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An exploration into self-harm in light of Heideggerian and Kierkegaardian concepts of repetition.

Introduction

One of my first clients as a psychotherapist was an 18-year-old girl within a National Health Service mental health service presenting with self harming behaviour. As my clinical experience grew, I became increasingly aware of how prevalent this act was within the demographic I was being exposed to. I began to see self-harm articles in the media and psychological journals, which highlighted the growing prevalence of self-harm within young and adolescent groups (Hawton, Hall, Simkin et al., 2003).

Many of the studies focused on demographics, percentages, diagnostics and highlighted the approaches that have proved to be effective in treating these behaviours (Klonsky & Muehlenkamp, 2007). These studies suggested that self-harm was prevalent in individuals that have experienced certain conditions and can be categorised into certain personality types or disorders (ibid). I began to understand self-harm through the articles cited, but my understanding felt one-dimensional. I was encouraged to read in one report, that 'we all engage in self-harm to some degree or other' (Heslop & Macaulay, 2009), because the statement suggests that the phenomenon is encased in humanity rather than in certain personality types. I began to see that self-harm is a term that encapsulates an array of acts. I now felt inclined to ask: What is self-harm?

In order to shed some light on this question I would like to explore our past and present. I hope to uncover some of the values that our cultures have bestowed upon these expressions and explore the motivation behind them. I aim to extrapolate a common thread in the acts of self-harm, so I will finally liaise with the Heideggerian and Kierkegaardian concepts of repetition in order to enrich the discussion.

Harm, injury and mutilation: A moral panic?

These terms and their use have evolved over the course of history and have arguably highlighted a moral panic within modern society (Gilman, 2012). A moral panic has been defined as 'an episode, condition, person or group of persons' that have recently been 'defined as a threat to societal values and interests' (Cohen, 1972, p.9). Considering the term 'moral panic' may help us understand the impact that knowledge and culture can have on the individuals who self-harm.

From reviewing articles concerned with self-injury (Klonsky & Muehlenkamp, 2007) and self-harm (Heslop & Macaulay, 2009) it would appear that these terms are used to describe the same group of phenomena, but at either side of a spectrum. The terms are also used interchangeably throughout literature on either side of the Atlantic. Lovell (2007) states that self-injury is normally used within the context of learning disabilities and self-harm in relation to mental health. I am intrigued by this distinction having supported an individual with a severe learning disability. This individual had to be restrained due to his tendency to scratch and pick his eyes. I often wondered if he was aware of the damage he had caused to his body. The acts seemed impulsive or involuntary. I wonder if the intention to make a distinction between these activities and the behaviour of an individual with a mental health condition who cuts, is motivated by the concept of mental capacity. Could we suppose that individuals who self-injure are unaware of the significance of their actions, whereas those who are aware self-harm?

However, 'more recently organisations working in the field have started to view self-injury as a range of behaviours within the broader spectrum of self-harm' (Heslop & Macaulay, 2009, p.10). The acts towards the self-harm end of the spectrum (insufficient exercise, smoking, stress) are considered socially acceptable and Turp (2003) elaborates further by including sleep deprivation, body-piercing, over work and tattooing in addition to the activities depicted above. The acts towards the self-injury end of the spectrum (burns, ingesting objects, cutting, self-poisoning) are considered in Western cultures as not socially acceptable and thus contribute to 'moral panics'. One could argue that this has been fuelled by recent studies identifying a growing prevalence of self-harming behaviour in young people (Camelot Foundation/Mental Health Foundation, 2006). Self-mutilation can be considered a more extreme form of self-injury such as limb amputation, eye enucleation and castration (Favazza, 1998). However, the term mutilation was widely accepted as an umbrella term for all forms of behaviour that we can now interpret as mutilating, harmful or injurious (Gilman 2012). Despite the apparent interchangeable use of terms I will resort to using self-harm in order to achieve some form of consistency in the discussion that follows.

