What_Are_the_Challenges_That_Face_a_Psychotherapist_Working_with_Self-Harm_or_Eating_Disorders

“What are the challenges that face a psychotherapist working with self-harm or eating disorders'” Introduction In this essay I will endeavour to discuss the challenges that face a psychotherapist working with self-harm and eating disorders. I am going to explain what self harm is and the possible triggers of self harm. I will comment on some of the psychological theories associated with self harm such as Cognitive behaviour therapy, Person centred therapy and Psychodynamic approach and in doing so I will comment on how Carl Jung’s Shadow archetype influences treatment. I will include issues in relation to ethical perspectives and show awareness of personal responsibility. Although I will pay more attention to self-harm in particular, I will also talk about eating disorders and their relationship to self-harm. Main essay Self-harm can be said to be the act of self-inflicting physical attacks on the body (Gardner, 2001). In self-harming, the client aims to deliberately, and usually habitually harm their body but not to destroy or kill it. Levitt et al (2004 ) also reiterates that the act of self-harming is an attempt to draw attention to one’s plight or to scream for help rather than an attempt to achieve death. Self-mutilation and self-starvation are said to be pleas for recognition (Hewitt, 1997 cited in Levitt et al,). Gardner reiterates that self-harming is a metaphoric representation of earlier psychic wounds and also internalised processes obtained from early object relationships (Gardner, 2001). She sees both our real experiences of and our fantasies about parental and other figures/objects as internalised and being embedded in the way we cope with life. I agree with the theorist as it is a fact that the inner objects shape our psyches and influence other relationships and also how we behave. Engaging in self-harm can therefore be perceived as a way of making statements about ourselves, our past relationships and also our previous experiences. Clients can engage in self-harming behaviours in so many different ways like: smoking, drinking or abusing any substances, comfort eating, existing in abusive relationships, denying needs in areas of their lives, doing excessive exercises or hard manual labour. Most of these activities are done unconsciously by people (Chrysalis notes, module 5). The body can also be harmed in a number of ways such as, through eating disorders, frequent and often unnecessary cosmetic surgeries and excessive dieting and many other such ways (Miller, 2005). The most common type of self-harm is cutting of the skin. People who are likely to engage in self-harming are; those who already are into drug and alcohol abuse, have signs and symptoms of depression, those with eating disorders, those who felt unloved as children, those with difficulty to express their feelings and in most cases, those with a history of childhood abuse. REF!!!!!!!!!!!! The deliberate self-harm without the intent to die, is generally characterised by unbearable emotional pain coupled with periodic strong and persistent urges to physically hurt oneself. Thus, it is important in any therapeutic approach to acknowledge that self-harm is a way of coping with the pain. The urges may be resisted for a short time, but ultimately the individual becomes overwhelmed with negative emotion and engages in self-harming, often resulting in tissue damage (Simeon & Favazza, 2001; Stanley, Gameroff, Michalsen, & Mann, 2001). In a sense, self-harm is a coping mechanism similar to overeating, excessive drinking and drug abuse. The danger of self-harm, of course, is in its most extreme forms it may cause accidental death. Furthermore, non-suicidal self-harm is one of the strongest risk factors for suicidal behaviour. REF!!!!!!!!!!!!It is fair to say those who self-harm offer a variety of reasons for their behaviour some of the reasons are to experience relief from unbearable tension and upset, to distract themselves from intolerable feelings, to communicate distress, to improve their mood, to self-punish, to restore a sense of equilibrium, to provide proof to themselves that they are, in fact, suffering, and to achieve a sense of control (Brown, Comtois, & Linehan, 2002; Klonsky, 2007; Nixon, Cloutier, &Aggarwal, 2002). A number of studies reviewed in Landecker (1992), cited in Miller, (2005) found a high correlation between severe childhood abuse or neglect and adult self-destructive behaviour. The adult behaviour patterns are linked to a lack of secure attachments in childhood and leads to the victim to dissociate. In that respect, self-harm can be done to escape feelings of emptiness, depersonalization, to express emotional pain and to punish the body as a way of expressing responsibility for the abuse. In literature it is suggested that following the act, individuals generally report feeling better, and thus the behaviour continues as a viable solution to their problems. Self-injury is explained as functional rather than manipulative behaviour and detailed clinical guidelines and examples are provided to better illustrate approaches that will improve the therapeutic alliance. Past traumatised clients seem to be the most common in self-harming, however, not all abused people engage in self-harm and not all self-harming people were abused. Some clients engage in self-harm because they perceive it as a way of escaping from feelings of depression and emptiness. Some feel that by self-harming, their anger or aggression is relieved and some feel that it eases the pain within them as the act eases their anxiety and tension. REF!!!!!!!!! A person centred approach (Carl Rogers), would be ideal to use for the first few sessions with clients who self-harm. This approach focuses more on the “here and now” issues. In this treatment the quality of the therapist and the client relationship is considered paramount. Rogers believed that to build a therapeutic alliance and growth promoting climate, three core conditions must be demonstrated by the therapist. 