Part six of my article published in the Healthcare Counselling and Psychotherapy Journal last year.
People who work with clients who self-injure need to be prepared to give up their preconceptions and accept that self-injury has a purpose, a function and that it is a ‘valid’ way to cope for those who feel they have no other way.
The work requires patience, setting aside judgement, and effective use of supervision and/or debriefing in order to help and empower clients.
Before considering how to provide new choices for people whose self-injure, professionals working with such clients should reflect on how they may feel throughout the process. Self-injury is such an emotive subject that it will affect anyone working with people who self-injure on an emotional level, and they may end up feeling uncomfortable and less than confident in their treatment and support services. Ensuring that you have colleagues with whom to discuss your observations and feelings, and that you make use of supervision and/or team debriefing sessions is very important.
When I am delivering training to carers, doctors and welfare officers, we often talk about how frustrating it is to be able to help a person for only a few weeks. We talk about feelings of inadequacy, and even anger at some clients’ lack of progress. Thus I am hoping that the majority of professionals work within a close team, and that they have excellent debriefing processes whereby they have chance to express themselves and seek counsel from others who are experienced in regard to working with clients who may self-harm.
There is also a need for professionals and professional teams to recognise that self-injury is often a long-term entrenched behaviour. There is no quick fix, drug, or therapy that offers a solution for all. Moreover, people often self-injure for years before disclosing their behaviour to a professional. This professional’s reaction may set the scene for any help the person may seek and receive in future. It is therefore vital that anyone working with a client who self-injures be open, non-judgemental and fairly non-directional, as any hint of exasperation or dismissiveness may switch the client off to receiving help that is offered.
It follows that anyone working with a client who self-injures should not expect a change overnight. A person does not move away from self-injury just because they have professional help and support, however excellent that support may be. Professionals should be prepared for the long haul: even with a client who responds well and acts on everything they have put before them there may be multiple relapses. A person may have an absolute understanding of their self-injury and the advice given, yet still return to self-injury when they feel crushed by life.
Professional should not berate themselves for being just a small part of a larger chain of support. They may not see the full value of their part in therapy come to fruition, but the seeds they plant in their time working with a client can be life-changing for that person later on. They should not discount their impact, even if it is a smaller contribution than they would like.
It can be helpful for professionals to talk about self-injury in a frank and practical manner with clients who self-injure. However, the focus should be on the emotional drivers behind the behaviour, rather than behaviour itself or its physical effects. ’Scar checks’ are inappropriate except in the case of physicians who need to physically treat a patient. A person’s emotional distress cannot be judged by their wounds. Self-injury may tell a story that is written on the body, but only the person involved can read it. Body checks invade a person’s personal privacy and destroy the trust and honesty required in a therapeutic relationship.
It is also important to avoid ‘no-harm contracts’ or any attempt to impose one’s will as a professional upon the client. A person may well be in a powerless situation at home or work, and self-injury may feel like their only way of retaining some authority over their lives – this should not be taken away. Instead, a client should be reassured that they are not being asked to ‘stop’, but to develop new ways of coping so that they have more choices. To empower people they must be provided with more, not fewer, choices. The choice to self-injure is always the client’s.
Coming next: Distraction and alternatives.
Finally, a professional working with a young client should explain their confidentiality policy in a clear and open manner, and inform the young person of exactly how the professional means to work with their parents or guardians. The parents of young clients can often need managing, and professionals should dissuade them from over-reacting. Removing all the knives from the kitchen does nothing but force shame upon a child, and they will become even more secretive about their self-injury. If their bedrooms are raided and ‘tools’ and items (like bandages) are taken away, they may be forced to use alternative methods of self-injury they are not familiar with. Broken glass and lighter flames can be more dangerous than razor blades and safety pins.