Anyone For EBT*....?

You may be aware that there are plans afoot to expand access to psychological therapies in the NHS. This is a Good Thing, in my opinion. You may also be aware that there are plans afoot to ensure that CBT will be pretty much the only therapy on offer. This is a Very Bad Thing in my opinion. Perhaps you already know that. We have had some stimulating discussions on this blog about the pros and cons of CBT. See here and here if you want to catch up.

I have worked with a number of clients who self harm; who will routinely cut themselves as a way of managing a deeper distress than the physical pain of a wound. I have a friend who does this. She is exceptionally bright. She runs a successful business and has a broad CV. She knows more about psychology and psychotherapy than most, including many who work in the field. She invests in her personal development, and has an awareness and intuition that make her a valuable friend. She also cuts herself.

We present to you a joint post, on cutting and soothing, from the perspective of the one who cuts and the one who listens to some of those who cut. Find her words here.

There are a number of techniques that therapists are taught to use with those who cut. These include:

• Challenging the negative self talk, and replacing it with a positive internal narrative
• Distraction techniques, like going for a walk or a run
• Using an elastic band to inflict pain without damage
• Stabbing a melon with a large knife (!)
• Taking a bath with aromatherapy oils

These techniques don’t work. I know, because in my early days I have encouraged people to use them and have been dismayed at their lack of effectiveness.

They don’t work, because they absolutely fail to understand the purpose of the cutting. They fail to take account of the simple fact that, for those who do it, cutting soothes. That cutting has an effect on the physiology of the individual, and provides an experience that going for a run or pinging with an elastic band simply can’t replicate.

People don’t cut because they are attention seeking or histrionic. They cut because sometimes it is the only thing that soothes. Everyone who relies on self-harm for comfort has a level of significant internal disorganisation, resulting from either early trauma or lack of attachment in their early years.

This is hard for a therapist. We sit and hear the level of distress, the despair, the hurt and the pain and we feel overwhelmed. We may feel the distress ourselves. We feel pain at watching another in pain. We feel frustrated with ourselves that we cannot relieve it, and then we project that frustration onto the client for not making the techniques work for them. We may feel intolerant at their impotence and at their apparent inability to soothe themselves. We may pick up the projected impotence and feel like a failure at not being able to help. None of this is easy for a therapist.

And so we come up with yet another technique, the purpose of which is to soothe our own feelings of impotence or inadequacy. We Try Hard. It ceases to be about soothing the person in front of us, who is still in despair. The person who cuts knows that they are causing the therapist despair. It hurts them. They know that we are Trying Hard. They leave feeling misunderstood and blamed, confirming a belief that no one can help and they can only find respite through self-harm.

I have found something that sometimes works. It is not a technique. It is not a clever psychological trick. I have learnt that when I walk in their shoes, I start to understand what cutting gives them. I start to understand the primal experience, and recognise that inflicting deep pain on oneself can be physically soothing. It is a very different experience for each person who cuts, and it is not helpful to try to come up with a universal theory to explain the whys. For some people it is about manifesting psychic pain. For some it is about control. For some it is akin to a sexual experience. I have heard people say that it is like having an orgasm, only better. There is no doubt that the physiological experience is as important as the psychological one. Neuropsychologists are starting to research the possibility that cutting releases oxytocin – the same hormone that is released at the point of orgasm. It is possible that cutting performs a function of affect regulation.

So if I could sit alongside the person who is telling me of their pain and their need to cut, if I could walk in their shoes without acting out my own frustration, impotence or discomfort at my own distress, what effect would that have?

We know that to be in the presence of a self-regulating other is soothing in itself. We learn to tolerate our own deep despair by having another tolerate it for us, and show us that it is indeed tolerable. Neuropsychology tells us that when this happens in childhood positive neural pathways are formed, which allow us to continue to soothe ourselves in distressing moments when the other is not there. The secure attachment facilitates the production of oxytocin, serotonin and possibly other neurotransmitters. For those of us who don’t have enough of this experience in childhood, it is hoped that therapy can help us to develop it later in life.

So if the therapist can be a truly self-regulating other alongside the person who cuts, and a holding witness to their pain and distress, this will soothe. And as the relationship strengthens, the attachment will enable the other to internalise the positive object that is the therapist.

There may be time then for techniques. Or perhaps for simply saying “I don’t want you to hurt yourself. I want you to be safe because I care about you.”

I have grave concerns about CBT being the only therapy on offer for people who rely on the NHS. With many clients and issues it simply doesn’t work. With some clients it is positively harmful and reinforces their self blaming pathology. If you want to hear what this is like for users of NHS mental health services, read this excellent post by PatientGuard.

* Elastic Band Therapy