Self-Injury and Young People: Untangling the myths and weaving helpful responses -  Kay Inckle

Self-Injury and Young People: Untangling the myths and weaving helpful responses
Kay Inckle

The following scenario and discussion sets out some of the key issues for counsellors and therapists working with young people who self-injure. The characters portrayed in the scenario are composites1. Composite characters are drawn from the experiences of a number of individuals such that real-life issues and dilemmas can be portrayed without compromising the confidentiality or anonymity of any one person (see Inckle, 2010).

Pat is a 40 year-old, white-British counsellor with many years’ experience who works part-time in private practice with adults, and part-time for an organisation that provides counselling services to a local secondary school. Janeal is 14 and has been referred to Pat by the school after one of her teachers expressed concerns about her mental health following significant changes in her behaviour. Janeal’s parents migrated to Britain in the late 1990’s from Ghana, and Janeal and her elder brother both attend the same, predominantly white, school. Pat has been told informally that Janeal’s bother has “also” had some “behavioural problems” and is now in a SEN (special educational needs) class. The referral states that Janeal has changed from a quiet, but friendly and co-operative pupil to an unpredictable young woman with extreme mood states which shift from being sullen and withdrawn to aggressive angry outbursts. Until recently she had a very good relationship with her art teacher, and it was this teacher who made the referral.

In their first session Janeal seems quite timid and is not very forthcoming, but ten minutes before the end of the session she asks if she can tell Pat something. Pat is about to remind her that anything she says that indicates she, or another young person, is at risk cannot be kept confidential, but before Pat has finished the sentence Janeal blurts out that she has been cutting herself.

What should Pat do next?

A commonplace, diagnostic reading of Janeal’s story might be as follows: Janeal is cutting herself and therefore at risk, her cutting probably explains the change in her behaviour – especially given that there are already known to be behavioural problems in the family. Therefore, Pat should report Janeal’s cutting to her parents and to the school authorities. Pat’s work with Janeal should focus on stopping her cutting and amending her behaviour, perhaps using CBT and a “no-harm contract”. If Janeal cooperates with the treatment everything should be resolved within six to eight sessions.

Despite the increasing prevalence of such interventions it is unlikely that any of the above will have a positive impact – indeed, they actually risk alienating Janeal, increasing her distress and exacerbating her self-injury. So, what can a counsellor in Pat’s position do? If we look back over the short paragraph about Janeal it not only highlights a number of common issues for counsellors working with young people who self-injure, but it also provides some significant clues for what might be a helpful way to respond. These cues and issues include: risks and confidentiality; self-injury as a response to, not the cause of problems; racism and diagnosis in schools; creative or arts-based interventions.

Most counsellors and therapists whether working with young people or adults, in private practice or institutional settings, commence their sessions by contracting with clients about the boundaries and limitations of the sessions. A standard protocol is to confirm that the content of the session will remain confidential “unless a person is at risk of causing harm to themself or others”. Taken literally, as it often is for young people, this statement indicates that any act of self-injury requires external intervention. However, this assumption is based on a widespread misunderstanding that self-injury is either a suicide attempt, or will inevitably lead to a suicide attempt. In reality self-injury and attempted suicide are entirely different in intention and motivation. Self-injury is a means of coping and surviving distress: harming the body enables life to continue; while suicide and attempted suicide reflect being no longer able or willing to cope with life – intending to die rather than live. While the injuries may look similar, their meaning and intention are entirely different. In my research Joseph explained: “To me it’s very obvious, that just because you’re self-harming does not mean that you want to commit suicide. You don’t want to do yourself deep, irreversible damage... It’s not about suicide. I never ever, ever wanted to commit suicide” (in Inckle, 2017: 8). Joseph also highlighted how crisis-responses based on suicide-risk were uncomfortable and counter-productive.

I was embarrassed – because when you swallow tablets they think that you’re trying to commit suicide, and I wasn’t. I was doing the swallowing of tablets for the same reason that I was cutting myself... I always associated it in the same way, but to them you were trying to commit suicide. And I wasn’t. And I didn’t need it defined or looked upon like that, so I just wanted to get out of there as quickly as possible (in Inckle, 2017: 9).

