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Most guys are nonexperimental. On the fringe of this group is an extreme faction of fashion survivalists, men who look up to such rugged individualists as Teddy Roosevelt, Douglas MacArthur and Ernest Hemingway, yet dare not explore the territory beyond cavalry twill trousers, shawl-collared wool cardigans and bucket hats. They take refuge in the familiar. Donna Karan and Calvin Klein can make any fashion statement they like. But vanity is still one of the cardinal sins for most men.

And while they might be interested in fashion, in order to give themselves permission to buy something, it has to serve some kind of practical or useful function.

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He appreciates that the Pendleton wool shirt, L. When the lenses were introduced to consumers in , the anti-glare label was dropped in favor of Ray-Ban. Developed for loggers and gold-seekers working the rivers off the coast of Maine at the turn of the century, the classic Henley knit shirt--adapted from early thermal underwear--has been copied the world over. Developed in Pendleton, Ore. Made of bush cotton poplin, the jacket features two expandable chest pockets, two cargo pockets for bullet shells, and a sleeve pocket for shooting glasses.

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To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. Find out more about sending content to Google Drive. The author explores key issues related to psychotherapeutic work with people who self-harm. Particular attention is given to the powerful countertransference feelings that practitioners often experience in this work and the importance of managing these.

Rather than maintaining a detached distance, therapists should emotionally engage with the patient's experience, creating a unique therapeutic relationship. The common patterns, functions and meanings of self-harm are discussed, with clinical vignettes that highlight the underlying dynamics of the behaviour. Self-harm is a survival stratagem, and methods for helping patients to find other ways to cope are suggested. One such is mentalisation, which can enhance the patient's capacity to think, not impulsively act. If patients learn how to assess more accurately their own and other people's states of mind, less destructive behaviours can emerge.

Self-harm is a stratagem for survival, but I can offer no simple explanation of it, as each act of self-harm must be considered in the light of the patient's idiosyncratic narrative. There are, however, patterns of self-harm that individuals share. In this article I will detail the different forms that these patterns take and the way self-harm comes to constitute a unique response to a particular life situation, a response that is ultimately about the survival of the self, not its destruction.

The psychotherapeutic task begins with an understanding of these shared patterns and progresses to achieving insight into the idiosyncratic narrative particular to each patient. Vital to this task is enabling the patient to work through their relationship to self-harm and expanding their repertoire so that other, less assaultive forms of relationship can begin to emerge. This raises an interconnected issue related to the nature of the therapeutic stance that the mental health practitioner needs to adopt, and it is with this I will begin.

Research has shown that patients who self-harm sometimes encounter hostile responses from practitioners in a variety of clinical settings Warm et al , This is easier said than done.

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Patients who self-harm pose a profound dilemma for staff. They are, by definition, both perpetrator and victim. In their role as perpetrators, they have mounted an attack on their own bodies.

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In these circumstances, we are all vulnerable to powerful negative countertransference reactions as self-harm is seen as the perpetration of violence. Their worlds, both internal and external, are already forbidding places. Paradoxically, when faced with intolerable and incomprehensible acts of self-assault, practitioners can be drawn into re-enactments of abuse. For example, practitioners find themselves taking a hostile, condemning stance with patients who self-harm, verbally re-enacting an abusive scenario with which the patients are all too familiar.

The alternative response is to see these individuals as victims who need to be rescued — and that might be precisely what the patient unconsciously longs for, an all-giving mother. Although less persecuting as a response, this leaves the patients infantilised, relinquished of responsibility for their self-destructive acts, thereby maintaining the psychic status quo. Such a response also plays into the black-and-white view of the human environment as all good or all bad.

A more productive therapeutic stance requires the clinician to attune to the survivalist nature of self-harm. This raises another dilemma, a dialectical tension, because the practitioner must, as an absolute starting point, accept the patient's self-harming behaviour Nathan, Without this, no work is possible.

Yet the practitioner has also to be able to challenge the patient's self-harming behaviour. Again, without this no work is possible. This is a complex issue as there can be no hard and fast rule about the timing of such challenges.

