Self Injurious Behaviour

Does this topic stir up certain emotions and responses from you?

It potentially could. Some therapists have said that it leads to the creation of a dialectic between oneself and another - common transferences and countertransferences take the form of Empathy, Concern, Curiosity, the Wish to Relate, as well as others like Revulsion, Rage and Wish to Run.

But what about the point about culture and its influence on our acceptance and perception of these acts? Some common things that come to mind like self-flagellation, smoking, scarification and body art are so embedded into our culture regardless of what age and country you're in.

According to the UK Nice Guidelines (NICE, 2004), self-harm is "self-poisoning or self-injury, irrespective of the apparent purpose of the act" and the WHO calls it "an act with non-fatal outcome, in which an individual deliberately initiates a non-habitual behaviour that, without intervention from others, will cause self-harm, or deliberately ingests a substance in excess of the prescribed or generally recognised therapeutic dosage, and which is aimed at realising changes which the subject desired via the actual or expected physical consequences" (Platt et al., 1992).

However, self-harm does not often result from the wish to die. Those who self-harm may do so to communicate, to secure help and care or to obtain relief from an overwhelming situation, as we may possibly comprehend. So why do people self-harm then? Here's a summary from a variety of sources.

The patient's stance: meanings and functions of self-harm

One way the practitioner can begin to tolerate the kind of disturbance aroused by patients who self-harm is to work with them to make sense of the idiosyncratic narrative that has produced their behaviour. I.e. to help them understand why they do it, and not to stop them from doing it.

In some way, this phenomenon may resemble substance use, where many individuals use for difference functions and holds different meanings for them, despite the biased view that they have no self-control. But I digress... substance use is another complex phenomenon that cannot be easily explained without individual context and sensitive enquiry.

Common meanings and functions of self-harm may be:

an attempt to end life
many acts of self-harm are not directly connected to suicidal intent
to influence or to secure help or care from others
a way of obtaining relief from a difficult and otherwise overwhelming situation or emotional state
paradoxically, to preserve life

a way of surviving a relationship
a form of communication
an expression of rage
a form of punishment of self and others
a defence against murderous rage
a way of dissociating
a way of feeling "real"
a defence against "bad" sexual affect

Clients are often unable to get past an experience of "feeling bad", sometimes accompanied by bodily sensations that are described as "weird", "blank", or "unreal". Nathan (2006) pointed out that the psychoanalyst W. Bion (1967) suggests that such individuals are unable to give meaning to somatic experience; they might have no idea that "butterflies in the stomach" are a sensation for which we might use the word worry or "I feel anxious". They are therefore less able to translate the language of the body into a language of a psyche apprehending a range of complex emotions. Theirs is therefore an experience that is raw and sometimes bizarrely psychotic, leaving them overwhelmed, out of control and terrified. It is not surprising that, in these circumstances, they resort to self-harm.

Theoretical views and interpretations

Armando Favazza's 1987 book “Bodies under siege: self-mutilation in Culture and Psychiatry”, second edition seminal text from 1996 “Self-Mutilation and Body Modification in Culture and Psychiatry”.

“the deliberate destruction of one’s body tissue without conscious suicidal intent”

He described self-injury as a morbid form of self- help, temporarily alleviating distressing symptoms, and attempting to heal themselves, to attain some measure of spirituality, and establish a sense of personal order.

Freud wrote "the ego is the first and foremost a bodily ego; it is not merely a surface entity, but is itself the projection of the surface" - he emphasised that the ego was ultimately derived from bodily sensations, especially those coming form the surface of the body.

Gwen Adshead's (1997) view of it being "written on the body"

Self-harm is the registering of the dynamics of an inner object formation, a form of mapping on the body, and an embodiment of the related mental phenomena.
As we will illustrate it is in part an “enactment” founded on projective identification of unintegrated feelings from these earlier experiences and trauma.
For example when we think about cutting: what is felt initially and internally as a sensation is externalised and fixed as memory on the skin.
Paradoxically, cutting is both a defence against thinking about the past, and an evocation of sensations of an earlier violation in another from.

