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Of the many issues we find ourselves regularly facing, self-harm and eating disorders are arguably two of the most prevalent, yet also the least well understood. The question I’m most often asked by colleagues is ‘But why?’ and it’s a good question, the answer to which can provide the underpinning of a meaningful, supportive and sustainable client relationship.

There are many different motivations underlying self-harm in its many forms. We’ll explore the most common ones in turn and consider how we might tailor our relationship with our client in each of these cases.

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In my research, I’ve talked to thousands of young people about the motivations underlying their self-harming or eating-disordered behaviours. The most common reason I hear is that it’s a way of gaining control. There are few things that adolescents feel they can truly control – but their own body is one of them. The need for control can have a few slightly different geneses which, in turn, impact on our relationship with our client.

First, there’s the client who feels that every moment of their life is dictated. Perhaps filled with schoolwork and extracurricular activities. With little time to just be themselves, these young people will often feel like they have little or no part to play in their own lives.

‘I was on a treadmill of school exams and dance exams, none of which I felt that I’d chosen. It felt like there was nothing I could change or control – but I could control what I ate, what I drank and what I did to my body.’

With clients such as these, a key role we can play is to empower them to feel they do have some control in their own lives and to recognise where and how they can safely assert this control. We can also help them develop the confidence and self-esteem they need to become more assertive and to challenge, rather than accept, the decisions of others where these conflict with internal goals.

Second, there’s the client whose life is in chaos, often as the result of parental separation or living in care. With their life in free fall, self-harm can offer moments of clarity, where they have complete control over one small aspect of their life.

‘Life was a mess. There was all this … stuff … just going on all the time. I felt really helpless, but when I burned myself I would feel the opposite. Really powerful and completely in control.’

If the issue is at home, we might look to involve the family in our sessions. Providing a safe and structured environment for difficult conversations can be a real help. Often, our client needs reassurance from their family and an opportunity to understand what’s happening. Young people are often forgotten about during adult negotiations, with adults failing to realise the impact of their words and actions. Once they become aware of this, they will often willingly engage and support; this can have a huge impact on the child’s wellbeing.

Children in care will often find that meetings are happening about them rather than with them, even where these meetings relate to fundamental decisions about the child’s future. This can, understandably, leave a child feeling helpless. Where multi-agency working enables us to do so, we can support colleagues to take a more child-centred approach to such meetings; ensuring that not only is our client present, but that they are actively able to access and engage with the process and can contribute to the direction these meetings take. Where we are unable to effect this type of change, we might work with the child to consider different strategies for making their voice heard and, importantly, take the time to help the child decide what outcomes they are hoping for and how these might be achieved. Often they will not even have considered this.

Release

Many young people will talk about self-harm as the only method they have for releasing or relieving difficult feelings.

‘When I see the blood coming out, it’s like all my problems are coming out.’

‘If I’m feeling really angry, it’s the only thing that helps.’

‘When I binge, it completely numbs my pain for a while.’

For these clients, our priority is about helping them to recognise and manage difficult feelings. We can work with them to develop a range of different strategies for releasing their feelings, whether it’s talking, art, music or drama. The best approach is one tailored to the individual and which we revisit over time. Basic work around understanding emotions and emotional triggers can be helpful with these clients too. Often they have no strategies at all for healthy coping, so you might find yourself trying out a few different things with them until you happen upon a method they get on with.

Escape

In much the same way as stubbing a toe blocks out all thoughts and feelings bar how much it hurts, self-harm often has the same effect. This can provide blessed relief if the other things a client would have been thinking about are constantly causing them misery and pain.

‘All day, every day, all I could think about was him and what he would do to me next. I was always either replaying the last night or worrying about the next night. I found that if I hurt myself badly enough, then the pain would be so intense that for a few minutes, the pain was all I could think about. It was heaven.’

In this case, you might work with your client to develop alternative escape strategies – sometimes mindfulness techniques can help here. Many young people have talked about the benefits of adult colouring as a way of taking their focus away from everything else. Alternatively, listening to music very loudly or getting involved with team sports can both have a similar effect.

Punishment

Some people who self-harm do so specifically to punish themselves. This is usually either because they have very high standards for themselves or because they have learned, through a pattern of being abused, that they deserve to be punished.

‘If my marks weren’t good enough, then I’d go to the toilets at break time and cut myself while this voice in my head was calling me stupid and reminding me I’d always be a failure.’

‘If I failed a test, I wasn’t allowed to eat for the rest of the day.’