1) Unconditional positive regard (UPR). The therapist believes that people are essentially good and displays this conviction to the client. Accepting the client as intrinsically worthwhile however does not mean that the therapist necessarily agrees with all aspects of the client’s behaviour rather the client is respected for the person they are, not judged by what they do. Acceptance recognises the potential of the client for self-help and encourages promotion of growth in the client. 2) Congruence, also known as genuineness, transparency and authenticity, meaning not hiding behind a façade acting out a role, putting up front or trying to make a good impression. The congruent therapist strives to be “real” and integrated in the relationship. Congruence by the therapist encourages genuineness, openness and realism by the client. 3) Empathic understanding. The empathic therapist strives to enter the client’s world as he sees it and by communicating that understanding cautiously, caringly and sensitively demonstrating empathic understanding means standing back far enough to remain objective (as if I was that client), without losing the as if quality, which runs the risk of becoming too enmeshed in the client’s world and loss of objectivity. In contrast to psychodynamic therapy, which concentrates on bringing to awareness what was previously unaware, person centred therapy The theories that are used for clients who self harm are Cognitive behaviour therapy (CBT) CBT is a short term problem focused psychological treatment, the average number of sessions is normally 8-20. It deals with the “here and now” issues as opposed to the unconscious conflicts originating from childhood. The relationship between therapist and a client is similar to that of tutor and student, both working collaboratively to identify thoughts and behaviour patterns that are causing difficulties and to plan a structured way ahead with agreed realistic goals. Homework tasks are formulated by the client with the therapist and they are a key component of the treatment. These may include challenging self defeating beliefs, thought stopping, assertiveness training, social skills training and developing relaxation techniques. CBT is essentially a structured programme of self help with the therapist acting as the guide. Psychodynamic counselling is the third theory I would like to discuss about. This theory evolved out of Sigmund Freud’s original theory of psychoanalysis. The psychodynamic approach focuses largely on identifying unconscious processes of the mind (outside of the client’s awareness) and making the unconscious conscious (bringing unconscious conflicts into the client’s awareness) thus enabling the client to develop insight into how the past influences their actions in the present and to discover more effective ways of coping with present day reality. Techiniques used by psychodynamic therapists to promote insight and reveal the unconscious include free association (encouraging clients to say whatever comes to their mind no matter how insignificant it might seem) interpretation (tentatively offering the client possible explanations for their difficulties) dream interpretation, overcoming resistance (sensitively, challenging, yet respecting any defence mechanisms the client may be using to keep anxiety provoking urges, impulses, thoughts, emotions and memories at bay) and working through the transference (drawing the client’s attention to unconscious reactions or patterns of relating to the therapist that derive from a significant person in the client’s past, or present such as a parent) The therapists hold the view that long standing unresolved conflicts are rooted in childhood experiences. This approach can be particularly used for individuals wishing to gain self awareness or to those with prolonged psychological or emotional issues arising from childhood trauma. For the therapist to effectively use the mentioned theories, Carl Jung’s personality archetypes and the idea of the shadow has to be understood. According to Jung (1923) personality reflects both our conscious and unconscious minds. The conscious mind is what we are aware of regarding ourselves, the unconscious mind is what we are not aware of regarding ourselves. From his extensive clinical practice, Carl Jung concluded that there are a limited number of personality types and that each individual is born with preference for a certain type. Jung argued that each of these personality types is equally valuable but our environment (eg parents, teachers friends) either encourages or discourages the expression of our inborn personality type. Jung believes that our personalities are