Self-Injury In Young People

Within days of qualifying as a therapist back in late 2012, I was given the opportunity to provide therapy to young people attending secondary school. Before long, I was working with adolescents who were telling me about their experiences of self injury, how it made them feel, and their understanding around why they did it.

I continued to work in a number of schools, some of which were multi- cultural and so I also had the privilege of working with young people from a range of different ethnic and cultural backgrounds. This included South Asian young women, some of whom were or had self injured.

For those I worked with, the reasons for their self injurious behaviour were similar to those given by other groups for their self injurious behaviour ( see Cutting and Self Injury- What is it and why do people do it). However, additional issues were also identified from clinical work with young South Asian women. This included understanding the impact of developing a sense of self, a major task of adolescence, in the context of racism and culture.

Five year later, I undertook some more study in the area of child and adolescent psychotherapy. As part of my MA studies in Child and Adolescent Psychotherapy, I undertook a literature review exploring these issues in the hope that it might shed light on additional ways of working clinically with this group and develop our understanding of the cultural and non- cultural factors associated in influencing their self injurious experiences.

At another level, I wrote this dissertation to give voice to their experiences, and honour the courage they showed throughout the process of therapy. They were my greatest teachers and it was a privilege to have worked with each and every one of them.

I include below, a summary of the dissertation. It is an academic piece of work, and is written in that style.

If you are currently self injuring, or know someone who is then you also have the option of reading the other article that I have written on self injury which is contained in the "Articles" section of the website. (see- Cutting and Self Injury- What is it and why do people do it). This is written in a non- academic style and includes details of agencies who you may wish to contact to gain some support as living with self injury or seeing someone live with self injury can be debilitating, feel so very isolating, confusing, shameful and stressful.

If you are in this position, my hopes are that you get the help you need and take the best care you can of yourself on your onward journey. For many, this will continue to be a challenging one, and may at times, leave you feeling helpless and hopeless. In these moments, my wish for you is that you hold onto the truth... that with time, hope, patience, and courage, things can get better... that things can change..

Hold onto this as strongly as you can.

With all my best wishes,

Anjula

Self injury and British South Asian adolescent women- reflections on the nature, causes and clinical implications of self injury within this minority community.

While there is an extensive body of literature on self-injury, including self-injury in adolescent females, there is comparatively little on the experiences of self-injury among British South Asian adolescent women (BSAAW), even though the evidence suggests that self-injury and suicide rates are higher among this group than other groups. Such relative neglect prompted this article which offers reflections on the nature, causes and clinical implications of self-injury within this minority community.

To elucidate our understanding, the dissertation seeks to understand the lived experience or context in which these meanings may be constructed by reflecting upon the similarities and differences between their experiences and those of British white adolescent females (BWAF), considering the impact of culture and racism, as well as adolescence and trauma, in meaning-making of self-injury within the South Asian community. It concludes with recommendations for clinical practice and future research priorities.

While recognising that there is no universally agreed terminology for this behaviour (Sutton, 2007), for the purposes of this dissertation, the term “self- injury” is used, and this reflects contemporary use of this phrase for this phenomenon.

Self-injury among British South Asian adolescent women

While Hawton and Rodham’s (2006) school-based study indicates that self-injury rates among BSAAW are lower than for white female adolescents, there is contradictory evidence suggesting that self-injury rates of South Asian adolescent women are higher in this group than for white young women. Specifically, Cooper, Hussain and Webb et al. (2006) revealed that young South Asian women aged 16-24 years old experienced a 1.5-fold increase in self-injury compared with white women in the same age group.

Other research suggests that women of South Asian origin in the UK have higher rates of attempted suicide compared with other ethnic groups (Merill and Owens 1986; Glover 1989; Raleigh, Buusu, Balarajan et al., 1990). Bhugra, Baldwin, Desai et al. (1999) indicated that attempted suicide rates among younger Asian women were 2.5 times higher than those of white young women, and seven times higher than those of South Asian men. Moreover, Cooper, Hussain, Webb et al. (2006) demonstrated that completed suicide rates were higher for South Asian women than in the white population. These reports indicate how self-injury within these communities represents a most significant social and healthcare problem, with research being undertaken to offer explanations for this.

The meanings that British South Asian women give to their self-injury

A number of papers state that self-injury is a release from emotional pain: that it can be used to assert control over emotions (Bhardwaj, 2001; Woode, 2011) that could not otherwise be expressed through words, and to communicate emotions, including rage (Marshall and Yazdani, 1999; Bhardwaj, 2001), associated with mistreatment and/or injustice associated with abuse or trauma. Scars are retained as a commutative function of the pain that people have suffered. In this context, Marshall and Yazdani (1999) note that the body is regarded as the last site on which control and self-determination can be exercised when experiencing a lack of control within a family/community context, and, therefore, self-injury symbolises a sense of ownership over the body.

Self-injury can be used also to find help within contexts in which verbal communication is regarded as difficult, for example, regarding the disclosure of distress to other family members. Here, self-injury and cutting of the body act as a form of expression, a message that serves to contact “outside” support and help.

Self-injury is regarded as a solution that creates a problem. This notion is related to the paradoxical nature of self-injury. In other words, although self-injury could be validated in that emotional pain can be communicated, via cuts and burns, these physical manifestations can also engender feelings of disgust and shame. Furthermore, Marshall and Yazdani (1999), Bhardwaj (2001) and Bhugra (2001) demonstrate that when young women report their experiences of self-injury to hospital-based professionals, such as in the case of overdoses, they are regarded as time-wasters or attention-seekers. Some self-injurers feel that their experiences are invalidated, increasing feelings of powerlessness, shame, self- hatred, guilt and isolation, exacerbating their negative feelings towards themselves, and so impacting their sense of self and accentuating their emotional distress levels.

Another sub-theme is that self-injury could help “release the bad”. This issue is discussed as something that not only brought relief from feelings of self-hatred but was, for some, a form of self-punishment, and normally took place in the context of experiencing abuse (Bhardwaj, 2001; Marshall & Yazdani, 1999). Furthermore, self-injury could create a sense of disassociation (Klineberg, 2015; Bhardwaj, 2001) or end a state of dissociation (Bhardwaj, op cit; Marshall and Yazdini, 1999). Disassociation is regarded as a coping mechanism used to manage the emotional pain, while for others it could be used to stop the sense of feeling anything at all. It is evident also from the literature review that self-injury is used as a method for preventing suicide, and to manage the overwhelming feelings that, if left unmanaged, could lead to suicide (Marshall and Yazdani, 1999; Simpson, 2006).

