Many survivors of childhood trauma and abuse injure their bodies in direct and indirect ways. In addition to cutting, burning, hitting, etc. self-harming behaviours include alcohol and drug addictions. Alcohol and drug addiction often go hand in hand with unsafe behaviours (drink driving, unsafe sex, dangerous drug deals, etc). The tendency to repeat patterns of trauma in violent relationships can be considered another form of self-harm. All of these behaviours possibly represent the survivor's attempts to manage or eradicate feelings, prevent memories, or re-enact some aspects of the abusive experiences (Saakvitne et al., 2000).

Safety when working with self-harming clients

With survivor clients, some of the hardest challenges of working in a model of empowerment emerge around issues of self-harm. 'Empowering clients' is especially hard when they are in hospital, in great distress, asking us to protect them, or suicidal (Saakvitne et al., 2000). Self-injurious behaviours make many of us want to take control and move to action.

Traditional models of working with adult survivors of childhood trauma and abuse often emphasise control of unusual or dangerous behaviours that are deemed as 'dangerous to self or others' or 'out of control'. When control takes precedence over collaboration, treatment systems may use and overuse restraints (physical or chemical), locked doors, contracts, denial or privileges, and withdrawal of treatment. These programs unwittingly substitute control for change (Saakvitne et al., 2000) and are often not trauma informed.

Many of our current practices around restraint, involuntary medication, and emergency room procedures create re-traumatising conditions (Saakvitne et al., 2000). Often such re-traumatisation could be reduced or avoided by consulting and working with the client as much as possible. Clients need to be included in the development of crisis response plans, with clear communication around your responsibilities and limits, seeking their help to develop the best possible plan to provide helpful responses when they are in crisis. When a discussion about safety occurs in the context of a relationship, the discussion is less about rules and more about collaboration and cooperation (Saakvitne et al., 2000).

Strategies for working with self harming clients

The first step is to distinguish between self-harming and suicidal behaviour by paying attention to the client's underlying motivation. When working with self-harming behaviour it is important to remember that this behaviour serves a purpose. In collaboration with the client, try to identify what problem self-harm solves for the client. For example, from the client's perspective:

• To make me feel real (counteracts dissociation)
• To punish me (temporarily lessens guilt or shame)
• To stop me from feeling (when strong feelings are too dangerous)
• To mark the body (to show externally the internal scars)
• To let something bad out (symbolic way to try to get rid of shame, pain, etc.)
• To remember
• To keep from hurting someone else (to control my behaviour and my anger)
• To communicate (to let someone know how bad the pain is)
• To express anger indirectly (to punish someone without getting them angry at me)
• To reclaim control of the body (this time I'm in charge)

The more the client and therapist understand the function of the behaviour, the more effective the intervention can be (Saakvitne et al., 2000). By identifying the underlying purpose, strategies to address the specific function of self-harm can be identified. For example:

• Need to mark body - draw on your body with a red marker
• Need to feel pain - hold ice against your body
• Need to feel in control - try breathing exercises