Development, motivations and values

Gilman (2012) provides us with an illuminating account of how Western parameters and interpretations of self-harm have shifted over the course of history. He draws upon recorded accounts of self-harm and brings our attention to the differences in how the understanding of these behaviours have shifted from ancient ideas of the aetiology of madness, to a symptom of a mental disease and finally to 'a stand-alone diagnostic category' (Gilman, 2012, p.1014). Gilman (2012) explains the significance of this shift in terms of differing 'moral panics' that have emerged throughout history, fuelled by the popular thinking of the time. Gilman (2012) evidenced how initially acts such as tattooing and piercing (today thought of as socially sanctioned acts) were considered a category of mutilation. The shift in what constitutes self-harm shifts in the 20th century, because of Freudian theories of sexuality and the contributions of subsequent analytical theorists, which placed 'cutting rather than sexual self-abasement or self-mutilation' as the symptom defining this behaviour (Gilman, 2012, p.1011). This helps us understand how the aetiology of self-harm has evolved and is firmly entrenched in classical psychoanalytic concepts and propelled into diagnostic categories, arguably due to the influential work of Otto Kernberg (1975) and the introduction of Borderline Personality Disorder (BPD).

The above summary is focused on describing self-harm in terms of a psychological or neurological irregularity. Is it the motivation or thought behind the act that determines if it is classed as self-harming? Considering this question draws me towards the behaviour associated with Western African tribes who practice cutting, burning, etching or branding of the skin. This activity is not performed due to despair or an inability to affect regulate, but are mainly used to celebrate milestones in adulthood such as puberty or marriage. These methods are called scarification and are also used to communicate intricate aspects of identity such as the social or spiritual role of the individual. For example, scarring on the abdomen of a woman communicates her willingness to bear children and the process of experiencing the pain signifies her emotional maturity, strength and readiness for motherhood (Beckwith &Fisher, 2012). Scarification demonstrates psychological strength rather than a disorder of affect and demonstrates the fragility of categorising this behaviour alone as a symptom of a mental disorder, because clearly the meaning of the act has a fundamental role in its aetiology. Scarification has also been utilised by African tribes to treat physical aliments by cutting and applying medicine into the wound (Turner et al., 1998).

At this point I would like to summarise Humoral theory, which was developed by Hippocrates and subsequently utilised by ancient Greek society and informed the treatment and understanding of the human body. This theory influenced medical practices well into the early 1800s (Nutton et al. 2000) and postulated that the body contained four humours which were identified as blood, phlegm, black bile and yellow bile. Diseases were interpreted as an imbalance of these humours which resulted in the process of treatment attempting to rebalance the four. Equilibrium between the four would achieve a healthy body and mind. The treatments could include less evasive procedures such as modifying dietary habits, exercise and herbal remedies. However, more extreme methods were used including having the body purged using laxatives and emetics, skin blistering and bloodletting (ibid). We can now appreciate that the body is being scarred or modified spanning generations, cultures and continents. Aside from the body, I wonder if there is a common thread that can be identified between the acts of scarification, self-harm and self-cure.

In the Histories of Herodotus (1914, II: pp 91-92) we can review an ancient perspective on the demise of King Cleomenes, who becomes imprisoned due to his erratic behaviour.
   Then Cleomenes, when he had received the steel, began to maltreat
   himself upwards: for he went on cutting his flesh lengthways from
   the legs to the thighs and from the thighs to the loins and flanks,
   until at last he came to the belly; and cutting this into strips he
   died in that manner.


Delving further into the account provides some insight into the possible root of the act. The stresses of war, conflict between Spartan houses, betrayal, espionage, guilt and apparent disregard for the gods. Was Cleomenes under immense pressure, confusion and unable to contain his emotions? Herodotus concludes that 'the Spartans themselves say that Cleomenes was not driven mad by any divine power, but that he had become a drinker of unmixed wine ...' (1914, II: p 95).

The two main causes of Cleomenes' demise was either divine power or his foolishness to drink wine unmixed with water, but in today's terms Cleomenes may be classified as having Post Traumatic Stress Disorder, causing a psychotic episode. This account helps me realise that self-harm is not a new activity, but one which has been interpreted and influenced depending on the culture and knowledge of the time. It has altered through history and perhaps through the recording of the behaviour.

I would now like to turn our attention to a passage in the New Testament.

if thine eye offend thee, pluck it out, and cast it from thee: it is better for thee to enter into life with one eye, rather than having two eyes to be cast into hell fire.