How culture, Izzat, acculturation and racism impact the understanding of these meanings and elevate emotional distress to self-injury levels.

Soni (2012) defines Izzat as a fluid cultural form that, traditionally, specified rules and expectations around choice of partner, sexual identities and behaviours, but now includes expectations and rules around educational and career aspirations. Exploring the nature of these challenges and the emotional impact of Izzat, Klineberg (2015) and Bhardwaj (2001) argue that many women feel oppressed by men, who they feel “made the rules”, with some believing that men (their brothers or fathers) do not have to abide by those rules. There is a sense, therefore, of being treated unjustly and unfairly, leading to feelings of entrapment, despair and wanting to escape.

However, many individuals feel unable to effect change in their situation, and consequently experience a sense of resignation and hopelessness, believing they had limited choice but to accept the situation. Self-injury and suicidal attempts are used in this situation. Shaw (2002) notes that, in this context, self-injury can be understood as a way of women gaining control and exerting control over the one place they had control of: their bodies.

Woode (2011) indicates that adhering to Izzat makes it difficult disclosing the distress associated with upholding Izzat to an outsider, as there is often an unspoken rule that personal matters be discussed within families. Not doing so, especially when young women feel unable to speak to a member of family about their distress, furthers their sense of isolation, powerlessness and emotional distress, as well as feeling pressured to remain silent. In short, there is a sense of women struggling in silence. Self-injury is considered a consequence of this situation, and is used to cope with these feelings.

Gilbert and Sanghera’s (2004) study of young Asian women’s mental health reveals how feelings of shame, entrapment and subordination are linked to Izzat and the maintenance of family honour. This situation can engender feelings of shame, confusion, frustration and disappointment in women if these expectations or rules are not abided by, as well as the fear of the consequences of breaking Izzat. In this context, Bhardwaj (2001) states that Izzat creates a situation in which emotional distress can be accentuated, sometimes even leading women to consider suicide, believing that this is better than being seen to defy the values associated with Izzat.

Gunasinghe (2015), Khan and Waheed (2009) and Jackson (1981) have all explored the link between Izzat, suicide and generational values, suggesting there is a generational transmission of values of submissiveness, devotion and self-sacrifice (as seen, for instance, in religious and culturally approved ritual suicide among South Asian women, such as the practice of Satie, in which a Hindu widow would kill herself by burning on her husband’s funeral pyre). Exploring suicide rates further, and within the context of acculturation, Zhang, Wieczorek, Conwell et al. (2011) argue that psychological strain can be induced from two internal competing and contradictory beliefs that individuals hold, creating internal conflict. They believe that second-generation immigrants experience such strains because of the differing value systems associated in living within collectivist and individualist cultures and the strains associated with adapting to both. They further advocate that the larger the discrepancy between aspiration and reality, as defined within the context of these cultures, the higher the chance of suicide or suicidal ideation. Similarly, Merton’s (1957) study of strain theory highlights its impact on heightening feelings of isolation, rootlessness and alienation.

I suggest that this theory can help explain high rates of suicide among British South Asian young women involved in an inter-racial relationship, or one in which their partner is of a different religion (see Bhugra, Baldwin, Desai et al., 1999). It is likely that both these factors are considered to be a form of defiance of Izzat, possibly leading to an internalised sense of shame and isolation as a result of being ostracised by the family.

However, Izzat can also sometimes engender feelings of belonging to a community and act as a protective factor against suicide (see Gunasinghe, 2015), which is perhaps connected to Durkheim’s (1897) study, in which he suggests that if someone is well integrated into a social institution, this lowers the risk of suicide.

It is evident that many of these studies, including those that do not study Izzat specifically, consider the effect of such cultural practices on “self”. Gupta, Johnstone and Gleeson (2008) examined the experiences of six 16-to-20-year- old South Asian women, noting a conflict between separation-individuation ideals in both the collectivist and more individualistic societies in which they lived. Dwairy and Achoui (2010) add that, in South Asian cultures, self is regarded as part of the collective in which these ideals are experienced and created within a cultural context in which the needs of the collective outweigh the needs of the individual. In contrast, in a more individualistic culture, self is regarded as more autonomous from the family, and concerns for the needs of the collective are not regarded as so important. Studying this further, Ghuman, in his 1994 book “Coping with Two Cultures”, notes that, in collective cultures, the individual’s
wishes and concerns and expressions of individuation and separation need to be harmonised with those of the family. Bahatia and Ram (2004) argue that this could lead to internal conflict, creating feelings of isolation, confusion, guilt, frustration and restriction, especially when there is a significant difference between an individual’s aspirations, values and beliefs and those held by the parents.

Reflecting upon Winnicott’s (1960) ideas of the false self, I suggest that another consequence is that there is pressure for a person to become who they feel the collective wants them to become. Jones (2016) further explores the idea of the false self in a group of self-injuring adolescents, noting that they are not seen or heard for who they are, and consequently do not know or experience who they are for themselves. The struggle to develop a “core sense of self” is, therefore, challenged by the demands associated with living within these cultural contexts, demonstrating that Izzat, and culture in general, provide a background in which self is defined, as well as some of the adverse consequences of this for emotional wellbeing.

Nevertheless, as noted previously, other studies suggest that Izzat can act as a protective factor for young women’s emotional health. Mullendar et al. (2002) and Midlarsky, Venkataramani and Plante (2006) suggest that Izzat provides participants with a sense of belonging within the family and the collective, and reduces feelings of isolation, as there are people to talk to if there is a concern. This opinion clearly contradicts earlier parts of the review, yet both positions may clearly be valid in different circumstances.

Perhaps, as an explanation of the apparently conflicting evidence, the level of entrapment or control depends upon how the individual feels about the values (e.g. cultural and religious) and whether they form an appreciated part of their identity. Furthermore, some studies (e.g. Woode, 2011; Bhardwaj, 2001) claim that it is not cultural or religious values that inflict emotional distress, but the way men use Izzat to control or oppress, which BSAAW found disempowering and distressing. Shaw (2002) notes that, in this context, self-injury can be understood as a way of managing feelings, or of women gaining control (via their actions), or expressing their rage at living within what Shaw (2002) deems to be a patriarchal cultural form.

