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Mar 2016 by PCI College

Importance of responding empathically towards clients who engage in self-harming behaviors.

Liz Quish explores the issue of self-harm explaining its purpose and the importance of an empathic response.

Self-harm is a widespread and contentious issue, although not a recent phenomenon the presentation continues to be somewhat disconcerting which can present a range of challenges for mental health professional who support this client group. Some mental health professionals who endeavour to support this client group have reported experiencing a range of taxing emotions  (Johnstone 1997, Vivekananda 2000 ) and as such remaining empathic can be challenging particularly in cases where self-harm is persistent and extreme (Favazza 1989). Such negative reactions have been noted to greatly affect the quality of the therapeutic relationship (Sanderson 2006). Research highlights that the ability of a mental health professional to demonstrate empathic understanding towards a service user who engages in self-harm is a key feature in terms of positive treatment outcomes (Duncan & Miller 2000).


However, research conducted by Bywaters & Rolfe (2002) found that people who self-harmed often felt that mental health professionals displayed a sense of hopelessness when tending to them. Smith (2002) in her interviews with people who self-harmed found that professionals who supported them appeared unapproachable and favoured pharmaceutical treatment instead of engaging in a meaningful dialogue.  In addition research conducted by McAndrew & Warne (2005) found that many people who self-harmed and sought support, experienced negative and impersonal levels of care from professionals.  Many felt they were not listened to or asked questions in relation to their lives, their reasons for self-harming and stressors and as such were medicated and labelled as mentally ill (McAndrew & Warne 2005). 


Arnold (1995) noted that females who self-harmed found professionals unhelpful, judgemental, curt and punitive, communicating a message that their self-harming behaviour was attention seeking. It is worth noting that Reeves (2013) found that mental health professionals openness to hearing service users full narrative quickly disappeared once self-harm entered the frame thus leading to rupturing within the therapeutic alliance.
So what can we do as mental health professionals in order to ensure a positive and productive working alliance with clients who self-harm?

First we need to understand the purpose and function of self-harm. Self-Harm is the deliberate and intentional act of inflicting injury on oneself for the purpose of releasing inner emotional distress, more often than not with no suicidal intent. We must  understand that  self-harm is a coping strategy, utilised by people as a means to momentarily relieve emotional distress and as such could best be understood as a means of surviving ones psychological pain. In addition we need to create an empathic and collaborative therapeutic relationship with people who self-harm giving due credence to their personal narratives and attuning ourselves as professionals to the survivalist nature rather than the patholisation of their self-harming behaviours.

In investigating the importance ascribed to empathic engagement with clients who self-harm its significance and therapeutic effects are well established.  For example, Moyer & Nelson (2007) noted that many individuals who self-harm just want to be heard and listened to without being judged. Additionally, Moyer & Nelson (2007) found that engaging in a respectful curiosity about a client’s self-harming behaviours while ensuring an empathic stance had therapeutic effects. Furthermore, research by Craigen & Foster (2009) found that women who self-harmed noted the most helpful mental health professionals were those who listened with respect, understood and displayed empathic understanding and did not issue advice.


Moreover, Fortune et al. (2010) reported that adolescents identified encountering an empathic mental health professional who listened and was non-judgemental as a key factor in preventing further self-harming episodes. Long & Jenkins (2010) research which was based on the views of counsellors who supported this client group noted that counsellors themselves reported the importance and value of empathy, and the hearing of their client’s narrative and the meaning they ascribed to self-harming along with acceptance as key factors in aiding this client group on their journey towards healing. Bozarth (1998) noted when clients were exposed to and experience such empathic understanding by their counsellor their journey towards self-actualisation was accelerated and most importantly sustained.

It seems as mental health professionals we must first accept, and in doing so will be enabled to understand, our clients self-harming behaviour. We must however, be mindful and aware of transference and countertransference, before we can begin to utilise interventions appropriately and productively. In challenging our beliefs in relation to self-harming and embracing self-harm as a coping strategy it seems we as mental health professionals would be enabled to support clients in a more  empathic, productive and inclusive manner. 


Uncovering a client’s triggers, the function and purpose of their self-harming behaviours, developing workable and individualised solutions and psycho-education in order to increase client’s self-compassion, self-understanding and self-confidence through an empathic, collaborative and  non-judgemental process is vital in assisting clients who self-harm to recover their lives and develop more nurturing coping skills.

Author Bio: Liz Quish is a past student of PCI College and works as a Crisis Counsellor in Pieta House, Suicide and Self Harm Intervention Centre, she also works in private practice in Tipperary Town.  Liz designs and delivers a wide range of workshops relating to mental health and works part time as a lecturer with UCC. Liz is a published author her book “Overcoming Self-harm and Suicidal Thoughts a Practical Guide for the Adolescent Years” was published in February 2015 by Hammersmith Health Books and has been nominated for the Peoples Book Prize Award.


Liz Quish (March 2016)



Quish, L. (2015) Overcoming Self-harm and Suicidal Thoughts a Practical Guide for the Adolescent Years. London: Hammersmith Health Books.

Freeman J. (2010) Cover Up: Understanding Self-Harm. Dublin: Veritas Publications.
Empathic responses to self harm in counselling and psychotherapy




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