dynamic over our lives. The first half of the life should be dedicated to embracing our inborn personality types and the second half of life should be dedicated to embracing the polar opposites of our inborn personality types or our “shadow” personality. (Corlett, Millner 1993) He explained the shadow like a foreign personality, a primitive, instinctual kind of being. The recognition of the shadow or moving the shadow from our unconscious into our conscious requires considerable moral courage and much effort. Jung noted that there are two ways by which individual gain or lose energy. One way of gaining energy is through external stimuli by engaging with a wide variety of tasks, people and or things which is known as the extroverted approach. In contrast some individuals gain energy by going within by limiting external stimuli and focusing on inner thoughts and feelings which is the introverted approach. The shadow is a moral problem that challenges the whole ego-personality, for no one can become conscious of the shadow without considerable moral effort. To become conscious of it involves recognising the dark aspects of the personality as present and real. This act is the essential condition for any kind of self-knowledge, and it therefore, as a rule, meets with considerable resistance. Indeed, self-knowledge as a psychotherapeutic measure frequently requires much painstaking work extending over a long period. Closer examination of the dark characteristics— that is, the inferiorities constituting the shadow—reveals that they have an emotional nature, a kind of autonomy, and accordingly an obsessive or, better, possessive quality. Emotion, incidentally, is not an activity of the individual but something that happens to him. Affects occur usually where adaptation is weakest, and at the same time they reveal the reason for its weakness, namely a certain degree of inferiority and the existence of a lower level of personality. On this lower level with its uncontrolled or scarcely controlled emotions one behaves more or less like a primitive, who is not only the passive victim of his affects but also singularly incapable of moral judgment. Although, with insight and good will, the shadow can to some extent be assimilated into the conscious personality, experience shows that there are certain features which offer the most obstinate resistance to moral control and prove almost impossible to influence. These resistances are usually bound up with projections, which are not recognised as such, and their recognition is a moral achievement beyond the ordinary. While some traits peculiar to the shadow can be recognised without too much difficulty as one’s own personal qualities, in this case both insight and good will are unavailing because the cause of the emotion appears to lie, beyond all possibility of doubt, in the other person. No matter how obvious it may be to the neutral observer that it is a matter of projections, there is little hope that the subject will perceive this himself. He must be convinced that he throws a very long shadow before he is willing to withdraw his emotionally-toned projections from their object. Let us suppose that a certain individual shows no inclination whatever to recognise his projections. The projection-making factor then has a free hand and can realise its object, if it has one or bring about some other situation characteristic of its power. As we know, it is not the conscious subject but the unconscious which does the projecting. Hence one meets with projections, one does not make them. The effect of projection is to isolate the subject from his environment, since instead of a real relation to it there is now only an illusory one. Projections change the world into the replica of one’s own unknown face. In the last analysis, therefore, they lead to an autoerotic or autistic condition in which one dreams a world whose reality remains forever unattainable. The more projections are thrust in between the subject and the environment, the harder it is for the ego to see through its illusions. Therefore for the therapy to have a positive outcome the bond between the therapist and the client who self harm has to be strengthened. Self-harming clients present with a host of challenges that differ from other clients and certain approaches may be more effective than others. Among the strategies described are validation, checking in, working collaboratively toward goals, providing support, and repairing a ruptured alliance. Potential pitfalls (e.g., reinforcing maladaptive behaviour, negative judging, and the fundamental attribution error) to which psychotherapists often fall prey are to be avoided. An effective therapeutic alliance is one of the key factors that helps patients develop alternative modes of coping with intolerable affects when habitual self-injury has become common. Patients may choose to try alternative coping strategies only because they trust their therapist and believe that the therapist holds their best interests at the forefront. Furthermore, at the beginning of therapy, a patient may try to refrain from self-injuring because of a promise made to the therapist. A positive therapeutic relationship is not the solution to self-harm, but it provides a context in which problem solving and behaviour change can take place. Because patients must be willing to endure urges to self-harm without