How self-harmers use the body as an interpretive canvass

Alice comments: “Well no blood runs down, which is often what causes the feeling of relief or that a duty or punishment was accomplished. I couldn’t let go until I saw blood running down to the ground. However, because cutting myself is a kind of escape, the scapegoat for a worse problem rather than the root of the problem itself, I believe that any alternative to reduce the need to myself is always valid. Does anyone know about other ones?” (Arcoverde, Amazonas, & de Lima, 2016, p. 120, italics added)

In this statement, we see one conundrum that self-harming presents. Alice describes the feeling of relief and accomplishment, maybe related to religious reasons, punishment, absolving herself of guilty feelings, or just the physical sensation which cutting provides. However, to be effective she has to see blood run down to the ground (one is caught between imagining just how much is required to “run down,” seemingly more than a drop) indicating that self-cutting is a demanding mistress, a little won’t do, a lot is required. This is required to feel better or at the very least temporarily escape or “scapegoat” an unnamed worse problem. That her solution isn’t sufficient is indicated by her asking what are other ways of reducing the need to hurt herself; leading to the idea that she may not know what the unnamed problem is. In other words, the real source of her angst has not been formulated yet (Stern, 2003).

Self-harming and the contemporary therapeutic field

In this discussion, I elaborate upon this idea and discuss one view of self-harming, which understands using the corporal body as a medium to communicate feelings and thoughts that have not yet been formulated to the harmer (Stern, 2003). From this perspective, the harmer lacks other symbolic means to express their motivations and reasons for harming. Furthermore, they cannot use metaphor and may not even be able to name and identify feelings ¹ (Adshead, 2010). By paying attention to the therapeutic context that many self-harmers present in, I describe how bodies for self-harmers serve as both index and icon within the interpersonal field (Sebeok, 2001). They draw attention to self and the need for meaning making, but do not necessarily communicate meanings themselves. They serve as a potential interpretive canvass from which newly agreed upon meanings about the motivations for their conduct can be made within a therapeutic relationship.

Making meaning of self-harming behavior

The authors note that within most psychotherapeutic disciplines, self-harming is considered a form of maladaptive communication and acting out (Arcoverde, Amazonas, & de Lima, 2016, p. 113–114). In response, psychotherapists pressure the subject/patient to talk about feelings rather than act upon them. Foucault and presumably the authors consider this pressure a demand for confession (p. 8). Such a demand reifies power structures, where the therapist has the power of the authority and is thus in the position of knower, and the patient is comparably powerless and has to yield to the therapist’s authority (Aron, 2001; Mitchell, 1997). ²

While this view of the therapeutic situation may have been the case during Foucault’s time, current therapeutic technique—perhaps influenced by his and other similar critiques—has changed considerably and views the situation as significantly more complicated than this (Greenberg & Mitchell, 1983; Mitchell, 1997). The developments over the past 35–40 years have greatly leveled the relationship and shifted the focus from a priori knowledge to instead creating a co-constructed field, from which new meanings may emerge (Aron, 2001; Bromberg, 1998; Rosenbaum, 2015; Stern, 2015). The therapeutic field, far from being a space for confession, where all the meanings are known a priori is instead seen as a collaborative space where new personal meanings can and must emerge.

Contemporary practitioners understand that for many self-harmers, talking and dialogue involves formulating aspects of their experience for the first time (Stern, 2003, 2009). In other words, not only does the demand to confess not apply, for many it may also be epistemologically impossible, because the harmers themselves may not know what they are confessing. Experience and knowledge does not exist as pre-packaged forms waiting to be unpacked and given as confession (Salvatore, 2015), but instead as co-constructed and thus unique to a time and space (Stern, 2003; Valsiner, 2007).

In this respect, theories that demand confession or consider this knowledge as known a priori are problematic due to creating an expectation that can be doubly shaming. The initial shame stems from using self-harming as a way of coping with difficult feelings. Indeed, not knowing what is causing one to self-harm or feel bad is itself often a very troubling and painful experience. This is then compounded by the inability to then “confess” when asked by their therapist why, creating the feeling of having shame about shame.

This can quickly become a vicious feedback circle. From this perspective, self-harming should not necessarily be considered a type of acting out, where the assumption is that the individual acts instead of speaking. Instead, since symbolic expression can be understood as a type of developmental accomplishment, harming may be a type of acting in, signaling the need for a co-constructed inquiry to begin to try and put symbolic expression to experience (Levenson, 1979/2005).

