Date Posted: Monday, 6 September 2010
Salvaged in recent weeks from my attic,the following is the text I found on sheets of paper filled with handwritten words. I wrote this piece as an introductory exploration of how to deal with incidents of self-harm in residential child care. It was part of an induction programme I developed for my colleagues when I was a manager of a children’s home in the east midlands of England. Penned in October 1985 readers may find it outdated now but I hope it may still be useful in generating a discussion about self harm. For myself I think these days I would take a more “whole person” approach to this matter rather than isolate the symptom and I think there are hints within the article that I may even then have been beginning to move towards addressing this issue in that way.
When I wrote this there was a school of thought which considered my decision to include excessive consumption of alcohol as a self-harming escape from painful memories as contentious. I have never really understood this objection. I was then, and given the information that is currently available to me, I am now as certain as I can be that alcohol is used in a way that is self-harming. I also believe that like all behaviours described as self-harm the use of alcohol to an excess often masks deeper anxieties and fears.
Young people who self-harm : some theoretical and practical considerations for care workers when helping young people who harm themselves
What self-harm represents
Young people who behave in a way which manifests a need to harm themselves are very unhappy. For these young people, the acknowledgement and the communication of their problems are often the most threatening obstacles they have to surmount when they come within the ambit of our care. Self-harm can take many forms but usually it is symptomised by repeated episodes of injury to the self – often taking the form of self-mutilation – and a poisoning of the self. The process of preparation required of a young person if he is to successfully overcome tthis problem can be lengthy and painful. Accepting that at one time or another we all have difficulty acknowledging problems which influence how we act, we should not be surprised when these young people have difficulty communicating their problems to us. Invariably they have experienced a prolonged emotional battering and, despite anything they may defensively insist to us to the contrary, their self-harm invariably represents feelings of very low self-worth.
Identifying the problem
In the face of a young person’s self -harm, a task for the care worker is to begin to identify what the young person’s problems are. At a symptomatic level self-harm is manifested in many ways. It is evident in self mutilation such as wrist cutting, or cigarette burns, in substance abuse, alcohol abuse, drug abuse, drug or alcohol overdosing, and in eating disorders. It can lead to anti-social behaviour and to the destruction of valuable relationships as well as educational, career and other life prospects. Nonetheless I believe we should be wary of holding the view that only what we actually see is the problem. For example, when Peter, (a fifteen years old boy who has been placed in a children’s home primarily as a response to his alcohol abuse), is intoxicated, parasuicidal incidents occur. He takes an overdose of painkillers but places himself in a position where he feels assured that he will be discovered by someone who will take action to make sure he is made safe. When he is sober Peter has the conscious capacity to be aware of his problem and to acknowledge that drinking too much alcohol makes him vulnerable and places him in situations which are potentially fatal for him. Yet even when Peter’s conscious recognition of the issues is followed by his stated determination to stop the behaviours because if he does so he will become healthy and less vulnerable, we may find that Peter to consume alcohol to dangerous extremes. When this happens it is all too easy for us to conclude that the young person is ‘weak willed’, or even to conclude that he is acting out just to defy us. It is at this stage that it might be more helpful for us to be more open-minded about what is happening and assume that the cause of the problem may be something other than what presents itself to us. There are a number of theories which might help us try to make sense of the self -harm phenomenon. Here I consider two, social learning theory and psychodynamic theory which I believe may help gain an insight of what is happening emotionally for a young person like Peter.
Two theoretical approaches
I have chosen these two theories because I believe they can be combined to create effective practice strategies
1. Social learning theory
We may for instance begin to consider the young person’s the presenting problems in the light of social learning theory. We would observe that Peter had not reached a maturational level where he felt able or had the motivation to accept and take up aspects of behaviour demonstrated by what we might consider, as social learning theorists to be our positive adult role model. A further observation we might make is that Peter is at a stage where modelling is based on negative behaviours offered by adults or peers who have previously offered or are offering inappropriate role models. Social learning theorists argue that those who have a low estimate of themselves credited their achievements to external factors rather than themselves. The role of the care worker with a young person who is self-harming is to take opportunities to provide the young person with good experiences which by repeating or modelling them to the extent that they occupy areas of his inner world once inhabited by poor experience and negative modelling. The young person may then begin to feel that the good experience is inside him and is not external to him.
