There is a lot of misunderstanding about self-harm. It is frequently linked with suicide, although not all people who self-harm feel suicidal or take action to end their lives. It is however always a good idea if you ever become aware of someone you care for who self-harms to ask them if they feel like killing themselves. But remember, their answer may be no. So what is self-harm about? This is what the ‘C’s are about:
Coping and crisis intervention
If you talk to someone who self-harms they will tell you they self-harm as a way of coping in life’s crisis events. A good example is of a young woman who is out walking. A child walking in the opposite direction bumps into her. This triggers feelings of “why am I always picked on”, “Why do people always hurt me”. These are out of proportion to what has happened, but links to past experiences that were more traumatising have been triggered. The young woman starts to feel angry at the unfairness of life, while at the same time feeling powerless. These feelings lead her to feel anxious and unsafe. Her response to that is the dissociate herself from the feelings and she feels numb and out of it. Now she feels no pain. She self-harms and doesn’t feel it, but her body does and her brain releases endorphins, our natural pain killer. The endorphins act to reduce her feelings of anxiety. So she feels better. This is the first ‘C’ of self-harm – self harming to feel better.
Calming and comforting
In the example above, the young woman found cutting herself was calming and comforting. This is often referred to as self-soothing. Self-soothing is something a child learns from being comforted by its parents. A child who does not have that comfort will not learn to self-soothe. Self-harm is a coping strategy that is used to calm and comfort. It is highly effective as a tool for calming, but it is a tool that is harmful in other ways. A person who self-harms needs to learn other calming strategies. That takes time.
Another aspect of self-harm is the feeling of control. For someone whose life has been one of powerlessness and limited control, self-harm can be a way to feel in control. Another aim of therapy is to help the person so feel empowered and in control so that self-harm can be replaced as a strategy.
For some people, self-harm is a punishment for things they think they have done wrong in the past. In those circumstances, self-harm can feel very cleansing, as though their guilt and shame is being expunged by the act of self-harm.
Confirmation of existence
Many who self-harm will report they feel alive when they self-harm. It is a way to turn off the numbness. Some who cut themselves and draw blood say that they know they are alive when they see the blood flowing. When life has been traumatic, the person often dissociates from reality and self-harm brings them back. It helps the person feel more alive and connected to others.
Creating comfortable numbness
For others, the self-harm makes them feel numb. They report that is a good place to be because they do not have to feel any unpleasant feelings but instead can retreat into a place where feelings cannot be felt.
Chastisement is similar to cleansing, but it is more about things happening in the present. A boy desperate to get top marks in his exams may self-harm as punishment for not working hard enough to get top marks.
Although the person who self-harms hides what they have done, it is a form of communication. The marks say “I need help”. Because they are hidden, they are not often seen. It takes a lot of trust in a person for one who self-harms to show what they have been doing. For the person themself, the wound of self-harm is visible evidence of the pain they are feeling. Having a physical injury makes it okay to have pain. Should anyone else see the wounds, then the pain can be witnessed by others. For people who have suffered abuse in childhood, the wounds become a narrative of the abuse they suffered. For many children suffering abuse, the abuse is kept quiet and the child can be punished for speaking about it. In this case the wound is a way to speak of the abuse without saying anything.
Most people who self-harm seek to hide what they are doing. They may not be willing to let anyone know what is going on. It takes a lot of courage for a self-harmer to let another person know what is happening. Some of the things that prevent people from revealing their self-harm are:
- feelings of embarrassment and guilt;
- being frightened of how their parents or the person they have told will react;
- not knowing their parents to know and being frightened the person they tell will not maintain confidentiality;
- fear that they will be judged negatively and labelled negatively;
- fear that their parents will not be able to afford counselling;
- a negative experience with seeking help in the past;
- now knowing what support is available for them;
- not perceiving what they are doing as being dangerous.
The job of counsellor is not to judge the person who self-harms or force them to stop. People will stop self-harming when they are ready to. What I can do as a counsellor is help my client to learn new coping behaviours to use instead of self-harm. One approach is to teach my clients self-harm is a form of communication and offer other ways to communicate such as art, poetry, story writing or journaling.
The release of endorphins is an important way people who self-harm soothe themselves. There are many safe ways to release endorphins and I will help my clients explore those safe ways and learn how to replace self-harm with a safer way.
I will also teach my clients alternative ways to self-soothe that are not harmful.
These three things form the acronym CARESS (Communicate Alternatively, Release Endorphins, Self-Soothe). Once my client has identified other strategies to use I encourage them to use CARESS whenever the urge to self-harm arises, before self-harming. In other words, they are to try a different form of communication, such as painting, then release endorphins, for example by taking a brisk walk, then self-soothe by movement such as rocking or calling a friend.
Over time, clients learn to use different strategies to deal with the 8 ‘C’s and learn how not to self-harm.
I want to acknowledge Lisa Ferentz from whom I learned the CARESS approach to working with self-harm.