Tina, 14, is self-harming. How can a therapist win her trust that others can help?

Self-harm as a coping mechanism can be distressing and difficult to understand. Yet 12% of young Australians report having self-harmed on at least one occasion, most commonly via cutting. While we might associate such acts only with pain, cutting can release stress- and pain-reducing hormones and thus can have an addictive quality. Though the person cutting may experience emotional relief it is easy for parents and even mental health workers to view it as an act of aggression aimed at gaining attention and inducing distress. Indeed, cutting can serve as a impactful form of communication.

But communication is usually a secondary aim, even if this communication is powerfully felt by others. First and foremost, cutting is an attempt to deal with overwhelming feelings. Physical pain is preferred to psychic pain and, for some, seeing the blood and the scars allows the pain and anger felt inside to appear on the outside. This proved to be the case with my 14-year-old client, Tina*.

Tina arrived early for her first session, looking remarkably self-possessed given that her referral said she was chronically depressed and engaging in self-harm. She was quick to tell me that she was only there because her family and doctor wanted her to come. While she often felt sad, she didn’t think she needed my help as she could always relieve bad feelings by cutting herself on her thighs or arms. “Anyway, what do they know,” she added, pulling her long sleeves further down to cover multiple crisscrossing scars.

Tina’s “what do they know” was to the point. In our experience, often those who self-harm come from families who, while loving and caring, struggle with discipline and setting boundaries. Boundaries are vital for children to feel safe and, when they are not in place, children often feel alone.

These children can find themselves at the mercy of their emotions, consumed by rage, sadness and a raft of difficult feelings that they cannot regulate or manage. They struggle to identify what they feel, or what triggered their distress, and the need to rid themselves of the feelings is paramount, regardless of the consequences for themselves, their body or anyone else.

Not being able to think about others as real people with thoughts and feelings of their own characterises us all when we are in the grip of strong feelings. Witness the phenomenon of road rage, when the other motorist becomes an obstacle and not a person. This state assails those who self-cut more often as they have developed few resources to modulate strong feelings and are thus more often in their grip. They struggle to reflect and are quick to act.

As Tina sat sullenly staring out the window of my consulting room, I contemplated how we could move forward. How could I help her to take a moment of pause between her overwhelming feelings and the urge to cut? How could I help her to accept limits without needing all the time to test a physical limit? How could I help Tina to trust that others could help her?

First I would need to establish a trusting relationship by listening carefully to Tina so that in time she would be prepared to take a chance on my suggestions. I had an approach in mind – dialectical behaviour therapy – but I would need Tina’s buy-in for this to work.

DBT often takes place in groups and fosters five major skills: mindfulness, distress tolerance, interpersonal effectiveness, emotional regulation and walking the middle path. But there was no group available, and I was doubtful that Tina would immediately agree to join one. So I concentrated instead on how to use our relationship to begin to build these DBT skills in the interpersonal space between us. My focus was on allowing Tina to have a moment of pause between her feelings and actions, and to help her observe and reflect on what was happening for her.

An opportunity for this presented itself in our third session. Tina’s mother accompanied her as she was concerned that Tina had been to the emergency room after a significant cutting episode at the weekend. As her mother related the story, including her understandable distress and anger, I could see Tina becoming increasingly emotionally dysregulated. My sense was that she was on the verge of leaving the room. I asked her mother to pause, and I reflected on what I intuited Tina might be feeling – blamed, misunderstood, shamed – and how difficult it must be to sit with these intense feelings. I encouraged her to breathe deeply and to relax more fully into her chair. When she seemed calmer, I encouraged her to use words to express her feelings to her mother. I also encouraged her to consider her mother’s experience of what had happened and to connect with the concern and worry. In this way, I tried to help them both to reflect on what had played out between them, as I had no doubt this was a common pattern.

Moving forward, I knew the task in therapy would be to continue to work on allowing Tina’s feelings to be represented on the outside by using words and thoughts rather than scars. This is no mean feat but it is possible if the therapist is highly attuned to feelings, doesn’t avoid conflict and sets compassionate limits.

There is no quick fix but there is hope for a more bearable way to be in the world for those whose trust is broken.

  • Prof Gill Straker and Dr Jacqui Winship are co-authors of The Talking Cure. Straker also appears on the podcast Three Associating in which relational psychotherapists explore their blind spots. The therapist is a fictional amalgam of both authors and Tina* is a fictitious amalgam exemplifying many similar cases they see

  • In Australia, support is available at Beyond Blue on 1300 22 4636, Lifeline on 13 11 14, and at MensLine on 1300 789 978. In the UK, the charity Mind is available on 0300 123 3393 and Childline on 0800 1111. In the US, Mental Health America is available on 800-273-8255

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