These papers highlight the role of culture and Izzat in influencing emotional behaviour. There is evidence in some of the literature that the respondents did not think so-called “culture clash” was relevant to them. For example, Marshall and Yazdani (1999) suggest that the impact of Izzat or culture needs to be understood within the context of generational clashes that may or may not have to do with culture. Even so, these authors, and a number of other papers highlighted in the review, note that both Izzat and other cultural values may well have a significant influence on self-injury. Additionally, there is contrary evidence that suggests, in some circumstances, it can be constructive to emotional wellbeing. Finally, these papers suggest that our understanding of how culture helps explain this phenomenon may overemphasise, in its analysis, cultural conflicts, without analysing the impact of intergenerational relational conflict. As Hutnik (1991) suggests, a consequence of this lack is that papers exaggerate notions of Izzat and, more generally, of South Asian values, leading to the South Asian family being regarded as “restrictive and stifling of individuality” (p81) and, I argue, of BSAAW being regarded as submissive.

Furthermore, this view fails to consider how culture and Izzat are influenced by, or are a response to, racism. Littlewood and Karim (2000) argue that racism (from white people to black people) engenders feelings of rejection and alienation, to which a response may well be to reject dominant, Western cultural practices, and display more allegiance to traditional cultural practices brought over to the host culture.

According to Erikson (1994), any given trauma may be community and identity disrupting or solidifying. Perhaps this conceptualisation can be used to understand how BSAAW express and understand their own identity in a possible post-Brexit Britain and post-9/11, in which Islamophobia and the fear of physical assault may lead to the fear of wearing the hijab (Elahi and Khan, 2017). Akhtar (2011) states that the sense of being vulnerable to attack, of the loss associated with having an expression of identity taken away, and the acknowledgement that who they feel they are is unacceptable to members of the white community can lead to confusion and unpredictability; thus elevating emotional distress.

Berry (1994) examined this situation in relation to acculturation. Acculturation stress is the extent to which the individual has adopted the cultural ideas and behaviours of the host culture. Here, a sense of loss associated with a conscious and/or unconscious knowledge of what is being lost in order to acculturate may also be present. Bhugra (2004) notes that, in this context, self-injury is “an expression of disconnection and reaction to the sense of cultural alienation experienced by this particular group” (ibid. p39).

I argue, therefore, that self-injury occurs in the context of making meaning of both white and Asian culture, in which who you can be is defined by both, and in which there is a risk of solitude and rejection by both the majority and minority culture.

The above-described situation obliges us to consider the impact that racism may have on identity formation and emotional distress. It is reasonable to suggest, therefore, that analysing Izzat and culture in connection with racism can further enhance our understanding of Izzat, culture and the challenges associated with identity formation; and so thus, further defining a context in which to understand self-injury within BSAAW. It follows then that we need to examine the impact of racism that may be experienced by South Asian groups, and the extent to which it may elevate emotional distress.

How racism impacts emotional distress

Williams, Neighbors and Jackson (2003) and Sue (2010, 2011, 2015) note that all forms of racism are damaging, including micro-aggressions, which they define as preconscious or unconscious degradations and putdowns associated with race. These putdowns are often experienced as small, and often ignored or downplayed by others, leading the victim to feel self-doubt for noticing or reacting to the encounter. Greer and Chwalisz (2007) found that recipients of racism, including those who experience micro-aggressions, may feel anger, frustration or exhaustion over time and, according to Williams (2003) and Reiker, Kramer and Brown (1995), the cumulative effect is thought to lead to diminished self- confidence and a poor self-image, and potentially also to mental health problems such as depression, anxiety and trauma. Littlewood and Kareem (2000) similarly refer to racism as resulting in the “other”, which is someone who is prone to hold the unwanted projections placed upon them by the majority, creating a feeling of being the outsider, as well as engendering feelings of isolation. Furthermore, they note that an additional consequence of racism is that it can lead to negative representations of race, cultural heritage and skin colour; the black individual internalises this and exhibits feelings of envy, hate, jealousy, greed, anger, violence, suspicion and fear, as well as powerlessness, resulting in a lower sense of self-worth “believing that black by definition is not good enough...” (p151). Fanon (1986) likewise notes that power is regarded as white, and so to identify with the powerful, good and desirable means devaluing the black within our psyche, leading to a wish to be white.

From a different source, the book Anita and Me (Syal, 1996) describes how racial discrimination and racial insults led to a rethinking of the consequences of colour for one female adolescent British Asian.

“I feel... hurt, angry, confused and horribly powerless because this kind of hatred couldn’t be explained.” (ibid, p97)

Here, as reflected in this novel, Anita’s way of survival is to reject everything Indian:
“I began avoiding mirrors; I refused to put on the Indian suits my mother laid out for me on the bed when guests were due for dinner.”

(ibid, p146)

Davids’ (2010) work can be used to reflect upon this writer’s own experience and suggests that racist projections received are split off and projected onto black skin, which because of the way black skin is construed in a racist society is then considered to be bad, ugly and unworthy.

Although these writers do not specifically relate their teachings to self-injury, if black skin is regarded in this way, perhaps it is plausible to consider whether some attacks upon their own skin by BSAAW can be understood as a response to these projections. Indeed this may well be reflected in the quote below, which is again taken from the book Anita and Me.

“I had never wanted to be anyone except myself only older and famous. However, now, for some reason, I wanted to shed my body like a snake slithering out of its skin and emerge reborn, pink and unrecognisable.” (ibid: p146)

Developing this line of enquiry, Alleyne (2012) argues that to survive living in a racist culture and to preserve a sense of wellbeing, a false self (Winnicott, 1960) can be created, one consequence of which is the formation of an internal oppressor. Here, there is an excessive holding onto expectations of being judged harshly, or of silencing thoughts and feelings to fit in with the cultural majority and the expectations they are perceived to have. This can lead to self-hate, a defence, she argues, against psychic and cultural annihilation. Moreover, Alleyne (2012) writes about intergenerational trauma, suggesting that beliefs associated with racism can be passed on generationally. It has already been highlighted how punitive feelings associated with the self can lead to self-injury and the sense of a bad self. Clearly then, Alleyne’s findings should be considered within this context too, adding further reflections on feeling bad.

MacVinga (2009) comments that non-white people can experience rage associated with the injustices of racism, and a sense of being silenced from talking about it for fear of the repercussions of doing so. This present study has noted how self-injury may be used to communicate anger and rage. It feels intuitive to suggest that BSAAW could also be using their self-injury to communicate experiences of rage and despair with racism. One consequence of
this is that racism may also lead to psychological distress, with self-injury being used to communicate as well as to manage its emotional impact.

Considering similarities and differences between BSAAW and BWAF lived experiences of self-injury, with reflections on trauma, adolescence and self-injury.