Self-harm:- the body or skin as a medium for communication

Involves the body and our bodily selves. Often involves the boundary of the body- either the skin, or through ingestion of medication or poison – i.e. connects the external with the internal; boundary between ourselves and others.

This suggests something about transition:- the transition from outside to inside;- from external reality to internal mental life or from insides to out e.g. with the flow of blood. The idea of transition suggests that it may represent difficulties faced at points of transition in life and the challenges these face us with us individuals with links to earlier points of transition related to maturational processes. While it maybe be seen and used as a communication, it is often unseen and conceals hidden meanings.

Presence of the "bad object" and the absence of the "good"

Our sense of self is built up from internalised self- object representations in the presence of our primary care giver. We can start to get a sense of how when this goes well in the presence of a loving and caring understanding primary care giver that is able to help the developing infant make sense of both its internal and external environment, that a secure sense of self develops, and the mental processes that underpin this to be able make sense of and manage feelings, and to tolerate frustration, while maintaining a stable sense of integrity.

What Bion, Klein and Segal postulated is that these individuals have in common is an absence of a "good internal object" that can help contain their experience. According to Nathan (2006), the model for this is the mother-infant relationship, in which the mother (or carer) uses her understanding to help the infant with their anxieties. As these experiences are repeated over and over again, the infant comes to internalise this relationship. This benign relationship template is carried within helping to form a secure base (i.e. attachment security) that acts as a model for a self that is able, on the whole through supportive relationships, to regulate affect. This is then a development of a template that provides mental stability. Peter Fonagy at UCL and his colleagues assessed parents before the birth of their child and found that demonstrating a high capacity to reflect (mentalising capacity) predicted a secure attachment relationship in the child.

The absence of this secure relationship, however, would result in a template containing a persecutory and terrifying script taking a stranglehold on the individual's mental life. Marsha Linehan calls this the "invalidating environment" we're so fond of quoting. Thus, instead of finding a human relationship to contain overwhelming anxieties (and other distressing emotional states), the individual may turn to what is essentially a perverse relationship based on self-harm.

Psychic Pain

According to Freud internal pain can only take place after the child has experienced pleasure and satisfaction of the mother’s presence and from union with her. Mental pain in adulthood is a manifestation of the archaic longing for her. Freud posed the following questions: “when does separation from an object produce anxiety, when does it produce mourning, and when does it produce ...only pain?” He suggested that anxiety in response to the fantasy of loosing the object, depression when an object has been lost and pain is the experience of longing for a mother.

As Acting Out and Enactment - a symptom that needs to be understood

This the essence of what Freud (1920 11) saw as the repetition compulsion. “That which can not be understood inevitably reappears; like an unlaid ghost that cannot rest until the mystery has been solved and the spell broken.”

Acting out is the substitute for remembering a traumatic childhood experience, and unconsciously aims to reverse that early trauma. The person is spared the painful early memory of the trauma, and via her action is spared the painful memory of the trauma, and via action masters in the present the early experience she originally suffered passively.

Therefore the “actors” in the current situation are seen for what they are now rather than what they represent from the past. The crucial point is that the conflict is resolved, temporally, by use of the person’s body in a destructive way. They will implicate and involve others in this “enactment”. The others maybe innocent bystanders or have their own unconscious reasons for entering the and playing a continuing role in the person's scenario. The person creates the conflicts from his past in the people of the present forcing them by use of projection and projective identification to experience feelings that his consciousness can not contain.

The sufferer gains temporary relief but as the players in the patient's play disentangle themselves from their appointed roles projection breaks down and what has been projected returns to the patient. Because she knows no other solution by which to escape her inner conflicts the patient is forced to create the same scenario anew.

Freud's Mourning and Melancholia (1917)

Freud's contribution was to identify suicide (+ self-harm) as an activity that can be understood in relational terms. Underlying all suicides and similar acts of self destruction there is an attack upon the self that is self-identified with a hated object; and the act is simultaneously a punishment of the self for all its sadistic and cruel attacks upon the object.