Joseph’s experience highlights that responding to self-injury as a “risk”, crisis or threat to life is not only the opposite of how it functions for the person who hurts themself but it is also counterproductive. This is particularly so for young people whose confidentiality may be breached in ways which place them at increased risk of harm. For example, if a young person is self-injuring as a way to cope with violence or abuse in the home, immediate reporting to the parents without other safeguards in place might place that young person at increased risk. Moreover, breaching confidentiality, even in the case of suicidal thoughts, can be detrimental to a young person’s mental health. Emma described the long-term impacts of a counsellor who “broke my confidentiality to tell my parents I was suicidal”. Emma had experienced sexual abuse, rape and bullying and was self-injuring to cope, but “did not trust” the counsellor she saw as a teenager and “didn’t talk to her about my experiences of abuse or going into anything in much depth with her partly because I didn’t feel ready and partly because I figured that once I was over 18 I would have more of a right to confidentiality” (in Inckle, 2017: 208). Therefore, the very first thing that counsellors and therapists can do to promote good practice in regards to self-injury is to think clearly and carefully about the implications of their contract with clients and, if needs be, challenge the organisational policy and protocols that upon which these obligations are based.

The second issue that has a significant impact on how self-injury is framed in a counselling context is the priority it is given as a presenting issue. If self-injury is seen as a problem in and of itself then the work with the young person will never get beyond simply trying to change and/or control their behaviour – which are disciplinary rather than therapeutic interventions. On the other hand, if self-injury is recognised as a manifestation of distress, then much more effective practice can occur. Counsellors and therapists witness countless expressions of distress, pain and trauma, and have a range of skills and tools to work gently and effectively to untangle the distress and to work towards a meaningful resolution with the client, and this is precisely the kind of approach which is effective for those who self-injure. However, these skilful interventions are often bypassed because self-injury is framed as a serious psychiatric issue requiring an urgent and specialist intervention. Mark emphasised that a helpful response would focus on the cause of the distress, not the fact of the injury:

I would have hated anybody to try and separate the self-injury from what was going on. You know, if somebody had noticed the injuries or hair loss or other things and just concentrated on that. And still, that still sits very strongly with me, that that [i.e. the self-injury] wasn’t just what was going on. What was going on for me was how bad I felt, and all the other stuff that was going on around it. So, my fears, my fears about the world, loneliness, isolation at times, all of those different things of which the self-injury was a part of but not all, and that has stuck with me still, that, you know, self-injury is symptomatic of something else. Yes, in itself it is important, particularly when there were times when I would have put my life in danger, but what would have been more important was, ‘What’s the problem?’  (in Inckle, 2017: 27-8)

The distress which underpins self-injury emerges from an experience or, more commonly, a combination of experiences which have a profound impact on the young person. These experiences include those which cause individual or personal distress, such as grief, as well as those which arise from socially structured patterns of violence, victimisation and inequality, such as racist bullying. In both of these instances however, it is important to understand that the cause of the distress is external to the young person, not some mental or developmental flaw with in them. Furthermore, it is not just the experience in and of itself which leads to self-injury, but the context in which it was experienced. For example, if a young person experiences terrible loss, such as the death of parent, if they are supported in their grieving, enabled to express their feelings and needs, and responded to in accordance with them, then it is likely that the grief will be processed in ways which do not involve harm to the self. However, if a young person’s feelings and needs are not responded to appropriately, if they are not heard or supported or enabled to express themselves, then it is much more likely that the distress will become internalised and managed in more difficult ways. Young people’s feelings and experiences are often overlooked or invalidated and, indeed, society itself can be an invalidating environment for many young people.

In the UK social invalidation is particularly significant for Black British people. Black British adults experience significant social and material disadvantage and consequently much poorer mental and physical health than their white – or other ethnic minority – counterparts. In schools Black British children are much more likely to be labelled as “disruptive” or as having behavioural disorders than white British children, and they significantly underperform throughout the education system, and are over-represented in SEN provision (Rollick et. al. 2015). Historically, these patterns have been used to shore up racist ideologies about the biological inferiority of people of Black/African descent. And while these kind of overt ideologies have somewhat retreated, there is nonetheless evidence of systematic discrimination against Black British children in UK schools. Rollick et. al. (2015) found complex patterns of disadvantage whereby Black children – and boys in particular – were frequently placed in SEN provision without reference to their actual educational attainment or abilities, while Black children who did have SEN, such as dyslexia, were much less likely than white children to have appropriate provision in place. Similarly, Black children who were the targets of racism and bullying were more likely to have their behaviour challenged and problematized by the school than the white perpetrators. Finally, bullying in general, and racist bullying in particular, is also known to have a relationship with self-injury (Martins, 2007). This context, then, suggests a range of possible interpretations for what Janeal – and her brother – are experiencing and indicates that school-level as well as individual interventions may be required.

