and lead to self-harm. For example, if a person is sad, it may be suggested that they take a scented bath, play with a pet, or visit a friend. If angry, strategies include squeezing ice, pinging the wrist with a rubber band, or drawing a picture outline of the body, indicating where you would like to cut and then ripping up the image. While soothing and calming strategies make sense, there is a level where strategies which produce ‘safe’ self-harm do not. Violence begets violence and research has shown that active expressions of anger like hitting a pillow or screaming fuel anger rather than dissipate it.

Understanding self-harm requires an understanding of how this behavior has evolved over time and is now firmly located in the individual, family, and wider context system to which the person belongs. It has become part of the sequence of interaction between all those involved that fuels itself and needs no other reason than this.  What is this behavior ‘showing’ to the person hurting themselves and to those around them? It is not uncommon for a young person who is cutting to leave bloodied tissues which their parent hunts for and finds, triggering a predictable and repeating interaction between parent and child and sometimes those in the wider system. It is a message and when it becomes entrenched it is a message that fuels the next part of the pattern, perpetuating rather than interrupting it.

Given that self-harm is often understood as a way of managing unbearably intense feelings that cannot be effectively expressed any other way, it seems preferable to address this at a different level of system than that in which it is currently embedded. That is moving from the individual to a more social interactional and relational response. This can include supporting the person to accurately identify, label and respond to such feelings in another, less harmful way. It also requires a different response from those who as embedded in the interaction as the person who is engaged in the self-harm.  It seems paradoxical to ask a person to stop using pain to manage their feelings and then substitute this with a painful action. Better to alter both the system in which the distress is expressed, from the individual to relational and to substitute an activity which clearly suggests that when one has the urge to hurt, a compassionate, kind, and gentle response is more helpful.