It is evident that there are similarities between the meanings identified in studies that examined the experiences of BSAAW and young women who have self- injured and papers that considered the experiences of self-injury among BWAF. Hawton and Rodham (2006) demonstrated how white females use self-injury as a coping mechanism to release overwhelming feelings, while others highlight the role of self-injury in self-punishment. Harris (2000) revealed how self-injury is a punishment that helps some women when teenagers to feel a sense of absolution. This finding is replicated in other studies, such as McAndrew and Warne (2005), in which one participant stated that self-injury rid her body of the “bad”. Here, the concept of release is facilitated by “bringing the inside out” (i.e. producing a sense of containment over emotional life), but also to remediate a sense of self and constancy in which the physical skin acts as a boundary between the self and the outside world. In this context, self-injury affirms identity, signals distress and elicits personal and interpersonal attention (Klonsky, 2007). Sutton (2007) discusses how self-injury can be used to express anger, and Van der Kolk (2007) and Farber (2006) note how it can be used to disassociate or reconnect with the body. For some respondents, this was achieved when seeing the blood and scars associated with their self-injury. Rao (2006) points out that this visual aspect acts as proof and confirmation that their feelings and distress were real, tangible and physical. He notes also that this could end a state of dissociation or disconnection from their emotional distress. As Rao (2006, p54) summarises it, “Cutting brings the cutter back to herself”.

It should be remembered that disassociation is also evidenced in a number of studies that examine the meanings that BSAAW give to their self-injury (Marshall and Yazdani, 1999; Bhardwaj, 2001), and this includes many self-injurers regarding themselves as “bad” (Marshall and Yazdani, 1999; Bhardwaj, 2001). It is demonstrated also in the broader literature search that self-injury can occur due to examination pressure or issues with friends (e.g. fall outs and bullying) (Klineberg, 2015). This is reaffirmed in Fox and Hawton (2004), which is a school-based study, and again in the work of Bhardwaj (2001). Furthermore, it is evident that self-injury occurs within the context of domestic violence, sexual abuse, neglect and trauma (Bhardwaj, 2001; Marshal and Yazdani, 1999; Gunasinghe, 2015). Additionally, the literature revealed further studies with BSAAW, such as Marshall and Thiara (2005) and Izzidien (2008), which indicate how South Asian young women use self-injury to cope with the feelings of isolation, low self-confidence, low self-respect, mental illness, fear and shame associated with living with domestic abuse, as well as the silence arising from an inability to speak about their abuse. Here, the body is used to communicate despair/anger.

All this suggests that the meanings given to self-injury within the community in question need also to consider the generic factors referred to in the literature to explain self-injury. Given that there is significant evidence to suggest that self- injury occurs in the context of trauma, it is appropriate to prioritise this in the review.

The relationship between self-injury and trauma

Van der Kolk et al. (2007,2009) and Gallop, Everett and Yates (2004) all note that abuse, emotional neglect or trauma, especially when there has been prolonged exposure, or when the person is known to the child, results in disruption in emotional regulation and relatedness to others. As Bowlby (1988), Holmes (2001) and Gerhardt (2004) mention, this can lead to distrust in the caretaker to co-regulate, or to a belief that the caregiver may heighten their emotional dysregulation. Here, the child may manage affect by themselves, using their body to relieve tension or act out impulses.

In this context, Conterio and Lader (1998) note:

“Self-injury represents a frantic attempt by someone with low coping skills to ‘mother herself’....she feels alone, with no hope that a soothing presence will come ‘make it all better’. Bodily care has been transformed into bodily harm; the razor blade becomes the wounding caregiver.” (p21)

Studying further the effect of trauma on self-injury and the body, Gardner (2001) states:
“body violation... can... be seen... in part as repetition and unconscious re-enactment of the processes derived from the experiences between the abuser and the abused... By opening up the surface of the skin, aspects of the dynamics of the internalised experience are repetitiously evoked... One functions seemingly to excise and expunge what was internalised, by getting it out of the body and externalising it by fixing it on the body surface. The angry violence is unconsciously directed both at the tyrannical, abusive object and the victim self.” (p48) She further notes:

“Repeatedly attacking the body can be seen as a form of mastery...The need for repetition can either be seen as a process that allows us to slowly gain control of a situation that was previously out of control – a form of revenge and so triumph over childhood trauma.”

(p 48)

These statements indicate the way in which the relational dynamics of trauma are internalised by the young women; self-injury becomes a reflection of her taking on the roles of the abused and the abuser over the domains of her body.

Self-injury and parental deficits

Additionally, Fonagy and Bateman (2006) suggest that deficits in the parent-child relationship may lead to a situation in which there is an inability to represent affect in language or of integrating affect with cognition. This, they argue, is related to a disruption in the capacity to mentalise, that is, an ability to perceive and interpret human behaviours in terms of intentional mental states (namely needs, desires, feelings, beliefs, goals, purposes and reasons). This, in turn, can inhibit the individual’s reflective function (Holmes, 2004) (i.e. the ability to process experience using thought and language):

“aggression directed against the body may be closely linked to failures of mentalisation, as the lack of capacity to think about mental states may force individuals to manage thoughts, beliefs and desires in the physical domain [where mental states are experienced as physical]’’

(Fonagy & Target, 1997, p487)

Violence is regarded as an attempt to eradicate intolerable psychic experiences. In this context, the parental care received in the early years may negatively affect the ability of children to self-regulate, leading to a situation in which, instead of feelings being expressed in words, they are expressed via actions, including self- injury.

This echoes the work of Turp (1999), who, drawing on Winnicott (1986), stresses the importance of holding and handling in pre-verbal years, implying that we are unable to hold ourselves if we have not, in turn, been appropriately held. She argues that a lack of “holding”, that is a poor history of the experience of touch, inadequate maternal handling, and a lack of emotional support, leads to “seeing self-injury as a kind of self-attention to the need for handling in order to stay alive” (Turp, 1999, p317). Thus, the above suggests that the lack of appropriate parental care received in the early years may later become a contributory factor in causing self-injury.

Ellis (1997) explores this further, noting how racism may affect the parental care received. She argues that racism amplifies inner persecutory anxieties, such as fear of physical and psychic annihilation, in which external objects may be regarded as persecutory and unsafe. This, she suggests, can affect the mother’s ability to take in feelings, including the unbearable feelings or aspects of the infant’s self, objects, effects and unprocessed sensory experiences; and in providing a mirroring of how to handle such feelings. If a mother is unable to do so, she cannot provide containment (Bion, 1984). Ellis (1997) argues that here, the mother will push back into her baby her intolerable distress.

