Self Harm as a Sign of Hope

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Self Harm as a Sign of Hope

• Anna Motz
• Consultant Clinical and Forensic
  Psychologist, Past President IAFP

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Self Harm as a Sign of Hope

• Anna Motz
• Consultant Clinical and Forensic Psychologist,
  Past President IAFP
• October 2009

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Self Harm as a Sign of Hope

• In the hopeful moment...the environment must be
  tested and re-tested in its capacity to stand the
  aggression, to prevent or repair the destruction,
  to tolerate the nuisance, to recognise the
  positive element in the antisocial tendency
  (Winnicott, 1956.)

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Self Harm as Violence against the Self

• In self harm, rage is split off and projected
  onto the body
• The body as an object to be written on, tortured,
  and at times, mutilated
• The mind is preserved as a safe place, as psychic
  pain is discharged onto body, and the body
  withstands this.

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Self Harm as Hidden Violence

• Typically female expression of violence
• Often directed at hidden parts of the body
• Woman are using one part of themselves as an
  object onto which to target rage
• Releases tension, pain, feeling, and replaces
  thought

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Development of Violence

• Failure to mentalise (Fonagy and Target 1999.)
• Violence, aggression directed against the body,
  may be closely linked to failures of
  mentalisation, as the lack of capacity to think
  about mental states may force individuals to
  manage thoughts, beliefs, and desires in the
  physical domain, primarily in the realm of body
  states and processes. (Fonagy and Target 1999
  53)
• Objectification of oneself and othersno real
  sense of subjectivity.

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Cycle of Violence

• Cycle of violence develop violent fantasies as
  release, escape (Welldon, 1988)---failure of
  fantasies to comfort, discharge tension.
• Addiction to violent actionagainst the self or
  others
• Compulsion to act-brings short-lived sense of
  euphoria
• Release only temporary toxic affect returns

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A Psychological Model of Female Violence (Motz,
2001)

• Violence seen primarily as communication
• As a response to powerlessness
• Solution (however maladaptive it seems)to
  underlying psychological difficulties
• For women often hidden, in the home, against the
  self, in secret, private places

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Self-harm as an Act of Hope

• Assault the environment (the body) to see what it
  can withstand, and provide
• Allows the mind to be freed temporarily of toxic
  material, painful memories
• Expression of unarticulated feelings
• Ultimately an attempt to reach out to others in
  the hope of a response attempt at relating

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Self Harm as Communication

• Self harm is distinct from suicide or suicide
  attempts
• paradoxically, self-injury is usually a life
  sustaining act
• It is communication through the use of violence
  against the self, and its impact

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Clinical Illustration

• Self Harm as Life Preservative Violence

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Scalding, Blood-letting and Cutting Miss Y

• Miss Y was a 34 year old resident of a
  therapeutic community on a forensic unit
• She had a history of physical abuse and
  emotional neglect, suspected sexual abuse
• At times of great distress she poured pouring
  water on herself, cut herself and meticulously
  drained blood from wounds

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A Platform for Performance

• Miss Y described being in the TC ward unhelpful
  it encouraged histrionic and public expressions
  of distress
• She preferred to hurt herself in private and then
  present herself to the staff much later, once her
  wounds or burns had healed
• She admitted to enjoying taking care of her own
  injuries, but then showing them to others, and
  seeing the scars heal over time

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Bodily Countertransference Initial

• My eyes were drawn to her dramatic, visible
  scars, forming criss cross pattern all over her
  arms--I felt sick and compelled to stare
• I had a powerful urge to interrupt the session to
  leave being in the room was almost unbearable
• Sight of naked arms with scars, mottled flesh
  compelling and alarming

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Therapy Stages and Themes

• Introduction Creativity and Seduction
• Poetry-presenting me with realms of written work
• Images-verbal, visual, visceral
• Dream diaries-filled to the brim
• Developing trust and hinting at untold and
  unbearable secrets