Melanie Klein's contribution

Klein showed how the inner world is built up through a complex interplay of the process of projection and introjection. As noted fundamental to development is the establishment internally of a good object to sustain the self in various anxiety situations.

To preserve the good object it is necessary for the infantile mind to create splits, the most critical is that between his own loving and aggressive impulses. The world is then divided between idealised “good” objects which are maintained internally, and “bad” ones which are felt as persecuting are projected externally.

Therefore the more intense the infant’s own sadistic feelings, the more terrifying the external “bad” object and the more intense the idealisation of the “good” object which is felt to offer a perfect world with the absence of frustration, anxiety and mental pain.

In this situation there is a lack of capacity to experience loss as an absence of a good object. Instead the place where there might have been awareness of the absence of a good object is replaced by the presence of an object felt to be bad and responsible for all the painful feelings of loss and frustration. As development proceeds →↓ of splitting and projective processes and a move towards integration - described by Klein as the move towards the depressive position from the paranoid schizoid position.

→ an awareness that cruel impulses have been directed to an object that is not just bad but complex, both good and bad. This recognition brings forth painful feelings of remorse and guilt, which are the foundation for the capacity to be aware of an object which although lost remains good. This brings feelings of pining for the lost object and a mourning of its loss.

Klein and Freud

For Freud the ego was first and foremost a bodily ego so it maybe easier to understand the attack on the body in identification with the lost object. Klein's understanding of the inner world helps us to understand how deep splits in the inner world between a part of the self in relation with idealised object, and a part of the self felt to be bad and subject to terrifying cruel attacks are characteristic of suicidal patients. The idealisation serves to protect the good object from self’s own cruel murderous wishes and the “bad” parts of the self become identified with part or whole of the body.

Glasser's Core Complex (1992)

Glaser describes this as a universal complex which he places as central to the structure of the psyche. The fantasy of fusion with the idealised mother who satisfies the (infants) basic need and longing for security:- a wish to merge “a state of oneness”/ “a blissful union” (normal in devel.):- the ultimate narcissistic fulfilment. But the mother is seen as a split figure; relating narcissistically to the subject.

Being both:

Avaricious: so the fusion involves incorporation with a mother that threatens to annihilate the self (engulfment, possession etc.).
Indifferent: paying insufficient attention to the needs of the subject:- experienced as rejecting.

This configuration → annihilation anxiety and concurrent defensive responses.

Defensive responses to annihilation anxiety:

(narcissistic) withdrawal to a place of safety and self sufficiency:→worries about being abandoned and falling apart with associated states of depression, isolation and low self esteem, which in turn leads again to the wish for fusion.
(self-preservative) aggression aiming to destroy or neutralise the powerful, annihilatory mother, which → fears of her loss and rejection.
Since these responses are concurrent the aggression is also turned on the self.

Gardner's - The Encaptive Conflict

Gardner suggests that a particular configuration of this conflict is involved that is similar to the core complex but also different in significant ways. In the psychic conflict she highlights the fantasy is being stuck with the malevolent figure of an avaricious overwhelming mother. This is a development from early infancy and early object relations where the self is captivated and held in thrall by a particular aspect of the mother that threatens complete incorporation. This forms into a tyrannical inner object configuration who both overwhelms and from whom there is ambivalence about separation.

There is then a desperate oscillation going towards and away from the malevolent figure. Her work with young women who were cutting revealed this “intrapsychic struggle characterised by a quality of enslavement and a longing to cut the ties that so tightly bound this relationship”. A further characteristic was that “the young women appeared to be almost enthralled in this state of mind” - hence “Encaptive”.

It means a state of being captivated and includes a sense of omnipotence and aggression: an intense involvement and possession characterised by the wish to get away; manifest as withdrawal and aggression turned on the self.

The dynamics of Abuse:-Physical and sexual (Gardener)

Relation with the extent of the trauma and the degree of powerlessness felt by the child. The child will often feel different and distant from others and way of future relationships. Overwhelming feelings maybe coped with by a passive resistance and dissociation as a type of defence. Dissociation works because it gives a sense of personal control and power, in a situation where there was none. It can become incorporated into the self and become reinforced as a way of being.