engaging in the behaviour itself, having a therapist who provides support, encouragement, and validation for how difficult this is, becomes vital. Self-harm can elicit fear, blame, and disgust, although these emotions are understandable, as a therapist, I must effectively manage these feelings or they may otherwise interfere with the creation of a productive therapeutic relationship and jeopardise the client’s well-being. During validation, it is a challenge to maintain a compassionate attitude in the face of feeling frightened, frustrated, or ineffective. These experiences are common when treating individuals who self-harm. It is therefore important as a therapist to “validate the valid” in the client’s experiences. Cooley et al suggests that not only does validation promote confidence and help clients learn to trust themselves, but it also strengthens the client/therapist alliance and is associated with effective psychotherapy (Norcross, 2002). Another common goal of self-harm is to avoid some feared emotion or interaction. In fact, many clients describe self-harm as a useful coping mechanism that helps them feel better without having to confront their painful feelings or thoughts. For these clients, confrontation is fraught with the potential for rejection, disapproval, and criticism. It is, therefore, no surprise that these clients are unlikely to articulate their feelings and concerns openly to their therapists. Not only do these clients seek to avoid confrontation, but they may also be overly complimentary or apologetic towards the therapist, for fear that any expression of disagreement will be met with rejection of the client’s ideas or, at an extreme, discharge from the therapy. Also at the time of integrating the client and therapist goals, the therapist may be frightened to give direct advice to the client. Many teaching about therapy are that a client must come to their own insights for meaningful change to occur. This may be true with certain clients; however, I argue that one of the most compassionate actions is to tell the client not to self-harm. By asserting the elimination of self-harm, I do not only help to protect the client from physical harm, but I also demonstrate genuine caring. In a world where they may rarely feel cared for, this directive may be a welcome change. It is one clear way to stand on the side of self-preservation and self-care and not been seen as tacitly approving of the self destructiveness by ignoring or not addressing the behaviour. It is surprising to know that many clients are motivated to stop self-harming and are aware of the negative consequences of self-harm, but they have not been able to develop effective alternatives to the behaviour. An on the other hand some clients have no motivation to stop their damaging behaviours. This is a thorny issue: as the therapist one does not want to jeopardise the relationship with client by promoting one’s own agenda. On the other hand, one does not want to provide poor client care to maintain a good alliance. Therefore when a therapist and their client differ in the priorities, collaboration and goal consensus suffer as will the probability of a successful course of psychotherapy (Tryon & Winograd, 2002). In such case the sessions tend to become more tense than therapeutic. The keys to collaboration and consensus are not to let the client set the therapeutic agenda entirely. If a therapist feels very strongly that a behaviour or plan is life threatening or extremely self-destructive, then that therapist is obligated to make it a treatment priority in the treatment. There are various ways of dealing with this difficult matter. If therapists explain in a compassionate and non judgmental manner why they believe that it is vital to address self-harming behaviour, clients almost always respond with a desire to try to change even if they feel they do not want to relinquish the Behaviour because “it works.” Strategically, if the client can be convinced that there is something else that will work just as well without involving bodily damage, they are willing to listen and to try. From the outset, therapist should collaborate toward a goal that is, first and foremost, to preserve the client’s physical health. At this point, it is useful to ask the client to generate a list of negative consequences of self-harm so that they do not view ceasing self-harm as solely the therapist’s goal, but rather as a joint objective. Negative consequences will be different for each patient, and taking time to understand what is aversive about self harm for a particular client will help personalise and focus treatment. A final approach is one of compromise. A therapist’s willingness to consider alternative objectives often promotes greater cooperation on the part of patients. Compromise also instils in patients a sense of control over their therapy. Negotiation can take the form of lessening the intensity of a request (e.g., rather than throwing the razor blade away, give it to someone to hold), the frequency of a request (e.g., write down your thoughts 3 days a week rather than 7 days a week), or the duration of a request (e.g., if you won’t promise not to cut yourself for the next 3 months, then promise not to cut yourself for the next month). A word of caution: Before psychotherapists compromise their treatment goals, they must decide what is non negotiable