(Matthew 18:9)

Favazza (1998) cites an article published in 1846 by Bergman, in which a widow walks through the streets naked, asking men to marry her. After being hospitalised for this conduct she felt sinful and enucleated both her eyes and insisted her legs and arms be amputated in order for her to become saintly. Interestingly, at the tail end of the same century, seventeen inpatients at Bethlem Royal Hospital tried to pluck out their eyes (Chaney, 2011b, p.284). Is there a link between how accounts are written or passed down through history and how individuals use their body? We must also be aware that in psychiatric and conventional hospitals in the early 1800s, medical practice was still largely informed by Humoral theory, so patients were subjected to bloodletting and purging to cure their unstable behaviour (Ingram, 1998). I find it interesting how psychiatric patients nowadays, who profess to feel relief from purging and cutting, are not self-curing but considered to be self-harming and manifesting a symptom of a mental disorder. The body is being used for a similar function, but the value has shifted from a possible cure to clinical symptom in a matter of centuries.

The act of flagellantism also highlights the impact that value and culture can have on how an individual uses their body. It is a practice often associated with fervent Catholics in the 13 th and 14th centuries who mutilated their flesh by whipping it repeatedly. This behaviour dates further back to Ancient Rome where on 'Dies Sanguinis' (Day of Blood) Roman votaries would cut themselves and drink the blood or flog themselves to appease the deity (Meyer, 1987). Often this activity was an expression of sacrifice and devotion.

Culture and knowledge seem major influences on acts that are categorised as scarification or flagellation. Can we postulate that our current knowledge and culture has influenced the act of self-harm in a similar fashion to how African culture has cultivated the act of scarification? Is there a link between the increased media coverage of self-harm and the growing prevalence of self-harm in young people? I am also aware that by using the term self-harm I am adopting a language that has been handed down to me through my culture and fixes the phenomenon within a specific pathological realm. Another striking similarity is that these acts seem to be recorded, passed down through history and in essence repeated.

Repetition

Contemporary opinion suggests that the most prevalent function of self-harm is affect regulation. This position is validated to a degree by individuals who cut and state that they experience a release of tension. For example, the clients I have worked with have often stated that they cut in order to 'release pressure that builds up inside of me' or 'to manage anxiety'. This function has been coupled with typical psychological characteristics such as negative temperament, anxiety, depression, emotion dysregulation and self-derogation (Klonsky & Muehlenkamp, 2007). In the DSM IV, self-harm is seen as a symptom of BPD and studies conclude that anxiety and depressive disorders are also strongly linked with self-harm (Andover et al., 2005). One must also pay attention to other functions of self-harm including self-punishment, interpersonal influence, anti-dissociation, anti-suicide, sensation seeking and re-establishing interpersonal boundaries (ibid).

Through clinical experience I have become aware that identity seems to play an integral part in the motivation behind the behaviour. The concept of identity seems firmly held within people's family life, culture and time they find themselves in. I am intrigued by how self-harm has been recorded and passed down through time as well as how we understand ourselves in terms of history and how it is recorded. This is the reason I am searching for solace in Heidegger's and Kierkegaard's accounts of repetition. Heidegger states that 'by repetition, Dasein first has its own history made manifest' (1962, p 438). I want to find out more about this statement and what it could contribute to the understanding of self-harm. Repetition seems important because self-harm seems to be a repetitive behaviour.

I will touch upon Heidegger's challenge to the concept of time, so we can begin to understand history and repetition. Heidegger challenged Plato's view and therefore the Western tradition of viewing time as a movable image of eternity (Alweiss, 2002). His main challenge was that to understand time we cannot have eternity as our starting point, because we are finite creatures (Heidegger, 1962). Therefore to understand time we need our starting point to be our temporality ... our finitude. Perhaps we are time. This is why repetition is so significant in relation to time and our personal histories, because 'repeating is handing down explicitly--that is to say, going back into the possibilities of the Dasein that has-been-there' (Heidegger, 1962, p.437). Repetition provides the opportunity for Dasein to reopen the past and transfer that which has been into possibilities that can be chosen time and again. Considering this quote has brought to my attention another quotation attributed to Heraclitus in Plato's Cratylus (Sedley, 2003); No man ever steps in the same river twice, for it is not the same river and he is not the same man. These two remarks enable me to view repetition from Heidegger's perspective of handing back possibility and how in each attempt to repeat, a new experience is inevitably born and subsequently made into a possibility that can be chosen time and again. Why does Dasein seem to fall into this repetitive, constantly changing mode of being?