Bion (1984) refers to this as “nameless dread” (p116). Moreover, and in this context, Bick (1968) asserts that the baby develops a “second skin” (p66) to defend against the defensive chaos that arises from this. Turp (2003) suggests that forms of self-injury such as skin scratching or rubbing are attempts to create this second skin to hold the parts of the personality together; thus, providing a contained and continuous sense of self.

Ellis’s teachings are important because they imply the possible impact of racism on parental care and on the ability of parents to mentalise. This speaks to the idea of the alien self, which Fonagy and Bateman (2008) suggest is created when the caregiver’s representations of the infant are based on mistuned attributions, that is in failures of mentalisation. Consequently, a secondary representation develops in the mind of the child. This alien representation becomes part of an inner self concept, in which the alien self is experienced as an inner tormentor; there is a constant experience of inner criticism, self-hatred, disgust, shame and expectation of failure, and a need for punishment. This alludes to the idea of the “bad self”, as highlighted in a number of the papers (e.g. Marshall and Yazdani, 1999; Bhardwaj, 2001).

The relationship between adolescence and self-injury

Frankel (1998) believes that the major tasks associated with adolescence are “letting go” of the child self and “forming” the adult self. These tasks involve the process of individuating and separating from parents to become more autonomous. Gardner (2001) advances that, in adolescence, self-injury can be used to manage the conflictual states of mind associated with this, including the heightened aggressive desires and unconscious or conscious desires to remain a child. She postulates that body changes as a consequence of puberty could lead to emotional dissonance, with some women hating their body or regarding it as a cause of pain and anxiety, as it signals the end of childhood, yet they want it to return to its childhood state. In this context, self-injury, she argues, could be used to punish the body for these changes.

Regarding separation, she notes that cutting is akin to cutting the links between daughter and mother, creating a psychological space for the adolescent to create a self that is separate from the mother. This space is necessary to allow the adolescent to begin searching for and gaining a sense of who she is. In this respect, self-injury is used as a method of avoiding a sense of the annihilation of the self. Thus, self-injury and attacks on the adolescent body are deemed to be a consequence of the developmental challenges associated with separation and individuation.

Although no literature could be found that explored this within BSAAW, Klineberg (2015), Marshall and Yazdani (1999) and Bhardwaj (2001) imply this, although they do not elaborate on the impact of generational conflicts between mothers, fathers and daughters. Furthermore, it could be argued that, for BSAAW, perceptions of the body, in the context of adolescence, need to consider the issues identified above which suggest that there will be additional challenges associated with the experience of adolescence and individuation given the cultural and racist context in which they live their life, which could lead to negative projections of black skin and the black psyche.

Contextualising these findings, especially on our understanding of the bad self (as well as on the body and skin), provides more comprehensive ways in which to understand the experiences, meanings and explanations of self-injury within this group.

The impact of culture, Izzat, acculturation and racism on elevating emotional distress to self-injury levels

Izzat

A number of the papers (e.g. Klineberg, 2015) that consider the issue of Izzat, link it mainly to concepts of South Asian culture without fully considering the different values and beliefs regarding it and self-injury that exist in South Asian communities. For example, in Islam, suicide is forbidden; whereas, in Hinduism, views on suicide are more ambivalent (Bhugra, 2004). This may have influenced the respondents’ readiness to discuss or admit to having such thoughts, possibly leading to an under-reporting of these factors. Furthermore, there is little consideration of the impact of differences that arose from ethnicity, educational background, class, caste, generation or indeed the country of origin. This lack is evident in a number of the studies failing to stipulate where individuals came from (e.g. Pakistan, Sri Lanka, Bangladesh or India) or supply information on class, educational background or length of stay in the country (Waheed and Hussain, 2006). Arguably, this lack led to an omission in the analysis of the possible impact of these variables on culture and Izzat, restricting the edification of the complexities, contradictions and differences associated with the meanings that may be held by these subgroups.

Indeed, most of the literature that looks specifically at Izzat does not explore in any great detail the intersectionality of these factors, such as class or caste, on the meanings this group gives to their self-injuring. Again, this may well have compromised our understanding of the complexities involved in the analysis of Izzat in elevating emotional distress to self-injury levels. Moreover, Mucina (2015) studied Izzat in the context of a continuum, in which there is a gradation of acceptable and non-acceptable behaviour. A number of the studies cited (e.g. Bhardwaj, 2001) do not elucidate upon the implications of studying Izzat in this way. Arguably, this could have restricted the identification of the complexities in the meanings and perceptions these groups give to self-injury.

Equally of importance is that a number of the studies used focus groups to consider these issues (e.g. Gilbert and Sanghera, 2004). It may well have been that, given the sensitive nature of Izzat, which encourages individuals to observe their social standing and be concerned about how their behaviours are viewed by others (Gunasinghe, 2015) and the fear of being seen to be breaking Izzat, even by talking about it (Bhardwaj, 2001), one-to-one interviews may have been more suitable for exploring the emotional impact of Izzat on BSAAW.

Culture

Several other important points can be made about these papers. Many fail to make explicit reference to whether the samples were first, second or third generation. Given the literature just reviewed (see Littlewood and Karim, 2001), it is clear that this omission may have affected their (and their parents’) experiences of acculturation and Izzat, again simplifying the analysis of the impact of culture on elevating BSAAW’s emotional distress to self-injury levels. Furthermore, in the papers that focus on exploring acculturation and culture, and that reflected upon the effect on separation and individuation, it is evident that a number of these studies do not explore the concept of “white culture”, focusing more heavily on Asian culture, on elevating emotional distress levels to self- injury. Marshall and Yazdani (1999) note that, by emphasising so, there is an imbalance of the self-injury condition and the deconstruction of the impact of stresses and conflicts that arise from living “within two cultures”. Arguably, this could impair our understanding of the meanings of self-injury, and the nature of challenges that BSAAW face in adolescence, when separation and individuation take places within this context.

Many of the papers on acculturation use terms such as “collectivist” and “individualist” cultures. Arguably, by doing so, the literature fails to recognise the complexity and fluidity of cultural forms, and that, for many South Asian families, they are a hybrid, using values associated with both. The papers do not fully recognise this aspect, nor indeed the impact of different family systems on acculturational and separation-individuation processes again, simplifying the analyses. Additionally, it is evident that some papers do not reflect upon the benefits of a collectivist culture. I argue that constructs of culture, family and individuation are influenced by the dominant racist discourse, in which the understanding of these concepts stems from a position that favours the white Western perspective (Reid, 1997). Furthermore, cultural stereotypes are employed, leading to an overemphasis on the family as the cause of emotional distress or oppression; consequently, failing to adequately consider other oppressions, such as discrimination.

