Self-harm: a strategy for survival and nodal point of change

Formerly a social work manager at London’s Maudsley Hospital, Jack Nathan is now a lecturer in the Institute of Psychiatry’s Health Services Research Department (PO29, David Goldberg Centre, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK. Email: jacknathan54{at}hotmail.co.uk). He is also an Associate Member of the London Centre of Psychotherapy and is currently working as a consultant adult psychotherapist in the Maudsley Psychotherapy Service and Self-Harm Out-Patients Service.

The author explores key issues related to psychotherapeutic work with people who self-harm. Particular attention is given to the powerful countertransference feelings that practitioners often experience in this work and the importance of managing these. Rather than maintaining a detached distance, therapists should emotionally engage with the patient’s experience, creating a unique therapeutic relationship. The common patterns, functions and meanings of self-harm are discussed, with clinical vignettes that highlight the underlying dynamics of the behaviour. Self-harm is a survival stratagem, and methods for helping patients to find other ways to cope are suggested. One such is mentalisation, which can enhance the patient’s capacity to think, not impulsively act. If patients learn how to assess more accurately their own and other people’s states of mind, less destructive behaviours can emerge.