‘I would replay situations and want to just die. As I thought about the stupid things I’d said or done, I hit my head against the wall as hard as I could. Almost like I could bang out those memories.’

‘I went through a phase of only eating bland or rotting foods. I didn’t feel worthy of anything else.’

In these cases, a key focus is self-esteem. We need to help young people to understand that they do not deserve to be punished – which can be hard if they have been punishing themselves, or have been punished by others, for a long time. We can begin to help by challenging the negative thoughts and feelings that accompany the need to punish, and thinking carefully about the types of situations that our client feels warrant punishment. Often, they have set themselves unrealistic standards and will not forgive the slightest slip. Sometimes imagining these behaviours in a friend and asking, ‘Do you think they’d deserve to be punished?’ can help the client to look outside themselves and start to re-evaluate longstanding assumptions.

More general building of self-esteem can also help. As a child begins to feel more positive about themselves, they’ll be better able to challenge negative thoughts and feel less deserving of their punishment.

To feel cared for

Sometimes, young people self-harm in order to access kindness and physical care. Historically, we’d associate this behaviour with younger children experiencing neglect, whose physical and emotional needs were not being met at home and who would welcome the attention and support of a school nurse, counsellor or caring teacher.

‘It started with an accident – but the nurse was so kind and so careful that I found myself trying to have accidents more. I’d run around the playground as fast as I could, looking for things to trip over so she would look after me. I was forever ‘accidentally’ knocking off scabs so I had an excuse to go to see the nurse. I was six. I don’t think my parents even knew I existed.’

Increasingly, we’re seeing a similar pattern of behaviours in adolescents who appear to have it all: nice home, loving family, wanting for nothing – but they will talk of feeling alone. Often parents are working hard to maintain their lifestyle and there just aren’t enough hours in the day for emotional needs to be met.

‘My parents were always working – my school fees were expensive and we had this massive house and the nice car and all that, but all I wanted was someone to actually talk to me. To ask me how my day had been and have time to listen to the answer.’

Young people need to understand how to access support and care without the need for cuts, bruises or self-starvation. We can work on helping them understand that they are worthy of care, love and support whether or not their body physically spells out that need. However, we need to take care to help them identify where this support may come from as, unfortunately, it is currently far easier for the child who is self-harming or restricting their food intake to access appropriate support than it is for the child who is not.

Where a child is willing for their family to be involved in their recovery, it can be useful to help them understand that their child is feeling lonely, and provide practical suggestions for rebuilding these relationships. In many cases we will find that we are confronted with caring parents whose absence is born out of a desire to do the very best for their child and who will often make rapid and drastic changes to their working patterns and lifestyle in order to support their son or daughter if they think this will help them.

However, if we feel that there may be underlying child protection issues surrounding our client’s neglect, we must always follow the appropriate procedures.

To feel real

Young people who are suffering with depression will often turn to self-harm just to feel real for a little while.

‘I was numb all the time. I felt nothing. No feelings of happiness or sadness or anything. Just numb. The only thing I could feel was pain – so I would pull out my hair so I would feel alive. It was like pinching yourself in a dream.’

It can be very hard for people with depression to feel connected with the world, and these physical reminders that they are alive can offer a lot of reassurance. You might explore different strategies for achieving the same thing. Cold can be very effective – clenching ice cubes, eating an ice lolly and thinking about how cold it feels. Or plunging their hands or face into a bowl of ice water might help our client to feel more real.

I hope this helps to highlight how a similar pattern of self-harming or eating-disordered behaviours in our clients might have a whole range of different underlying reasons – and that as we begin to understand and question these reasons, we become more able to help. Of course, each case is unique and many young people will arrive at our door with a lack of insight and understanding of their own condition, so we can feel a little bit like we’re in the dark at first. Once we’ve established trust and helped our client to develop the skills they need to explore and express their own experiences, we will be in a position to begin to understand the underlying issues. At this point, we can begin to work towards developing the skills, strategies and support needed to keep our client safe, not just this week or next, but for a lifetime.

Pooky Knightsmith completed a PhD in child and adolescent mental health at the Institute of Psychiatry after winning her own battle with anorexia and selfharm. She works as an associate trainer with the Charlie Waller Memorial Trust.¹

Reference

1 www.cwmt.org.uk (01635869754; admin@cwmt.org). The Charlie Waller Memorial Trust provides funded training on depression and related issues such as self-harm, eating disorders and stress/anxiety for schools and other organisations working with children and young people.

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