Self-harming as non-symbolic experience

Symbolic here refers to consensually validated experiences (Sullivan, 1953) or the agreement of a community (Peirce, 1877/1982) and not simply to the using of signs (Sullivan, 1953). In other words, symbolic refers to self-reflective or self-conscious sign usage (Valsiner, 2007; Wagoner & Rosenbaum, 2009), which is also purposeful and intentional. This view differs from other expressions of symbolic that refer to a more general process of something standing for something else. As self-conscious, or symbolic consciousness in the words of Harry Stack Sullivan (1953), the sign user holds together different aspects of the socially constructed nature of experience (Lincourt & Olczak, 1974; Wagoner & Rosenbaum, 2009). They can hold two different thoughts together (Stern, 2009), thus occupying two places at the same time (Bromberg, 1998), such as required in metaphor (Lakoff & Johnson, 2003). For instance, symbolic consciousness recognizes that other people may interpret experiences differently or have different experiences themselves. This ability to recognize and tolerate differences is considered by many a developmental achievement (Beebe & Lachmann, 2003; Klein, 1975), and has elsewhere been referred to as the ability to mentalize (Fonagy, Gergely, Jurist, & Target, 2003). ³ Its absence, in self-harmers, but also in others has been considered a source and a sign of significant psychic distress and as we will see may be one of the reasons for harming in the first place. ⁴

While self-harming may achieve symbolic consciousness often, it does not. This is likely in large part because of a cyclical relationship between self-harming’s status as socially unacceptable, the difficulty harmers experience with recognizing their experience and it happening in private and being considered a source of shame. Unlike other forms of self-modification, self-harm rarely involves the same socially agreed upon process. In other words, since it occurs in private it is not subject to processes of consensual validation as well as other societally agreed upon processes that encourage the creation of links and the construction of meaning (Bruner, 1990).

By way of contrast, compare the experience of a cutter to someone getting a tattoo. While both involve changing the skin, a tattoo requires a visit to a tattoo parlor, interaction with an artist, selecting a design, and so forth. Moreover, there is an intended audience for a tattoo, even if it is very private and personal. The relativistic aspect and the power of convention can be seen in some tattoos, such as those on the face or denoting gang representation being much less acceptable than others. However, as a whole, society supports a host of meanings around getting a tattoo that it does not support for self-harming.

As noted in the target article, without such support, self-harming quickly becomes canalized as a type of pathological behavior and as such, the meanings available to those who self-harm are extremely limited. Self-harming appears overregulated and fixated as problematic and bad. Thus, a self-harmer may not know why they harm but may know that it is “bad” and that they need to “stop.” The situation is further complicated by the fact that self-harming triggers a strong response from others, which if not moderated may lead to the harmer experience the double shaming described earlier. ⁵

Self-harming as a sign within the therapeutic field

When considered from this perspective, the meaning of self-harming within the therapeutic field cannot be known a priori, but instead requires a collaborative effort between therapist and patient to make symbolic meaning. Having said this, self-harming is not without effect. Specifically, it initially serves an iconic and indexical function, which can both direct the inquiry, and also threaten to undermine it as well. Self-harming functions as a sign marking the presence of ongoing psychological processes that if not elaborated can easily sabotage meaning making efforts. Indeed, efforts to elaborate meaning can readily stall out, undermining the therapeutic process.

Icons bear a physical resemblance or likeness to what they are representing (Sebeok, 2001), and as such self-harming clearly functions in this capacity. The actual marks on the skin, whether a light scratch, a deep scar, or burn marks, physically represent a feeling of hurt and pain, but also possibly of pleasure, compulsion and impulsivity that may represent ways of coping and expressing feelings. While this may seem obvious, it is interesting to note that for many self-harmers this connection can only come about after a first instance of harming. Consider the following quote from Pardal:

It all started when I was curious and made some superficial cuts on my wrists to find out what the feeling of committing suicide might be [like]. Oddly enough, I had a comforting feeling of relief and from that time onwards, whenever I was sad or full of hate, I’d get some cutting thing and hurt myself to feel better (…). I’m aware this odd habit is a mental disease that is very hard to control and that I might have to live with it for the rest of my life. (Arcoverde, Amazonas, & de Lima, 2016, p. 118, italics added)

The curiosity towards understanding something leads this individual to make cuts on their skin. Afterwards, they feel relief and can acknowledge feelings of sadness or hatred, though do not talk about why they were thinking about suicide. That the cutting makes them feel better may in fact not only be because of the physical sensations (see below), but also seeing an iconic representation of their feelings or emotional states. Simultaneously, Pardal’s consideration of this as representative of a “mental disease” and thus not psychologically interesting or a form of communications, threatens the therapeutic effort of meaning making. Though it appears like a form of acceptance, the heuristic of mental disease defeats efforts at elaboration of the feelings and meanings underlying the need to make cuts in order to feel something. Not only can Pardal not imagine what suicide might be like (could anyone?), but also more importantly, she cannot seem to imagine other ways of dealing with her emotional world.