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Retreat from Therapy

• After this initial outpouring of thoughts,
  feelings (first three months of therapy)Miss Y
  began to retreat into a non verbal state
• I can think only in images, and flashes, not
  words
• Intensification in self harm--internal and
  external
• Lying down in the sessions, curling up,
• Despair at thought of stopping self harm I feel
  I will have lost my best friend

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Violence to Self as Displacement

• Miss Y became terrified that as she gradually
  gave up her self-harm activities she would become
  more likely to attack others, or set fires (as
  she once had)
• She revealed that blood letting had followed her
  own experience of a life-threatening operation
  -sense of power, control and omniscience-knew
  what was inside

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Cutting up and Cutting out

• Afer initial reduction in self harm, Miss Y
  became very scared, and then a period followed
  where self harm intensified, and then periods of
  time when she was silent, rocking, and
  dissociated.
• Cutting internally, a letter to tell me she is
  storing up weapons to use against herself.
• Loss of focus in powerful and unreachable states
  of pure dissociation--I am cut out and words are
  lost--she has withdrawn.

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Bodily Countertransference-Intensified

• As the self harm becomes more evident my mind is
  assaulted more powerfully and my body is
  hyper-responsive to her communications.
• I respond with intense visceral, physical
  feelings to the projections that are put into me.
• Primitive defences are expressed in this way and
  the violence is enacted in part through my
  responses--my thinking is attacked and my body
  brought increasingly into play.

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Amnesty and Recovery

• After this crisis period of several weeks, where
  she returned to self-harming, Miss Y, gradually
  became less preoccupied with it, and focussed on
  words, on art materials and on engaging in
  therapy and with the team
• She handed in her secret supplies of razors,
  safety pins and broken cd cases sense of trust
  in the capacity of staff to keep her weapons
  from her, and hold her in mind

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Meaning of Miss Ys self harm

• Body as text
• Physical mode of expressing psychic pain
• Making private experiences public
• Showing not saying, in dramatic and tangible form

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The Signficance of Self Injury Understanding
its Symbols

• The significance of the body parts that are
  harmed
• Arms evoke mothers--that are intended to hold
  and comfort, but in this case, have not.
• Arms that could reach out, but instead, fold in,
  keeping away.
• Arms that held her down and beat her.
• Scars all over, keep people away, no touch, no
  holding
• Public expression of private pain (Adshead) and
  concrete symbol of this secret trauma.

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Lace-making in the Dark

• Slow and gradual engagement-profound difficulties
  in trusting me
• Inevitable moments of regression, and worsening
  of violent fantasies and behaviour.
• Danger of my recreating neglectful or perverse
  parenting, potential to re-enact earlier
  abuse,/abandonment or intrusion

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Powerful Functions of Self Harm

• Miss Y used it to ward off thoughts of suicide,
  or other forms of emotional disorganisation life
  sustaining coping mechanism
• Released tension
• Communication through her use of her body
  (sometimes directly in the form of viscerally
  felt projections) of her mental state

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Choosing Physical over Psychic Pain

• Elements of control, self-regulation of the
  physical, secrecy, risk taking and privacy
  demonstrate the degree of conscious choice when
  and how to self harm
• This does not preclude the possiblity of
  unconscious motivations that take the form of
  compulsionsthe violent thought cannot be kept in
  the mind

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Self harm as Affective Communication

• Idea of signing with a scar (Straker, 2006)
• Using the marks on the body to signify ones
  state of mind to another
• Language of the body seen as more primitive,
  direct form of communication than words
• Primacy and directness of bodily states and the
  immediacy/violence of their voice

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Psychological Motivations(self-directed)

• Feeling real
• Distraction
• Expression of anger
• Get out of intolerable state
• Affect regulation
• Assert sense of control
• Create sense of ownership of own body

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Self Harm and Life Preservation

• Reflects a choice between chaos, gray submersion
  in depression and articulated, delineated
  feeling-focusses the mind
• Self harm creates a boundary between feeling and
  not feeling, gives shape, time, colour and
  substance to sense of total deadness or
  fear-creates a dimension
• Brings back the feeling of being real (alive),
  contact with external world when numb

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Psychological Motivations(other directed)