In Plato's Symposium (1986) it is explained that through the recollection of ideas, science is preserved and similarly thorough repeating, creatures achieve a sense of sameness. Heidegger expands on this with the concept of resoluteness and couches this term in repetition. He describes the authentic way of being as holding-for-true:

in which one maintains oneself in what resoluteness discloses .... The certainty of the resolution signifies that one holds oneself free for the possibility of taking it back--a possibility which is factically necessary ... this holding for true, as a resolute holding-oneself-free for taking back, is authentic resoluteness which resolves to keep repeating itself .... The holding-for true which belongs to resoluteness, tends, in accordance with its meaning, to hold itself free constantly--that is, to hold itself free for Dasein's whole potentiality-for-Being.

(Heidegger, 1962: pp 355-356)

The resolution repeats itself and in doing so, Dasein's holdings attain constancy. As implied previously Dasein is its time and the constancy attained through repetition and authentic resoluteness contributes to wholeness.

Is it possible that an aspect of self-harm is an attempt to create a sense of constancy through its repetitiveness? Heidegger (1962) may offer an explanation for this by explaining that 'it is the resoluteness that one first chooses the choice which makes one free for the struggle of loyally following in the footsteps of that which can be repeated' (p 437). Heidegger is referring to anticipatory resoluteness, which he regards as the authentic way of Dasein's Being-towards-Death and the 'uneasiness' unleashed within this mode of being. The counter-possibility of this is to flee from it and fall into the default mode of the tranquilising 'they'. What is the counter-possibility of resoluteness? Heidegger (1962) explains that 'the constancy of the Self ... is the authentic counter-possibility to the non-Self-constancy which is characteristic of irresolute falling' (p 369). Could we postulate that self-harm is a mode of escaping the certainty of death by irresolutely falling into and contributing to a shared anxiety, fear or moral panic of the 'they'. This attempt also provides Dasein non-Self-constancy (sameness of sorts) through the repetition ... a false sense of constancy and wholeness, but one that is validated by the tranquilising 'they' and therefore a powerful alternative to the possibility of 'the fact that it is the null basis of its own nullity' (Heidegger, 1962, p 354). Favazza's (1998) formulation that 'the presence of a self-mutilator threatens the sense of mental or physical integrity of those around him or her" (p xii), would certainly support part of this hypothesis.

Kierkegaard's Repetition (1983) could also provide us with some useful pointers with regards to constancy as well as repetition. According to Constantin, the dilemma of the young fiance who is going through a process of becoming in light of his differing feelings concerning marriage can be resolved through repetition. This concept and the delivery must be seen in the context of Kierkegaard's aim to show the reader the task of 'becoming a Christian'. However, this project is intriguing in itself when you consider the 'loyalty' Heidegger postulated was ingrained in repetition and how Kierkegaard's concept of repetition provides a route to a true Christian via loyally renewing vows. The constancy achieved through the act of faith. A Christian can maintain his faith by repeatedly recognising his weaknesses and seeking forgiveness. Loyalty and faith are now intertwined. In The Concept of Anxiety (1980) Kierkegaard expands on this further when he discusses the repetition of sin, repentance and grace. Is there a link between this observation and the repetitive behaviour of an individual who cuts (a societal sin), feeling guilty in the aftermath of healing (repentance) and receiving judgement from the other (grace)? Once again Favazza's (1998) provides some credence to this possibility with his assertion that self-harm is 'culturally and psychologically embedded in the profound, elemental experiences of healing, religion, and social amity' (p. 191). I am also intrigued by the experience of making the cut and the feeling that accompanies the process of watching the wound heal. Does this process contribute to constancy by watching the body renew itself? Could the experience of cutting and healing provide the individual with an escape route from the inevitability of death, by providing a false sense that the possibility of resurrection exists? With this perspective an individual may be cutting in an attempt to maintain (anti-suicide) rather than destroy themselves.

