Engaging in self-harm does not mean a client is suicidal. Having thoughts of suicide does not always mean the person intends to take their own life. Not everyone with BPD self-harms and not everyone who self-harms has a mental health disorder. Essentially the person who self-harms uses it as a coping mechanism. They could be saying that, “life is overwhelming me at this moment and this is the way I cope. I don’t know how to make myself better any other way,” Clients who do not have an adequate vocabulary for their thoughts and feelings can act out, rather than articulate their trauma.
TRAUMA
Trauma is very personal and can differ from person to person. Trauma can include situations where you can experience being frightened, under threat, abandoned, rejected, humiliated, invalidated, unsafe, powerless, ashamed, trapped and unsupported. Self-harm, such as cutting, burning or picking at skin can make people feel alive as well as silencing their demons for a while. Or on the other hand, just the sight of their own blood can also emotionally regulate difficult feelings by bringing their energy levels down to the point where they dissociate. Both concepts can feel counter-intuitive and difficult to grasp for family or friends of the self-harming client.
TRUST, RAPPORT, SAFETY AND SECURITY
I work with a focus on the relationship between client and therapist, trust and rapport, safety and security before working on the survival skills in Dialectical Behaviour Therapy. These are learning behavioural skills so people have an idea of what they can do to ensure they stay safe in their body, their mind, their home and in the community. This is slow, careful work. The last thing I want to do is retraumatise clients. At this point I don’t need to know the content of someone’s trauma. It’s not that it’s not important, it is. But the abovementioned work needs to be done so Client and Therapist can feel safe in the room. Trauma telling is the last part of this type of therapy.
HARM MINIMISATION
I advocate for harm-minimisation. Until a client has tools, skills and strategies for emotional regulation in their life, it’s important that a therapist does not take their self-harm away, but works with the client to put something in place that is just as effective. Also, I encourage the client to only self-harm on one body part, not all the parts, leaving some parts to heal.
FIRST AID KITS
I also encourage self-harming clients to make up a first aid kit with sterilised equipment, such as razors, needles, knives, steri-strips, scissors, needle-driver and suture material for stitching up wounds at home, gauze bandages and long bandages etc. These are generally obtainable at the local chemist, rather than going to the local Emergency Department, as this can be a retraumatising event in itself where you can wait for hours and hours sitting on hard plastic chairs in a room with forty or fifty other wounded people, with the noise and the lights, and the hustle and bustle. Hardly conducive to mental well-being, it can be a terrifying experience. Hospital emergency Departments are slowly getting better for people with mental health issues, but do have a way to go yet.
FEEL GOOD SENSORY BOX
As well as a first aid kit, I ask clients to make another box, with things they like as well as elements from the five senses to help ground someone who is either under or over stimulated. Such as:
Seeing: a photograph of their favourite pet.
Hearing: a favourite CD to listen to (or iTunes or Spotify).
Feeling: a stress ball, or a silky teddy bear or rocks.
Smelling: Cloves, cinnamon sticks, perfume.
Tasting: Packets of hot chocolate, or sweets or strong mints.
The box is all your favourite personal choices as a go-to when feeling not great.
TRAUMA THERAPY
Before I address a client’s trauma, the client has to feel comfortable enough with me. This rapport and relationship building is crucial to engendering trust between client and therapist. Safety and security are paramount. My room is as safe as I can make it with shades of blue and grey, with water themed photos and pictures. Trauma is best done through the “Window of Opportunity” where the client doesn’t get too aroused or feels under stimulated. My therapy tries to stay in this Goldilocks zone.
Recognising the warning signs of dissociation is also crucial. Clients have reported floating out of their body and around my room. I help them back into their bodies with breathing exercises, grounding exercises and progressive muscle relaxation. I keep my voice soft and slow and I have a blanket if people feel that would be helpful. I offer a glass or water or herbal tea. During my sessions, five minutes before the end, I wind down the conversation. At the close of the session, if they feel dysregulated, I ask them if they can guarantee their own safety when they leave. If they are suicidal or self-harming and are not well regulated, I ask if I can call their emergency contact, the MHERL team or they can see a GP downstairs from my office at Aveley Medical Centre. I don’t just leave them.
After trust and safety are established, if permissible, I ask a client about their trauma history, I find it helps if I ask safer questions such as what sort of childhood messages did you learn growing up? It’s important not to blame the parents especially the mother. No mother or parent sets out to deliberately destroy their child. There are of course exceptions to this, when clearly the parents did not have their child’s best interests at heart, such as abuse from the parents themselves.
Childhood messages or core beliefs can stem from parents, siblings, aunties, uncles, cousins, grand-parents, teachers, schools and anything else in the child’s environment growing up. Finding out what happened to the client and helping them understand, process and integrate those memories where they didn’t understand what was happening and were so overwhelmed by the situation, is the heart and lungs of trauma therapy.
Integrating is about changing where the trauma memories are located in the brain. Simply put, they go from everyday working memory, where it is always fresh in the mind and prone to recall when triggered, to a more longer-term memory system where the client can remember the memories are but are no longer continuously triggered by them. They are now a part of the greater history of their life along with many other events. Upon recall, they have little effect on the on the body or the mind and soul. Eventually, they live a long way behind you, and are no longer the driving force of your existence.