• Generate response in others, including medical
  treatment, suturing, cutting of ligature.
  nursing
• Attack carers who fail to protect
• Communicate rage and distress
• Defence against intimacy (regulate distance)
• Keep people at bay-warped skin as barrier
• Enlist help, support or concern

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Self Harm as Truth-telling

• Attack on beauty
• Through mutilation the self-harmer wants to
  reveal underlying internal damage
• She is demonstrating that there is something
  real, hurt and ugly underneath the surface
• The brutality of self-harm is felt to mirror the
  violence of being seen (only) as a thing of beauty

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Hurting as a kind of healing

• Paradoxical nature of self-harm
• Fantasy of toxic elimination
• Reality of release of intolerable feeling
• Distraction from psychic pain
• At times some pleasure in the pain
• Driven by the hope of healing

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Talisman

• Significance of scar is profound
• How deep is your damage?
• Marking on the flesh invisible wounds
• Mapping memories
• Physical, tangible evidence of wound
• Symbol of passing through initiation of sorts
  (anthropological evidence of significance of
  scarification)

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Dialectical Movements in Self Harm

• The split self graphically articulated
• The self plays different roles in relation to
  itself
• It is both aggressor, harmer
• And the target of the violence
• And finally, the Nurse part of the self who can
  tend the wounds, soothe the injuries and act as
  witness to these.

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The Divided SelfVictim/Perpetrator

• Identification with the aggressor (Anna Freud,
  1936)
• Here body represents the victim, the mind that
  chooses to attack it is in identification with
  the aggressor, as it inflicts pain on the body

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Childhood Sexual and Physical Abuse and its Link
to Self Harm

• Links with shame, guilt, secrets, taboo
• Use of the body as site of shame, trauma and
  memory
• Repeats violations of the skin
• Dissociation associated with severe abuse and
  with self harm

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Self harm as Affect Regulation

• Way of escaping intolerable states of mind
• Releasing high levels of anxiety, depression and
  anger
• Controlled method of managing emotions at times
  of increased and unbearable stress
• Use of violence against the self to distract from
  guilt of fantasies of violence against others

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Female Perversion

• Womens anger turned against the self
• Defence against intimacy
• Secret and powerful expression of rage
• Cycle of behaviour, thoughts, feelings and
  fantasies that has an addictive, compulsive
  quality--with euphoric sense of release
• Symbolic attack on mothers body
• Enjoyment (at some level) of secrecy, rituals,
  risk-taking and damage

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Self Harm as Violence to Others

• The witnesses to self harm, carers who failed to
  protect, are indirect targets of rage
• Tremendous symbolic hostility and
  violence--murderous attack on the mothers body
• Generates feelings of pain, disgust, horror and
  guilt in carers

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Reciprocal Violence

Consultant psychiatrist Tim Kendall, the
co-director of Royal College of Psychiatrists
said that in extreme cases doctors and nurses had
stitched up patients' self-inflicted injuries
without giving them an anaesthetic. (seen as
undeserving of care or treatment as legitimate
injuries) The view some staff take is 'well you
cut yourself without anaesthetic so you don't
need one now'," said Dr Kendall.
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Finding Unconscious Hope

• Patients are trying to live with overwhelming
  emotional pain and project this into staff
  through various communications such as self
  injury, very direct sexualised communications,
  physical assaults and vicious personalised
  attacksthe unconscious hope is that the nursing
  staff can do something positive with the
  communication.,. (Aiyegbusi, 2004)

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Managing Self Harm and its Impact

• Supporting staff teams through Reflective
  Practice
• Supervision
• Retaining neutrality
• Working under fire
• Acknowledging countertransference
• Understanding underlying meaning

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Self Harm as a Sign of Hope

• It is essential to understand the underlying
  meaning of self harm
• Self harm to be viewed as communication
• Person who self-harms should be offered help to
  de-code their bodily language, and put into
  words, what needs to be articulated
• It is also crucial that the affective content of
  communication can be borne, and contained
• Through responding to the request for contact
  change becomes possible.

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