On a different note, there is a wide range of terminology around the condition of self-injury (see Borges et al., 1995 and Silverman, 2006 for more information). Favasso (2011) was referred to earlier as promoting the view that some forms of self-injury are culturally sanctioned. Here, it seems relevant to note that Favasso regards some self-injury as a rite of passage from childhood into adulthood in some communities. None of the studies in the literature review consider the phenomenon from both these perspectives. Furthermore, Turp (2003) envisaged a continuum between self-injury and self-care, with a gradation from adequate self-care through to mild, moderate and severe self-injury. It is evident that, in the studies examined, none consider self-injury within this continuum. Evidently, this could compromise our understanding of self-injury, as well as underestimate the prevalence of this phenomenon among BSAAW.

Racism

The literature review explored the effect of racism on these expressions of self injury, with reflections on black skin and the psyche. Evidently, most of the reports cited do not specifically study the impact of racism on self-injury, and, of those that do consider this, most related it to adults (Akhtar, 2011; Davids, 2011), possibly leading to an omission of factors relevant to the younger age group, such as racial bullying in schools. This element is important because, as already highlighted, bullying is a risk factor for self-injury (Fisher, Moffitt, Houts et al., 2012). However, of those reports in the review that consider the impact of racism on adolescent self-injury, most were conducted in multiracial areas (Marshall and Yazdani 1999; Bhardwaj, 2001). As noted previously, Hawton and Rodham (2002) make the additional point that the impact of racism on emotional distress levels in geographical areas where Asian and minority ethnic groups are in the minority, may be higher given that prejudice, racial bullying and harassment may be more endemic. Moreover, perceptions of what constitutes racist bullying may differ between respondents, possibly leading to an under-representation of this as an issue.

It is also evident that most of the literature cited does not consider the impact of religion on experiences of racism. Exploring the intersectionality of religion and racism in this way, may well have elucidated additional thoughts on its impact on black skin and the black psyche.

It is clear that the negative impact of racism is central in this present study of the literature under review. It is readily apparent that, apart from Alleyne (2012), the literature does not elucidate how living with racism can lead to resilience and resourcefulness in the scenario of seeking solutions in a challenging world context. A consideration of this may also have added additional depth to this work.

Racism and parenting

The literature examined here, also reflected upon the effect of racism on parenting ability. Of the papers cited in the literature review, for example, Bateman and Fonagy, (2008) and Fonagy and Target (1997), which were the only ones I could access that considered reflective capacity, a number do not explore in any great depth the intergenerational impact of racism, nor indeed the impact of racism and multiple forms of additional oppressions, such as social and economic, on parents abilities to mentalise.

Moreover, the analysis does not allow for a consideration of Alleyne’s (2012) concept of intergenerational trauma on the nature of expectations that parents have of their daughters.
Bhardwaj (2001) notes that some parents have high academic expectations for their daughters, which is regarded as a factor in elevating emotional distress levels to self-injury levels (see Hawton and Rodham, 2002). Studying this as a response to intergenerational trauma, in which racism may leave parents with a belief that their daughter needs to be twice as good as her white counterparts to benefit from the same opportunities, may have added further meaning to the papers cited in this area, increasing perhaps our understanding of the internal mindset of these parents, as well as exploring how cultural oppressions intersect with wider oppressions.

Similarities and differences between BSAAW and BWAF lived experiences of self-injury, exploring the relationship between trauma, adolescence and self-injury

This section of the literature review examines similarities in the meanings given to self-injury among BSAAW and WAW, arguing that they are shaped by the contextual continuum in which these women live their lives, such as trauma, abuse and adolescence. None of the literature cited identified significant differences in the meanings these groups give to self-injury. Given that discrimination against women, in general, is endemic, and that there are cultural differences in the way women are treated, for example, between white working -class families and white middle-class families, it would have been interesting for the literature to consider differences in the perceptions and attitudes both groups ascribe to these experiences. This approach may have further exposed the relative importance of culture and cultural oppressions and economic, racial and class-based discrimination regarding self-injury among BSAAW, and advanced our understanding of the intersectionality of variables, such as race and class, on BSAAW meanings of self-injury. Additionally, and for completeness, the literature also fails to consider the impact of misogyny on self-injury.

Areas for further research

Generally, as demonstrated, many of the papers fail to explore the intersectionality of issues of race, gender, class, sexual orientation or disability in the analysis of cultural oppressions and racism in elevating emotional distress to self-harm levels within BSAAW, nor do they fully recognise the impact of additional oppressions on these experiences. Exploring the possible relevance of being hated or disliked not only for being Asian or Muslim, but also for being a woman within the cultural context of Izzat, or a non-cultural context of racism, would intensify the effect of these on the meanings and functions that BSAAW face and further elucidate the relationship between cultural and wider forms of oppression on this experience.

Moreover, none of the reports examined, specifically studied the mother- daughter relationship within South Asian families and the impact this may have on separation, individuation and self-injury. I suggest, therefore, that, more research is undertaken, in this area, including a consideration of the perceptions daughters have of the role of their mothers in ensuring their compliance with the rules of Izzat. Such an analysis might lead to further insights into how, in this context, self-injury is used to express and manage internalised rage at mothers, as well as considering the effect on perceptions of womanhood, motherhood and the female body. It has been demonstrated already how these concepts may well be important in furthering our understanding of the ways in which meanings on self-injury are constructed.

Additionally, I argue that the case can be made to undertake research that considers Favasso’s (1996) ideas that some acts of self-injury could be regarded as a rite of passage within these communities. Further research that explores self-injury in this context might be useful in delineating psychological and cultural factors more clearly. Furthermore, I advocate that research that employs Turp’s (2003) continuum of self-care and self-injury would be sensible and useful too for considering other forms of self-injury not covered in the literature reviewed; for example, increased alcohol consumption within South Asian young women from the Panjabi (Sikh) community (see Hurcombe, Bayley and Goodman 2010; Orford, Natera, Copello et al., 2005). In other words, exploring the different cultural perspectives regarding what constitutes self-injury may need to be considered within both these contexts.

Similarly, no studies were found that explore issues of sexual orientation or the impact of disability on BSAAW who self-injure. Studies of adult disabled British South Asian women (Hussain, 2005) and white British adolescents have treated this as a variable that elevates emotional distress and leads to self-injury (Hawton and Rodham, 2002). Exploring this factor in the context of Izzat, for example, and the rules it can associate with sexual conduct, as well as disability in the context of perceptions of the body, would be useful, adding more meaning to our study in this area.