Taking a psychodynamic view of Peter’s presenting problems then we see the symptoms as secondary issues – though nonetheless worrying ones – which are the symptoms of a deeper primary problem. Over time we may conclude that these secondary issues – the drinking and the incidence of parasuicide – are symptomatic of a more fundamental emotional problem created by unhappy past experiences such as sexual abuse, continual physical or emotional abuse which have not been resolved. The psychodynamic argument would also posit that the young person cannot understand the cause of the unhappiness because it is so deeply embedded in his unconscious and because the original cause is so painful to rationalise. Accordingly it becomes preferable for the young person to communicate the problem through self-destructive behaviours, or to use those behaviours as a way of escaping or denying his bad feelings about himself and significant figures in his life. It should be noted that though in the final analysis self-harm may be a cry for help, it can be something which the young person wishes to hide from others. The psychodynamic approach insists that until the cause of the unhappiness is confronted, with all the emotional pain this may cause, the young person is unlikely to be able to be at one with himself.
Remaining emotionally in touch with a young person who self-harms
Whichever avenue of approach we take in our work with young people who appear to be bent on self harm, we should keep in close social and emotional touch with the young person, in spite of the variety of stratagems that will be used by the young person to divert us and reject us when we close in on what is really motivating the self-destructive behaviours. In most cases self harm is not intended by the young person as a way of ending life. It is more likely to be a dramatic way of drawing the attention of others to the fact that something is wrong. The young person is saying that he or she cannot for whatever reason express in words what is wrong at that time. It is undoubtably an attempt, to take some control of what at the time must seem an unbearable emotional crisis as well as an attempt, however bizarre its method, to make a cry for pity, a cry for care, and most of all a cry for help.
Responding to incidents of self-harm
Responding to, and dealing with such behaviours is of course very stressful for support workers. While coping in practical terms with the aftermath of an incident of self-harm and ensuring also that emotional first aid is available throughout the recovery period, workers also have to deal with the emotional impact the incident has had on themselves and continually work with the potentially life threatening risk in which the quality of their judgement and decision making is critical.
Given the high potential for self harm to have long lasting injurious or even fatal consequences, a care worker should not only be sensitised to a young person’s current emotional state but also be alert to the extent that she can anticipate events by offering strategically timed encouragement with a view to preventing an episode of self harm. The care worker’s encouragement may not always be welcomed but it is important to be determined in your support. This requires a great deal of emotional stamina on the care worker’s part.
Managing an incident of self harm it is important seek qualified medical help as soon as is possible. It is important too that a care worker seeks the cooperation of colleagues to deal with the situation. This may not necessarily demand the continued presence of a colleague but it requires that such a colleague remains highly aware of the dynamics of the situation and is ready to support if called upon. There may also be a need to try to ensure that the objects or substances which the young person is using to harm themselves are removed. It not always be wise to achieve this by direct physical action since this may endanger both the young person and the care worker. Working gently to establish calm is more likely to be safer and in the long term more effective than direct physical intervention.
After the young person has been seen by a medical practitioner, he will need close, sensitive, and frequent care and encouragement after an incident of self harm. On a practical note it will be important that each time before you leave a young person who is recovering from a recent incident of self harm that the care worker is assured that the young person has reached an emotional state of equilibrium which you judge is safe. Often workers are emotionally affected by these events and their judgment might not be as fine as it normally is and so it a sign of professional insight and strength to seek a second opinion from a colleague on the young person’s emotional state.
Working in longer term with a young person who is self-harm, though it may be essential to keep a young person focused on looking at what lies behind self-destructive behaviour, consideration must also be given, as to when to confront a young person about what it is that lies behind their presenting behaviour and care should be taken to remain empathic while the young person tries to face his emotional pain. Here listening is all important as well as the acknowledgement of what the young person has said. The worker should not have her own ready made solution which she communicates to the young person. To do this may be to make light of his very real suffering. Much more likely to succeed is sensitive listening perhaps on many occasions over what may be an extended period of time which will allow the young person to begin to make his own emotional sense of his difficulties.
Charles Sharpe, October, 1985
© Charles Sharpe 1985
Links to other articles on the site
Social Learning Theory http://www.goodenoughcaring.com/Writings/Writing72.htm