Racism and bullying are two of many possible reasons why a young person may hurt themselves, indeed it is often a combination of experiences which have cumulative effect. Other common factors include: neglect, abuse, sexual violence, issues around sexuality, grief and loss, trauma – all of which are familiar territory for counsellors and therapists. Nonetheless it is also important to remember that self-injury functions as an embodied response to these difficulties; managing and expressing the feelings and experiences through the body. Physicalizing distress in this way occurs when experiences are too difficult or painful to express verbally, or because words don’t seem to fit the experience – for example, young people do not always use the language of rape or sexual violence to describe their experiences of sexual victimisation (Coy et.al. 2013). Therefore, simply asking Janeal to explain the reasons for her self-injury is unlikely to be productive. However, we do know that she studies art, and creative practices can be a useful way for someone to express their feelings and experiences. Michael Moyer (2008), a school counsellor, developed a “safe kit” as a way to help young people to explore their self-injury. The safe kit is a special container, selected by the young person, in which they place items which relate to their self-injury. Moyer invited his young clients to decorate the container in a way which represented their feelings about self-injury2. The process of selecting the items and decorating the container became a significant touchstone for conversations about self-injury and the reasons behind it – the creative non-directive approach facilitated an opening for symbolic exploration. Many people who hurt themselves highlight the importance of being “heard” in a variety of ways. For example, Clare emphasised that, “listening is not always about your ears listening to somebody talking, it might be listening to their behaviour or their other ways of expressing themselves, but just engage with that and try and understand where somebody is coming from, and respond with caring and kindness” (in Inckle 2017: 66). Emma recounted how at age 19 she found a counsellor who showed caring and flexibility in her approach and “helped me to feel safe enough to talk about, and draw, the things that I needed to” (in Inckle, 2017: 123) (see also Long & Jenkins, 2010).

Overall then, Pat and Janeal’s experiences3 highlight a number of important issues for counsellors and therapists working with young people who self-injure. These include: thinking carefully about how risk is framed in confidentiality policy, understanding that self-injury is a way of coping with problems rather than being a problem in itself, considering – and addressing – the social/contextual factors (such as racism) that shape a young person’s world, and using creative forms of expression. Finally, it is also useful to remember that self-injury is a physical manifestation of distress, and distress and the different ways in which is embodied, experienced and resolved, are all areas in which counsellors and therapists are well practiced and have much to offer young people who hurt themselves.

Notes
1 Quotes and examples in the discussion which follows the scenario are from research participants. All research participants chose the name by which they would be referred to, for most this was a pseudonym, but some elected to use their real name.
2 This kind of safe kit can also be further developed as a resource to promote harm-reduction interventions and practices – see Inckle (2017).
3 Pat, the counsellor, is not gendered in this scenario, how did you interpret Pat’s gender and what impact did this have on your perception of how the sessions might proceed?

References
Coy, M; Kelly, L; Elvines, F; Garner, M; Kanyeredzi, A (2013) “Sex without consent, I suppose that is rape”: How young people in England understand sexual consent. London: Office of the Children’s Comissioner.
Inckle, K (2017) Safe with Self-Injury: A Practical Guide to Understanding, Responding and Harm-Reduction. Monmouth: PCCS Books
Inckle, K (2010) Flesh Wounds? New Ways of Understanding Self-Injury. Ross-on-Wye: PCCS Books.
Long, M; Jenkins, M (2010) Counsellors Perspectives on Self-Harm and the Role of the Therapeutic Relationship for Working with Clients who Self-Harm, Counselling and Psychotherapy Research, 10(3): 192-200
Moyer, M (2008) Working with Self-Injurious Adolescents using the Safe Kit. Journal of Creativity in Mental Health 3(1): 60-68
Martins, V (2007) to That Piece of Each of Us which Refuses to be Silent pp.121-134 in H Spandler and S Warner (editors) Beyond Fear and Control: Working with Young People who Self-Harm Ross-on-Wye: PCCS Books.
Rollock, N; Gillbourn, D; Vincent, C; Ball, SJ (2015) The Colour of Class: The Educational Strategies of the Black Middle Classes. Oxon: Routledge