Similarly, there is limited literature that explicitly explores the impact of racism on BSAAW’s perceptions of black skin and introjections of the self and bad self on their experiences of self-injury. Given that the literature review identified these aspects as being important areas to consider when understanding these phenomena, I argue that this is surely another important area for further research.

Regarding the analysis of racism in this context, I recommend that there is too ,the need for more research to be undertaken in areas where BSA communities are in the minority, which includes the situations of micro- aggressions and bullying. Furthermore, it would be useful also to investigate the effect of Islamophobia on these experiences. This might improve our understanding of the experiences of racism on specific groups by introducing issues of intersectionality, such as religion and race, adding both depth and breadth to the analysis.

The above recommendations, then, highlight the relative paucity of research into potential causation factors. I suggest this lack may have created a silence around the topic, leading to cultural stereotyping and an oversimplification of the complexity of the issue. It could be argued, too, that it reflects the silence often associated with the act of self-injury. Moreover, and with further reference to the work of Scheurich and Young (1997), these research implications may reinforce, together with overly restrictive codes of conduct governing the scope and presentation of research in this area, the research epistemologies of the dominant groups in society, in which issues of race, culture, religion and ethnicity may not be properly delineated.

To conclude, thus far, the research literature review has met its objectives, even though, as highlighted in the above section, weaknesses in the literature have been identified, which means certain questions inevitably remain unanswered. These questions include the relative importance of each of these factors and those identified from the generic literature as risk factors regarding self-injury among BSAAW and the influence of cultural and non-cultural forms of oppression on this serious mental health condition.

Having completed the literature review, I now consider the implications of the literature review for child psychotherapeutic practice.

What are the implications for child psychotherapeutic practice?

Racism and parenting

Hall, McIntosh, Neitzert et al. (2017) noted that 50% of Bangladeshi and 46% of Pakistani households were living in poverty, as opposed to 19% of white British households. Fonagy and Bateman (2008) argue that a consequence of stress, or when exposed to enormous pressure, including financial, is that it adversely affects the ability of reflective capacity, leading to a compromised ability in the child to regulate their emotions and to self-soothe in later life. It was mentioned that this inability may lead to self-injury being used to self-regulate, including when trauma is present.

This has obvious implications for our work with parents, one of which may include, as a starting point, the importance of practitioners recognising the impact of multiple forms of oppression on the reflective capacity of these parents.

Furthermore, and recalling Frailberg, Adelson and Shapiro’s (1975) work on generational trauma and Alleyne’s (2012) concept of intergenerational trauma (already discussed in the literature review) this demonstrates a need for practitioners to work with parents to consider their effect on reflective capacity. Word count limitations restrict discussion of this in necessary depth, but it would include reflecting upon the impact of intergenerational trauma, racism and oppressions (cultural or otherwise) on parents’ internal experiences and understandings of the child.

Should we treat racism as a trauma?

Sue (2015) argues that racism, in the form of hate crimes, terrorist attacks (such as the recent New Zealand killings of 49 Muslims) and micro-aggressions, should be treated as a traumatic event as they share many of the criteria for trauma (DSM-5), including: (a) shock, fear, denial, or disbelief; (b) guilt, shame, or self-blame; (c) anger, irritability, mood swings; and (d) sadness and hopelessness. The findings of the studies in the literature review are consistent with such an approach and could be used to advocate racism being treated as a trauma in its own right. This suggests that including a trauma-focused approach to self-injury is essential. This would need to be informed by insights from neuroscience, affect regulation, attachment theory (see Van der Kolk, 2009) and mindfulness (tailored to the specific trauma symptoms that each client manifests), and follow the NICE (2012) guidelines on self-injury, risk and assessment.

Race and transference

Second, the literature review has demonstrated that racism and discrimination affect the therapist’s views of the client. Dalal (2002) suggests racism assigns roles to specific ethnic and racial groups, with subsequent beliefs and value systems being assigned to them. As the structures of society are colour coded, he argues these are reflected in the structures of the psyche, conditioning our projections and introjections. He highlights the importance of psychotherapists acknowledging the impact of their race and potential racism on their understanding of, and beliefs and assumptions of South Asian cultural forms, as well as recognising the impact that race and racism can have on mental health. This includes acknowledging the additional oppressions clients bring (i.e. social, economic and gender), considering their intersectionality, and the clinical implications resulting from the imbalance in power deriving from internalised views about race, which, Dalal (2002) argues, might be perpetuated in the therapeutic encounter and in the transferential relationship.
Mavinga (2009) refers to this situation as a “black empathic approach” (2009:62). This also means offering
“responses that specifically and sensitively relate to a client’s racial and cultural experiences as they express them and as the therapist intuitively recognises them as an element of identity and personal psychology.” (p58) This entails engaging with the multiple meanings of self-injury, Izzat and oppressions, working from the clients’ perspectives and needs, rather than the psychotherapists’ own assumptions; thus, recognising the lack of homogeneity in these constructs, including the place of culture in accounting for BSAAW engaging in self-injury.

Working with the body

The literature review also noted the importance of identifying alternative ways of attending to self-handling or a “need for touch experiences as the lack of ‘handling’ or ‘holding’ was a contributory reason given for self-injury” (Turp, 2003). I argue that some clients, especially if they have experienced neglect, abuse or trauma in their lives, may not have developed a capacity for self-care, because neglect and “self-neglect” may be what feels “normal”. Additionally, some may not know what the experience of self-care is. It is essential, therefore, to explore what this might look like, while also providing strategies they can use to help with this. Furthermore, exploring issues around how racism may have affected the meanings they give to their skin and brown skin might be useful. This approach would take into account some of the findings of the papers cited in the literature review.

Additionally, and informed by my work with self-injurers, and discussed in the review, the negative view of themselves and their bodies may lead to BSAAW not wanting to look after themselves because they feel unworthy of doing so. Cognitive behavioural techniques could be used to explore cognitive biases and be utilised to focus on the client’s “inner scripts.”

As also evidenced from the literature review, self-injury can be used for affect regulation in a context in which the child, due to neglect or the above, has to turn to themselves, using her limited resources to affect regulate. Recognising that the self-injurer has found a way of managing emotional distress and exploring in this in the context, her internal conflicts regarding her self-injury, as opposed to the elimination of self-injury, would be necessary. This approach recognises the work of Turp (2003), as already highlighted, regarding self-injury as a form of self-care.