based on clinical judgment, the research evidence, and their own limits. Therapists should never act against their better judgment because of demands made by patients or patients’ family members. Such concessions may result in lethal patient outcomes (Hendin, Haas, Maltsberger, Koestner, & Szanto, 2006) and will not help patients progress. Using a “give and take” technique, therapists must strike the right balance between acceding to the patients’ wishes, safeguarding their well-being, and observing their own limits As learnt if self harming does not make the client feel better in some way, they would not continue to hurt themselves. Therefore in the process of helping the client the therapist must avoid inadvertent reinforcement of the client’s actions when interacting with them (Walsh, 2006). Whereas demonstrative compassion and kindness does wonders for solidifying a therapeutic alliance, one must be aware of the detrimental outcomes that over concern may have by way of promoting further self-harming. As the client may realise that if they self-harm, they will receive concern from others, which gives them positive reinforcement for their self-destructive behaviour. Therefore as a therapist one should try to maintain a neutral response style and be dispassionate (Walsh, 2006). In the same vein, an extreme negative reaction can jeopardise the relationship and the client’s care. Self-harming is a socially unacceptable behaviour because it runs counter to the human instinct of self-preservation. As a therapist one may experience a range of emotions, including fear, panic, upset, and despair. These emotions may leave the therapist worrying about being blamed by the client or client’s family, or feeling guilt for having missed a sign that ultimately led to the client’s self-harm. In response to these intense negative emotions, therapists can sometimes resort to scolding the client, withdrawing, avoiding assessment, or minimising the problem. Whereas those responses are understandable, they are far from helpful. As a consequence, client may feel judged or embarrassed, may retreat, may avoid reporting any further self-harm, or, in contrast, may take some satisfaction in worrying their therapist. To avoid alienating a client, the therapist can respond with non judgmental compassion and calm curiosity that focuses on understanding the facts (Walsh, 2006). It must be realised that seeking therapy is a giant step for the self-harming client as they normally keep their act as a secret. The prospect of someone harming themselves will arouse strong emotions in most people including therapists (Sanders et al, 2009). The therapist therefore is challenged to listening to the client’s whole story and use the right psychotherapy approach at the right time. The client’s story should get the therapist to listen to; what is happening, who said what to whom, what ideas they’ve got about it, how they felt then and how they are feeling now. Listening also entails listening to explore thoughts and also to explore feelings. If the therapist has problems expressing feelings, it is likely that they will have problems being present with strong feeling expressed like those the client who self-harms might have. Empathy will play a big part in trying to understand what the client who self-harms is feeling and also what their reasons are. The therapist, on reflecting can only do so on what the client has shown without the need to go to the unconscious material. If the therapist tries to mould his/her own process and way of being, then there might be problems (Sanders et al 2009). A language that the client is used to must be used by the therapist instead of technical or medical terms that the client might not understand. If the client’s life is at risk, medical profession should be sought and in some cases the client is hospitalised. Conclusion It is a great challenge to maintain equilibrium and optimism when treating self-harming clients. The key to a successful outcome is learning how to adapt to the specific obstacles presented by those who self-harm. Validation, collaboration, and patience will enable therapists to establish and maintain a strong therapeutic alliance. The subsequent opportunity to repair a faulty alliance comes with greater understanding and stronger communication. Conceptualising self-harm as functional, rather than manipulative, and avoiding common pitfalls will help maintain that working alliance. Even more importantly, the alliance will assist the client in moving forward toward eliminating the self-harming behaviour. References Corlett et al (1993) Navigating Midlife: Using Typology as a Guide Fiona Gardner (2001) Self harm-A psychotherapeutic Approach, Rutledge Hendin et al (2006) “Problems in Psychotherapy with Suicidal Patients” John L et al (2004) Self-harm Behaviour and Eating disorders dynamics, assessment and treatment, Routledge Module notes Norcross (2002) “Psychotherapy relationships that work: Therapist contributions and responsiveness to patient needs” (pp. 423–438). New York: Oxford University Press Walsh B W (2006) Treating self injury – A practical guide, Guilford Press William Q Judge ( ) The leader's shadow: exploring and developing executive character, read from pg 38 An overview of five therapeutic approaches used to treat clients who self harm - www.howto.co.uk/wellbeing/self harming/guidelines