The experience with the abuser can be internalised as a dangerous figure in the psyche, yet one with whom there is deep involvement and from whom it hard to break free. We can see this is especially complicated if the abuser was someone who was previously trusted and loved e.g. a parent. This creates a psychic dilemma when the child simultaneously perceives and confuses the “good” object with the “bad” behaviour and the unbearable confusion → with rage and horror internalised as parts of the “bad self”, allowing the child to hold onto a phantasy of the loved, needed object as “good”.

The body violation and actual penetration of the skin can be seen as in part a repetition and unconscious enactment. The opening up of the skin maybe a wish to excise and expunge what is felt to bad and externalise and fix on the body surface. The angry violence is unconsciously directed both at the tyrannical object and the victim self:- it is self preservative and sado-masochistic, and ultimately self-destructive. Appropriate anger at something that may have happened in childhood is expressed and supressed simultaneously.

Harming the body may then be seen as punishing the body for any gratification that maybe have been experienced. It maybe linked to feelings that they were somehow to be blamed for what took place and at a deep level the child takes on the guilt and responsibility and so feel the need to hurt herself and make reparation. Key aspects that link with abuse are control and power, owned by the perpetrator during abuse, retrieved and repeated by the abused when she harms herself. Mastery represents the desire to gain control over another either as in abuse; this is repeated in harming the self.

As a sign of Hope - Motz

Motz suggests that self-harm is fundamentally an attempt to stay a live. That through its communicative aspects and powerful function for the person and must be clearly distinguished from the suicidal attempt. She draws on Wnnicott’s (1956 (18) ) notion of the anti-social tendency (Delinquency) as a sign of hope. That the act of aggression, apparently destructive and hopeless, reflects the person’s hopefulness in an environment that can recognise and meet their needs.

"Signing with Scar" - Staker 2006

Straker studied transcripts from people who self-harmed. More than just a form of communication, or an inability to verbalise that fails to account for high levels of literacy and eloquence of many self-harmers. But a means of self-creation closer to affective states than words are. “...over and above the function of self- soothing, self cutting is an attempt to put into place the elements involved in building a self-structure”.

These include:

Mirroring
The establishment of the boundary.
The building of an autobiographical narrative.
The impregnation of verbal signifiers with signifiers of the flesh.
(the notion of the word made flesh - Motz)

Managing Self-Harm

Countertransference responses to self-harm are meaningful sources of information about the intentions and states of mind of their patients. The dilemma for the practitioner is to accept the self-harm while enabling their client to give it up.

Essential to have supervision and reflective space to manage responses and process the meanings and feelings it evokes. “To remain receptive without unthinkingly being caught up in projections and re-enactments.. The unconscious hope is nursing staff can do something positive with communication”(Aiyegbusi). To retain hope when the self-harmer feels lost and by surviving the hostility offer the possibility of containment and understanding. Through true relational contact lessen the grip of self-harm.

Recommended features of therapeutic work with patients who self-harm:

The work should be intensive and long-term (weekly sessions for at least 18 months to 2 years, or more)
Active emotional engagement of the therapist
Mistakes and enactments of the patient's problems will inevitably occur
The therapeutic environment should provide an opportunity to reflect on these mistakes and enactments (even when they are the therapist's)
A narrative contruction should emerge (of the "Oh, I see this is what happens when I feel attacked/ rejected/ bad, just as it did the last time" type variety)
This construction will be a product of both therapist and client
Experience of working on and through these repeated dynamics will help the formation of an enhanced reflective capacity (i.e., enabling complex metallisation). This will improve the client's ability to think rather than act destructively, or to act in a way that is more self-protective or less self-destructive (harm minimisation).

References.

Burbidge-James, W., and Heydari, H. (2014). Psychoanalytic Contributions to understanding self-harm. RCPsych International Congress London.

Nathan, J. (2006). Self-harm: a strategy for survival and nodal point of change. Advances in Psychiatric Treatment. Vol. 12, 329-337.