Moreover, because self-injury is often conducted in secrecy, occurring in the context in which the adolescent has been violated or betrayed, for instance, by a caregiver, it is vital that this is not replicated in work with the client. It is essential, therefore, to be open and transparent, including around issues of safety, risk, confidentiality and limits. Such an approach is likely to engender trust, which, given the traumatic experiences or attachment issues that many of these self- injurers may have experienced, is important to establish.

Furthermore, it is axiomatic that assessment is ongoing and informed by organisational procedures, such as those operating within the school, as well as the NICE guidelines on self-injury (2012) and professional, ethical guidelines. Key to all this work is putting words to the client’s pain; thus, helping to increase reflective capacities while monitoring risk.

Containment

Throughout this review, there have been references to “containment” (Bion, 1980; Turp, 2003), which refers to the “primitive horror” (p309) that self-injury may arouse in the clinician, suggesting that:

“To do this, the therapist has to have a capacity to bear pain and anxiety which come from this, as to not will affect our ability to make sense of the self-injuring behaviour, leading the clinician to take action or even rescue. If she can do so, mirroring to the self-injury of the capacity of ‘bearing pain through thinking’ as opposed to an immediate evacuation of feelings, which she believes the act of self-injury can be about, is provided.” (Turp, 1999:315)

This quotation highlights the importance of the therapist being able to offer containment in facilitating a move whereby the self-injurer can use words instead of actions to express and understand emotional distress.

This section has highlighted some helpful ways of working with self-injurers and considers the key findings from the literature review. I argue that of profound importance in this work is developing a relationship in which a sense of human, emotional connection is felt, together with a deep level of trust between client and therapist. This position is based on my clinical practice in which these conditions created an environment that helped my clients to feel safe to speak about experiences of self-injury. Such an approach is also a model of care and compassion, which, I argue, is equally necessary to challenge negative beliefs that often seem to arise from an internalisation of the “bad object”, whose relationship with self-injury has already been discussed.

Conclusion

The literature explored meanings given to self-injury among BSAAW, and suggests that self-injury could be used for affect regulation and serve to communicate emotional distress and tension, engendering a sense of control, while also experiencing what may be described as the “paradoxical nature of self-injury”. Also noted was the use of self-injury as self-punishment, often made in the context of trauma, in which the individual had incorporated a view of themselves as “bad”. In this context, self-injury is used by individuals to punish themselves for their perceived “badness”. The review highlights the importance of context, that is, the lived experience in which BSAAW women live their lives, and considered racism, including its impact on parental deficits, acculturation and Izzat in creating, communicating and managing emotional distress on the body, as well as on the creation of the “bad self”. By referring to the general literature on racism, the impact that racism can have on the body and notions of the bad self was considered, adding additional depth to understanding the possible causes of self-injury within this community.

Additionally, by identifying areas of commonality between the meanings and contexts given to white women’s experiences of self-injury and those of BSAAW, the significance of trauma and adolescence in elevating emotional distress to self-injury levels among BSAAW was brought into perspective.

Equally important, clinical considerations highlighting the importance of offering containment, providing a compassionate, non-judgemental space and a black empathic transcultural approach (MacVinga, 2009) that considers the impact of racism, oppressions and cultural issues on the psyche and emotional distress were made. The review considered the implications for work with clients and practitioners, and reflected briefly on the significance for families and the transferential relationship.

Limitations of the review

The limitations of this literature review include there being a restricted number of available reports on self-injury in adolescent South Asian women. Consequently, the review was necessarily supplemented by studies on women aged 18+, or research that includes young women aged over 18. This may well have influenced the meanings given to self-injury, but adds additional perspectives to the findings. Additionally, I was unable to discuss all the risk factors outlined in the introduction due to word count limitations and, again, the very limited accessible literature in this area. Moreover, of the reports cited, many do not fully consider issues of intersectionality, which may have elucidated the influence of non-cultural and cultural factors on the self injury condition, along with the weight of cultural and non-cultural forms of oppression. It is evident also that some studies included in the review are somewhat dated and relate to communities that are likely to have changed considerably since the research was conducted. Nevertheless, such recent literature that exists concerning young adults suggests that phenomena such as racism and Izzat remain highly relevant (see Berger and Sarnyai, 2015; Mizra, 2015).

Social and political contexts in which clients are situated

The literature review includes an analysis of the social and political contexts in which clients are situated, providing perspectives upon the impact of oppressions, namely those borne from racism and Izzat, on parents and their reflective capacity, and on young women in elevating emotional distress to self-injury levels. This is an area that has demonstrably been under- researched and, while recognising the limitations of the studies reviewed (see above), arguably, this review has added a further layer of understanding to the value and limitations of literature in this area.

Furthermore, I suggest that the NICE guidelines (2012) on self-injury might consider the research priorities identified here when working with BSAAW, and for a clinical approach that integrates findings from the research with WAW and BSAAW, which argues that the reasons for self-injury in this community may include a range of factors and oppressions, such as racism and Izzat, but also generic factors such as adolescence and trauma common to both groups.

Oakley (2018) writes in “Therapy Today”:
“We need to find a way not only to think and speak as therapists about social issues but to intervene in the wider social and political world of our clients.” (p35)

As therapists, therefore, we need to situate our clients and ourselves in a political and social context, recognising that the work is intrinsically attached to social and political forces. Accommodating these external realities is affirming and empathic and enhances the sense of the client being understood and valued. I argue that to avoid doing so merely continues the silence and the powerlessness associated with the oppressions that I have demonstrated many BSAAW who self-injure experience, and to which their self-injury may be a response.

Equally important is exploring and addressing the underlying reality of powerlessness that many of these young women experience, as women who are empowered are less vulnerable to self-injury.

As stated above, this approach places clients within a social and political context, in which the personal becomes the political. It does the same for therapists, prompting them to advocate for change and to address oppressions inside and outside the consulting room.

These conclusions have been influenced by my work with self-injurers which, throughout the process of writing this dissertation have been with me. I was able to use them to consider their experiences of self-injury or, indeed, self-care against the material discussed in the literature review, recognising the complexities associated with it, as well as reflecting upon the courage and resourcefulness of self-injurers who have found a way to manage and communicate emotional distress.
Having undertaken the review, my hope is that psychotherapists are provided with additional understandings of this subject, which they can use to help BSAAW through the therapeutic process to make more sense of the meanings of their self-injury. The aim is to engender a belief that things can change, to move away from the desperate levels of despair and anguish that many feel, all whilst being “contained” compassionately with much-needed cultural understanding, sensitivity and care.

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