Suicide Prevention

The importance of attachment in treating and investigating self-harm

By Julie Janssens.

“I don’t want you to include my parents in therapy!”
“I hate them!”
“They don’t love me…”
“They will not understand what I am going through.”
“They have enough on their plate already. I don’t want to burden them with my problems.”
“It is like there is a huge skyscraper between us.”
“I have to deal with everything by myself.”
“My parents will not come and comfort me when I am in tears.”
“I feel unseen.”
“I feel unheard.”

As a family therapist and first-year PhD student that combines clinical work with empirical research, I have come to realize how great adolescents, who engage in self-harm behaviour, are in convincing me to not include their parents in therapy. Given that adolescents do not want to burden their parents, why would we as therapists include them? Therapists are always in favour of supporting clients by helping them to reduce all forms of stress and conflict. Some argue that adolescents are in a stage of identity development that involves detaching from their parents and figuring out who they are, by themselves. We as therapists also have feelings and are sometimes scared to include parents. This is especially the case when both the adolescent and the parents are extremely resistant. But,  it is important to consider that, when adolescents scream with their whole body that they do not want you to include their parents, that they may have built protection to cover up their most natural and core instinct: the need for care, to be seen and heard by those they love. I plea for therapists to look behind anger, to listen to the words that cannot be said (yet). To hear their scream as a way of connecting to the ones they need.

Maybe true autonomy is being dependent and leaning on others?

Attachment

To provide a clear understanding of what attachment is, I will use the widely described attachment theory by Bowlby [1]. John Bowlby is a British psychiatrist that had his own ruptures in attachment growing up, and who dedicated his life to research about attachment and the impact it has on coping with intense negative emotions.

When children generally experience their parents as available, responsive and attuned, they will develop a secure attachment bond with them. A secure attachment bond promotes the development of intra- and interpersonal skills that are needed to buffer against stressors. As a result, people with secure attachment bonds trust that they can rely on others when they need it: they will seek support when they feel distressed which helps them to cope with their emotions.

According to Bowlby, children who have predominantly negative past attachment experiences will develop an insecure attachment bond with their parents. These ruptures in trust influence their exploration of the environment, as without the expectation that one can rely on an attachment figure during stress, exploration is potentially harmful. This comes at the expense of the developing skills that adolescents need to deal with important developmental tasks. As a result, they develop less effective emotion regulation skills and are less likely to   seek support when they feel distressed. This makes it harder for adolescents to solve emotional challenges on their own when transitioning into adulthood.

From a clinical perspective…

As a clinician, working with adolescents who self-harm, I cannot deny the interpersonal nature and relational meaning underlying self-harm behaviour. From my perspective, these adolescents are non-verbally communicating an essential message to the outside world that they feel that they cannot express in any other way. From my experience, adolescents who self-harm feel unseen, unheard, and sometimes overcome with a great amount of anger. However, their core need is to be seen, to be heard and to be loved by their most important attachment figures. During my work as a therapist, I assume 3 things:

  1. Adolescents who self-harm have stopped seeking support when they feel distressed because they lost trust in relying on important attachment figures.
  2. These trust-related ruptures can be repaired.
  3. More trust and more communication between the adolescent and important attachment figures may lead to a decrease in self-harm thoughts and behaviours.

We should not believe as therapists that we can do as much as a parental figure can do for them. No therapist can be of such powerful significance to an adolescent. So, we should not act as experts, as if we know better who they are than their own parental figures. Their shared blood is the natural glue that we therapists can only use to bring them closer together. I therefore call for humility towards the people we meet and to see the connection we make with them only as the means of reconnecting them with their important attachment figures. We are not the medicine for these young people, but the important attachment figures in their environment is. It is up to us to help repair trust between them. We should help them tear down the walls that have been built between them, to build bridges and create network because strong relationships may buffer the development of self-harm thoughts and behaviour.

From a research perspective…

While self-harm is among the leading causes of death and injury worldwide [2], it is still poorly understood. Unfortunately, we are not yet able to optimally intervene and prevent self-harm because we lack insights into the factors that are underlying to this harmful behaviour. A lot of research has focused on the intrapersonal factors that are related to self-harm, while it could be of even greater relevance to take into account the context where this behaviour occurs. I believe further insights into  social and environmental risk factors would enable a better understanding of the processes underpinning the development of self-harm thoughts and behaviours.

Some research suggests a link between family functioning and self-harm, for example, a study [3] shows how adolescents in poor functioning families with low levels of warmth and support, and excessive behavioural control, were more likely to engage in self-harm behaviours. However, only a few studies have investigated the association between attachment and the development of self-harm and findings from existing studies are conflicting. For example, some studies do find an association between maternal attachment and self-harm [4] when other studies fail to find this relationship, and instead find a link between paternal attachment and self-harm [5].

That is why, during my PhD, I will focus on the role of mother, father and peer attachment in the development of self-harm thoughts and behaviours in a large non-clinical adolescent sample. I would like to better understand why adolescents think about and/or engage in self-harm behaviour and what the precise link between attachments and self-harm is. I believe that this will expand the theoretical scope of self-harm research and improve understanding of this behaviour within the context of young people. As a result, I hope to gain knowledge for practice as this research may highlight opportunities for early intervention and prevention.

 

References

  1. Bowlby, J. (1969). Attachment and loss (2nd ed.). Attachment Vol. I. New York, NY: Basic Books.
  2. WHO. World Health Organization: Suicide Prevention (SUPRE) 2008 Retrieved 2008 June 20, from http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/
  3. Baetens, I., Andrews, T., Claes, L., & Martin, G. (2015). The association between family functioning and NSSI in adolescence: the mediating role of depressive symptoms. Family Science, 6(1), 330-337.
  4. Gandhi, A., Claes, L., Bosmans, G., Baetens, I., Wilderjans, T. F., Maitra, S., … & Luyckx, K. (2016). Non-suicidal self-injury and adolescents attachment with peers and mother: The mediating role of identity synthesis and confusion. Journal of Child and family Studies, 25(6), 1735-1745.
  5. Santens, T., Claes, L., Diamond, G. S., & Bosmans, G. (2018). Depressive symptoms and self-harm among youngsters referred to child welfare: the role of trust in caregiver support and communication. Child abuse & neglect, 77, 155-167.

 


Julie Janssens (@JulieJns2) is pursuing a PhD at the Center for Contextual Psychiatry (KU Leuven, Belgium). Email: julie.janssens2@kuleuven.be.

 

 

*Featuring Photo by Edvin Johansson on Unsplash.

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