Working With Self-Harming Adolescents

There is growing recognition and awareness of how frequently young people harm themselves and of the need for sensitive, informed responses. The trend towards reducing stigma, and facilitating talking about self-harm and mental health issues more generally, helps significantly. Yet thinking about self-harm is still bedeviled by confusions and contradictions. There are competing definitions that indicate different conceptualisations, and disputes about the relationship between self-harm and suicide. There is a tendency to take the problem of self-destructiveness out of self-harm acts, when they are seen as ‘coping mechanisms’. This reduces the multiple expressions, complex and often contradictory motives to simple formulae, or one-line expressions of motivations, such as ‘to feel relief’. Of course self-harm has an aspect that is – or can be – a coping mechanism and some people self-harm to experience a sense of relief. But what is going on beneath the surface can get lost.

Sometimes self-harm is seen as synonymous with self-cutting, though most definitions in current use – including NICE, Young Minds etc – define self-harm as any form of harm to the self, irrespective of method or motivation, and thus including suicide attempts. The relation between self-harm and suicide is central and complex. The notion of ‘non-suicidal self-injury’ suggests that two categories can be treated as distinct. There is a lot of evidence to say this is mistaken:

·      Self-harm is the most significant risk factor for suicide completion

·      Individuals who repeat self-harm use different methods for different episodes

·      Self-harm by cutting heightens the possibility of suicide completion

·      Individual’s accounts of their motives change over time; they can be multiple even in the same episode

·      Statements of conscious intention – whether there is a wish to die or not – are very poor predictors. Suicide is a rare event, and most episodes of self-harm do not lead to suicide completion, but the possibility – or risk – is often present

So psychotherapists are often preoccupied with assessing risks. This an anxiety provoking process. We can wish that assessing risks could be objective, neutral, and somehow providing certainty. Yet none of these are true or possible. It has been shown that risk protocols or scales are inaccurate, misleading, tokenistic, and interfere with the process of assessment. Assessing risks is ubiquitous; we live in a ‘risk society’ involving a calculative approach to decision making, when there are few social givens. But for psychotherapists, risk assessment needs to take place within a therapeutic approach, where consideration of risk factors is part of a comprehensive, collaborative assessment of needs and risks.

We can get past the problems of risk assessment by initiating and sustaining a therapeutic relationship, a space to think, offering multiple meetings with a young person. Seeing someone more than once is crucial anyway as the young person who comes to a second consultation is often quite different from the one we meet in the first meeting! We can focus more on implications.

Firstly, self-harm has an implication for development, through having traumatising effects. Secondly, it is a manifestation of disturbance of developmental processes. Working with the disturbances in the adolescent developmental process provides an important way to understand the meaning of individuals’ self-harm. Conflicts between becoming more separate – more adult, on the one hand, and retaining childhood ways of relating, on the other hand – provide the dilemma as to whether to try to face or to bypass the pains of growth, and the crucial but difficult process of mourning the loss of past, childhood relating. Relating to the new adult sexual body and its increased power to act on impulses and fantasies involves intense emotional experiences which disturb previous patterns of containment. New defences against anxiety become necessary, and some young people reach a developmental impasse, focussed on the ambivalence, tensions and conflicts about needing others, on the one hand, and being more separate on the other hand.

This takes us beneath the surface to the core struggles between destructiveness, growth, defence and development, and thus to the meaning of self-harm.

Self-harm and Suicidal Behaviour in Young People: Current issues and contemporary practice, a one-day workshop with Professor Stephen Briggs and Dr Terence Nice, is at Broadway House, London SW1H on March 1.