Instead, there is a need, almost a compulsive urge for a physical seeing or likeness to an emotional experience required to make it seem real. This physical connection of seeing blood and actually experiencing the sensations associated with cutting may be required for individuals lacking the ability to recognize their feelings and symbolically represent them. In the absence of symbolic formulation and elaboration, these individuals require a physical action to facilitate communication both to themselves and to others.

Within the therapeutic dyad, self-harming functions even more clearly as an icon. Marking the skin draws the attention of the therapist to the patient’s needs to physically mark him or herself as well as the potential difficulty formulating experience. Although its meaning may be unknown, upon seeing a mark, what becomes known is that the patient has to use their body to represent and communicate some aspect of their experience and thus their ongoing psychological process. Not only does this alert the therapist, it also shapes the interpersonal field between them.

As an act, self-harming structures the field in more indexical ways, provoking a very strong sense impression from both the harmer and the therapist. The use of the body as a canvas essentially demands a reaction and for people to pay attention. In this respect, the self-harmer communicates the need for the therapist to take them as they are, at least initially. As an aggressive act to the self, the self-harmer challenges the therapist whose role is necessarily about self-promotion and preservation. Accordingly, this has the effect of possibly putting the therapist at a disadvantage requiring that they negotiate how they will relate to the patient to create a space for newer conduct to emerge.

While the therapist may realize that this bodily usage may correlate to a psychological process that is less observable, the patient may not agree or want to know this. Indeed, this realization can even sometimes be lost in the strong feelings it generates for the other person, for who self-harming may be seen as a violation of social norms. Much like with Pardal considering her behavior as a disease, these views undermine meaning-making processes and challenge the therapeutic field. It is likely for this reason that within the therapeutic relationship self-harming has at times been seen as a violation of the boundaries of the relationship that emphasizes talking instead of acting.

Further challenges to meaning making

As both icon and index, self-harming transforms the body into an object on which to try and communicate some aspect of psychological experience. It is in other words, a physical manifestation of ongoing psychological processes, but not yet at the symbolic level. As seen above, the relative concreteness of these behaviors threatens to undermine the therapeutic aspect of meaning making. Through drawing attention to the physical and impressionistic relationships, self-harming indicates the need for symbolic formulation, but does not necessarily allow the space for it.

The explicit focus on the body triggers a demand to preserve its organic integrity. This can be seen in strong reactions to both light “superficial cuts,” and also deeper ones. As such, the therapist has to pay attention to the physical well-being of their patient and not just their psychic worlds (as is also the case with eating disorders, which could likewise be considered a form of self-harm). Simultaneously, the ongoing presence of shame and the knowledge of performing a socially unacceptable action may generate within the patient a need to minimize the attention paid to their actions. It is common for harmers like Tiago to cover themselves up, stating:

I cut myself on the arm as close to the shoulder as possible, so that I can wear common shirts without any concern; I also cut myself on the thigh, so that I can wear common clothes and nobody notices [the cuts]! (Arcoverde, Amazonas, & de Lima, 2016, p. 119).

Beyond this though, harmers may also attempt to cover up the potential significance of their actions. Trying to ensure a minimal absence of meaning may result in a transformation in the field (Levenson, 1973/2005), such that the therapist goes along with the patient in keeping things covered up.

Along with covering up what is shameful, patients may dissociate from painful feelings, including hurt, but also rage and aggression (Bromberg, 2001). This can be seen as an apparent absence of curiosity about their behavior or also only considering one aspect of it. Some harmers for instance, talk about the sense of enjoyment and pleasure but not the aggression that goes along with it. Peu stated: “Motives? For simple pleasure … I like the color of blood … I like deep cuts!!!)” (Arcoverde, Amazonas, & de Lima, 2016, p. 17). The authors also argue that for some, harming is artistic, religious or a form of self-expression. Yet, this individual’s assertion of simple pleasure practically begs follow-up questions. One must ask why this mode of pleasure, art or expression and not another and the narratives provided by the authors do not satisfy such questions. While this was not necessarily the point of their paper, it is worth wondering what do harmers gain instead of getting a tattoo or a piercing? Is it the sense of control? The thrill of doing something taboo or the feeling of being a rebel? While the brain-reward pathway and release of opioids, similar to drug users is suggested as a technical explanation, without greater detail its status as pleasurable remains problematic.

