Self-harm, Counselling and the issue of choice
Whenever I first meet with a client at my office in central Chichester our initial conversation is likely to cover a number of issues. It is always helpful to gain an early sense of what is happening in the client’s life. What are the current concerns and what it is that brings her or him into the counselling room.
I hope to gain an understanding of the client’s personal storyline and I am interested to learn about any previous counselling. This can allow both of us to consider what counselling approach is most likely to meet the client’s needs. Will she or he benefit from short term therapy which might include some Cognitive Behaviour Therapy techniques (CBT) or is longer term therapy work such as psychodynamic counselling more appropriate?
It is important to be aware of any immediate challenges that can impact on emotional wellbeing such as any addiction issues or eating concerns. I will also wonder about self-harm or suicidal thoughts but I am always mindful that this issue can be a particularly sensitive one.
Whenever the words self-harm are mentioned an image that is likely to come to mind for many people will be that of some form of overt physical activity use such as scratching or cutting. The excessive intake of substances including drugs and alcohol may also be seen as a form of self-harm as can serious eating issues.
In considering self-harm there seems to be a general expectation that this must involve a physical action. The self-harm event is seen as something tangible. It is regarded as an action which is capable of being observed or seen. Yet these observations seem to exclude emotional self-harm.
The reality is that emotional self-harm is actually far more commonplace than the physical action. Emotional self-harm is perhaps more invidious. It can be subtle and often well disguised. Yet it is a prevalent force which can be as potentially damaging and destructive as the physical equivalent.
Definitions of what constitutes self-harm will vary. Control and choice no matter how misguided often play a key part in any descriptor of what constitutes self-harm. When an individual deliberately and knowingly embarks upon a course of action or consciously pursues a damaging train of thought and makes no attempt to arrest that process despite being aware of the likely adverse impact, then we can perhaps start to regard this as a deliberate form of self-harm.
There is however a lack of clarity around specific definitions of emotional self-harm. If obsessive thoughts are allowed and even encouraged to continue unchecked should these thought processes be viewed as a sophisticated form of self-harm? When for example do cognitions relating to phobias become self-harming rather than just an irritating way of being?
Examples of emotional self-harm can be relational with the continual move into dysfunctional partnerships which always end the same way with recrimination, anger and hurt. Conversely an insistence on remaining apart, detached from others with the acknowledged pain of acute loneliness could be viewed as a self-inflicted emotional wound. Extreme self-criticism and denigration with continual internal belittling are also a common form of emotional self-harm which can spill over into behavioural consequences.
Individuals will self-harm whether emotional or physical, for good reasons although this reference to ‘good’ demands immediate clarification. It is certainly not intended to infer positive judgement or celebration about the act. It refers instead to the existence of a ‘reason why’. If someone deliberately suffers pain albeit emotional or physical there will be a reason underlying that action. It is not a natural consequence of our way of being to invite pain. Human development over millennia shows that our natural instinct is to take steps to avoid discomfort albeit physical or emotional. If in place of avoidance we deliberately turn towards pain there will invariably be a strong reason why.
If the reason underlying the self-harm is an irrational or involuntary act which is the direct result of mental illness with a physical causation then such cases will lie outside of the scope of this note. The focus within this paper is on those who deliberately choose to self-harm and do so as a conscious reaction to disturbing emotional situations, difficult circumstances or specific life events.
There is a popular narrative around self-harm which identifies issues around control. If there are aspects of the individual’s personal world which are uncontrollable (such as bullying or abuse by others) it is suggested that the self-harming actions can reaffirm a sense of internal regulation. Causation can also lie in the displacement effect of an alternative form of pain which deflects cognitive and emotional attention away from the initial catalyst. Another ‘reason why’ is seen through a prism of internal judgement with a self-loathing and extreme self-criticism resulting in a self-punishment which is regarded as deserved.
There are other more subtle reasons underpinning self-harm which may be method specific. Issues around body image, self-worth and anger can be seen as linked to specific expressions of self-harm. Often there may be a complexity of issues which creates a matrix of concerns from which the behaviour emerges. This covers both physical and emotional self-harm.
Self-harm is a complex issue for both client and counsellor alike. One additional ethical challenge for the therapist working with a client who is either self-harming or indicating that he or she is about to self-harm, is how to balance the client’s right to choose and to be self-determining whilst acknowledging the responsibilities held with regard to issues around harm to the client. This includes concerns around the adverse impact on others caught up in the event. There are conflicting tides of opinion on some aspects of this issue.
For example it seems that the medical world appears to be gradually edging towards a change of view on assisted suicide albeit with continued reference to the importance of many safeguards. My personal view is that we will see formal changes within the decade. At the same time the risk averse approach of some counselling bodies appears to be moving towards a greater insistence on safeguarding action by therapists if serious self-harm is identified as a likely outcome of client’s internal processing.
Most therapists will be influenced by their professional views on the importance and extent of client autonomy. My personal approach is always influenced by a very strong belief that it is not for the therapist to tell the client what they should or should not do. That does not prevent the counsellor from challenging the client to consider options and outcomes. Actions will have consequences.
Yet even for those who place great store by the client’s right to choose there are ethical dilemmas lying in wait. If the client is to seriously self-harm in a way that will adversely impact on others say through engineering a deliberate traffic accident it is surely incumbent upon the therapist to be active to prevent harm to others. It can of course be argued that any suicidal act will always adversely impact on others apart from the committer in a way which will be disturbing. This can range from the shock in viewing the outcome of an action through to the pain endured by those close to the actor where there may be at the very least profound feelings of guilt.
So where does this leave us with regard to issues around self-harm and choice as far as therapy work is concerned?
For therapy to be effective it is surely important that the client should feel able to raise any issue within the counselling room without the fear that the counsellor will move quickly to break confidentiality. Counselling should enhance rather than suppress a sense of self-determination and personal autonomy which the client may be looking to develop.
Nevertheless in order that therapy can be conducted ethically there clearly does have to be some limitations on that sense of laissez faire if only to protect others. Whenever possible the client and counsellor should explore these concerns together to enable the client to identify a way forward which is in his or her best interest without causing harm to others.
The client’s right to choose commences with the decision to come into the therapy room and to then continue with the work. We as therapists will have a role to play with regard to the counselling work but we cannot control the outcome of this work and not should we try to do so.
As counsellors we should support the client and be mindful of our wider responsibilities both to that client and the wider society. But the works starts and ends with the client and with her or his right to choose. As therapists we must be respectful of that autonomy.