When one patient was told that she had to stop threatening suicide whenever she felt disturbed, a major row broke out between her and her practitioner. The key point in this successful limit-setting is that it was based on the patient's attachment to the practitioner, built up over 2 years. Relationship therefore is also of primary importance in the work. Development takes place primarily in the context of an attachment relationship. This finding is accorded the greatest research-based weighting.

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This research is beginning to make it clear that, for treatment of personality disorder to be effective, the patient must have an attachment to the therapist. The intensity of the attachment brings into the treatment setting what I call the patient's relationship template. In other words, patients bring into the therapeutic setting their ways of thinking, feeling and, worryingly, behaving. How could they not do so? A massive dynamic tension emerges or sometimes erupts when the most sensitive areas of the patient's life are explored.

To deal with these inevitable dynamic tensions, the psychodynamic practitioner adopts a collaborative approach by engaging the patient's adult self in treatment. Their methodology has moved away from the requirements for technical neutrality and transference interpretation associated with the more classic psychoanalytic form.

When undertaking this work, the skill, experience, attitudes and interpersonal ability of the practitioner need to be taken into account. Studies have suggested that therapists who demonstrate characteristics such as competence and flexibility can positively influence outcome Shaw et al , It is likely that the interpersonal skills of the therapist may be a determining factor in patient retention and outcome.

In the terms that I am using here, what is required of the practitioner is a vigilant monitoring of the interpersonal dynamic tension. It must hold the dialectic between creating an atmosphere of tolerance in which the therapist can deal with the sheer awfulness of what the patient is revealing and their own engagement with that experience. Under such psychic pressures, it is even more necessary to maintain professional boundaries. Psychotherapists should never be friends with their patients. And yet to foster change and model tolerance and flexibility in a relationship, active emotional engagement is essential.

As suggested above, this approach lays stress on using the patient's adult self in the service of creating an interpersonal dynamic with the therapist; one that brings into the open the patient's relationship template.

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For the practitioner this means engaging with their own emotions in the hothouse of development, here-and-now atmosphere of the session. The objective therapist, if ever one existed, has to struggle with their own subjectivity. The shared sense of reality is affectively as well as cognitively experienced in the moment. The relationship template comes alive in the consulting room.

In the best of circumstances, when neither the patient nor the practitioner is too tormented by the experience and the adult thinking self of both has survived, an opening exists in which a new initiative is possible. It is one freed from the imperative to constantly replay the patient's pathological relationship template Stern et al , For the therapist, an essential requirement emerging from such an intense emotional engagement is the belief in their own benign impulses. From this perspective, psychotherapists have moved beyond the view of the Freudian practitioner presenting a mirror for reflection.

Patients who self-harm require a real relationship. By this I mean one in which the practitioner brings the best of themselves, their benign impulses, to the therapeutic encounter. Making judgements is not to be confused with being judgemental, which implies condemnation, superiority and rejection of the patient.


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These benign impulses cannot be counterfeited, as they will also be seen through by the patient. What the clinician requires is a capacity to believe that, whatever their own shortcomings, they are ultimately acting in the interest of their patients. In more graphic terms, the psychotherapist's good intentions outweigh their malign or even sadistic ones.

This struggle with their own complex conflicts, including sometimes hatred of what their patients put them through, is itself therapeutic and represents a modelling of an alternative mode of relating. However awful they may feel, they do not turn to self-harm, suicide or violence for resolution.

The patient is always observing this process, where the practitioner is struggling to manage their own ambivalences. For people who self-harm this is one key marker of what they cannot manage. It is therefore not enough to be a technically competent practitioner. For patients with personality disorders this is tantamount to a subtle form of abandonment and thereby rejection of a self that is already too depleted of any sense of self-worth.

Perhaps, above all, the clinician has to sustain a sense of hope in the possibilities of life. She was, I think, referring to this hope residing in me. As with many patients, Susan suffers the reverse.

She is filled with despair, fear of her own self-destructiveness and hopelessness.