Alternatively, ascribing pleasure to the behavior may be a way of not looking at it or coping with other aspects of harming, such as it being compulsive and difficult to stop. Consider the statement of Bina, who says: “I’ve been telling myself, like, for three days not to relapse; but it’s hard. That’s all I can think about, and I know that eventually I won’t be able to resist … . It’s like this all the time” (Arcoverde, Amazonas, & de Lima, 2016, p. 117). Her out of control feeling, common amongst self-harmers, speaks to the importance of working to ascribe meaning to her behavior and shift from using the body as a canvass, to understanding their experiences more fully.

The therapeutic process

Within the therapeutic field, the therapist can initially only attend to the iconic and indexical aspects of self-harming and tolerate not only the absence of meaning, but also the various impressions designed to prevent meaning from being made. Interestingly, this may involve resisting normative societal responses themselves, which harmers may hope to stimulate within the therapist by showing off the various marks on their bodies. In doing so, the therapist works to minimize the patient’s experience of shame, recognizing the implicit communications, but not expecting the patient to necessarily be able to talk about them in a symbolic fashion. As such, the therapist demonstrates and acknowledges their own lack of a priori meaning, along with an investment in constructing possible a posteriori meanings. Thus, while they are not the experts in what the patient’s experiences means to the patient, they do assert the importance of meaning making and the conviction that the patient’s self-harming behavior is meaningful.

For meaning to be created, the therapist has to establish a safe enough field that recognizes what the patient is trying to communicate, but also begins to enlist the patient in a collaborative effort of understanding (Stern, 2015). This is far from the pressure to confess or to make everything private publically available, but instead a way to help the patient become curious about their inner world and own symbolic processes. This perspective acknowledges that meaning can only be made after the fact (Stern, 2003; Valsiner, 2007), though it serves the function to constrain future experiences. For self-harmers, the opportunity to make new meaning via consensual validated interaction may hopefully lead to the emergence of new symbolic meanings rather than the repetition of iconic and indexical ones.

The presence of new meanings may allow for the patient to verbally express their aggressive feelings and thoughts rather than enact it on him or herself. The potential for verbal communication restores the symbolic process and enables a greater range of choice. This can lead to other forms of self-harming, which though still aggressive, are notably less permanent and dangerous. Alice for instance, describes:

An alternative to cutting … well I don’t know if anybody here in this community has mentioned that because I enterered for the first time today. But something that often helped me not cut myself was to place a hand in a bucket of ice for as long as I could (…) It HURTS like hell. The hand becomes so red, but it causes no harm, and obviously leaves no marks. The feeling of relief is very similar to the one afforded by cuts. It helps me a lot, has anyone tried it?

Other harmers, talk about drawing on themselves with a red marker when they feel an urge to hurt themselves. While these are still aggressive acts against the body, they presence of a choice, removes some of its compulsive component, and limits its destructive potential to the self. Moreover, once new meanings are introduced and experienced, the patient’s ability for symbolic expression and consciousness is expanded. The field has shifted and may allow for new meanings and behavior (though this may have to occur more than once for it become a new pattern). The presence of choice is in turn what would enable harming to become a meaningful form of discourse that exists as a choice along a host of possible forms of conduct.

Conclusion

Moving from the more private, physical and impressionistic to the social and consensually validated is an important aspect of the therapeutic process. It may also be the value of online communities (Orkut), as they are established locale where harmers can reasonably safely talk about their experiences and perhaps gain more symbolic control over their experiences, as Alice seems to want to do. The communities in which talk takes place provides opportunities for new meanings and interpretations. It is crucial that these communities support the creation of new meanings around self-harming to emerge. Otherwise, there is a real risk for a reproduction of forms of knowledge/power not much different than Foucault discusses. However, in this case the reproduction is of the self-harming conduct exerting power over the subject, while minimizing their own knowledge into why they harm. Self-harming thus symbolizes an opportunity to construct a new space of dialogue and discourse, but one that requires delicate social navigation.