In this guest blog, Peter Taylor shares some thoughts on the value of research into cognitive analytic therapy as an intervention for self-harm. His blog also gives early notice of an opportunity for a feasibility trial therapist. This role, part of an NIHR-funded study, involves other therapist/researchers (operating in their NHS roles) linked to Catalyse through other work over the years.
Recently I was party to an online discussion around treating self-harm. A key theme from these discussions was about the challenges in treating self-harm, given that this behaviour was typically a manifestation of a broad variety of different underlying difficulties. This argument is one backed up by the research. Self-harm is a trans-diagnostic phenomenon that can co-occur with a wide variety of different psychological difficulties.
We know that people who self-harm report an array of different functions or reasons for this behaviour. For one person, self-harm may be a form of self-punishment, in response to feelings of shame or guilt. For another, self-harm may be a way to communicate their distress to others when other means of expressing this are not possible. Moreover, self-harm may serve multiple functions, serving a variety of personal needs. The functions that self-harm serves may change over time for that individual. Given the idiosyncrasy of this behaviour, we can see how a therapeutic approach focused on this presenting problem may struggle.
One argument I have seen is that we should not aim to develop interventions for people who self-harm at all, but instead concern ourselves with the associated psychological difficulties. For example, an intervention might instead target anxiety or depression where this is present. Whilst I agree with the principle of moving beyond the behaviour, I also think its important not to completely dismiss the idea of developing interventions that focus on self-harm. There is evidence that therapies that target self-harm specifically may be more effective than those which focus on underlying problems.
In an ongoing trial of a relational therapy taking place in Liverpool, one piece of anecdotal feedback from clients has been that having a therapy that actually talks to the self-harm they experience has been positive and refreshing. In addition, we know that people who self-harm are often disempowered and under-served by our current health care system. They face high levels of stigma, and often struggle to access support. Many fall down the gaps between services.
Instead of dismissing self-harm as a focus for psychological interventions, I see self-harm as an important starting point. In my view, it is a manifestation of deeper distress, unmet needs, and conflict. Therapy should seek to move beneath the self-harm, to map out these underlying patterns and processes. Doing so can be meaningful, respectful, and ultimately more useful to the individual. I believe Cognitive Analytic Therapy (CAT) may be especially well suited to this task. CAT is an approach with collaboration at its heart. Moreover, it takes a ground-up approach to forging a shared picture of what is going on for a specific individual. I think CAT therefore has potential as a therapy for people who self-harm. It does not dismiss the presence and relevance of self-harm in a person’s life. It also avoids the trap of getting hung up on the behaviour, and not what lies beneath it.
However, we need evidence. There is currently very preliminary research concerning CAT and self-harm. CAT has a strong tradition of practice-based evidence. However there is a need for larger clinical trials, to further build on these foundations. Such studies will allow for more rigorous evaluation.
RELATE (relational approaches to treating self-harm) is a National Institute for Health and Care Research (NIHR) funded feasibility trial of CAT for adults who self-harm. It represents an important step in evaluating the suitability of CAT as a way to help people struggling with self-harm. The trial will involve two sites, one in Greater Manchester NHS Foundation Trust (GMMH), and one in Rotherham, Doncaster, & South Humber NHS Foundation Trust (RDASH). The study is due to start in December, and we will be advertising for trial therapists for the GMMH site. If you are a CAT therapist working in GMMH, and have any interest in the role, please do get in touch.
You can contact Peter using the details below.
Dr Peter Taylor, Senior Clinical lecturer & Clinical Psychologist
Division of Psychology & Mental Health| Room 2.33, Zochonis Building| Brunswick Street| University of Manchester| M13 9PL| Tel: 0161 306 0425| Email: firstname.lastname@example.org| Twitter: @PJTaylorClinPsy