Supposing loyalty and faith can be enmeshed within repetition, which in turn contributes to a sense of constancy. How does this relate to my client's expression of self-harm? This suggests to me that there is faith in the behaviour, with regards to it providing some relief, if only short-lived. There also seems to be loyalty to this repetition, with regards to how this act has served in the past. Perhaps this behaviour is not just about affect regulation or diagnostics, but a struggle for identity. Paradoxically this struggle between the possibility of non-self-constancy and self-constancy provides Dasein with the option to fall back into the default mode, the 'they', but attain a selfhood of sorts: a possibility for Dasein to fool itself into a constancy of irresolute falling.

The moral panic that is evident in response to self-harm and the possible gains of the behaviour may have caused a co-dependency between the 'they-self' and Dasein. The gain for the 'they-self' would be the moral panic and its tranquilising, constantly moving value, which sustains its purpose to be the default position of Dasein. Could we consider the recording of self-harm through time either by written or spoken word, a method to provide constancy for the 'they-self'? As Heidegger (1962) explains the default mode, the 'they', purpose is to escape the uneasiness of facing the possibility of death. Can self-harm be viewed as a vessel for the 'they' to pour its anxiety into, a vessel that can be named and identified? Anxiety of sorts is felt in this stance, but offers a powerful alternative to the possibility of 'the fact that it is the null basis of its own nullity' (Heidegger, 1962, p.354).

Let us review this paragraph from Being and Time (1962), which may support the idea of the constancy in irresolute falling and its ability to deceive:
   This downward plunge into and within the groundlessness of the
   inauthentic Being of the 'they has a kind of motion which
   constantly tears the understanding away from the projecting of
   authentic possibilities, and into the tranquillized supposition
   that it possesses everything, or that everything is within its
   reach. Since the understanding is thus constantly torn away from
   authenticity and into the 'they' (though always with a sham of
   authenticity), the movement of falling is characterised by
   turbulence.

   (p 223)


What is the motion that Heidegger refers to here? Is this similar to the movement that Kierkegaard mentions in Repetition (1983)? The word turbulence intrigues me too. Is it the 'anxiety of sorts' I mentioned above?

It seems to me that Kierkegaard is referring to a movement made possible by thought. An internal movement which allows an individual to become whole or in Kierkegaard's eyes Christian. The repetition of faith is not authentic when carried out blindly or with ease. A struggle is needed. The repetition and the subsequent movement are in the struggle and despair of not knowing, of sinning, of asking for forgiveness, of not knowing, of having faith, of doubting, of giving up and then continuing. Although Kierkegaard's project is to highlight the path to experiencing God and becoming a Christian, I wonder if it is the struggle and movement that provides the opportunity for the individual to become whole through the repetition. Is this similar to the uncertainty we face in the therapy room? Can it be useful to have the repetition of faith in therapy? Not of faith towards God per se, but faith in the space or in the dialogue created or in the difference between client and therapist.

Can we shed some further light on the hypothesis that Dasein and the 'they-self' have a co-dependent relationship through the guise of self-harm? Plato suggested, through the process of forgetting knowledge and recollecting the piece of knowledge, science sustains itself. Through the observations made by Kierkegaard and Heidegger we can see how repetition provides us with a sense of constancy. Hence Kierkegaard made an assertion that 'repetition and recollection are the same movement, except in the opposite directions' (1983, p 131). I wonder if the movement is reliant upon both repetition and recollection as Kierkegaard suggests. Can we see this reliance when we review history and the value bestowed upon self-harm? The knowledge, culture or belief at the time influences the value and the individual modifies his/her behaviour to accommodate the status quo? How significant is this for us to be able to achieve constancy with science, culture and ourselves as well as connecting the past with the present moment and pushing us forward into the future? Kierkegaard suggests that 'genuine repetition makes a person happy' (ibid) due to its forward moment, presumably resulting in an actualisation of potential or wholeness.

Relevance to psychotherapy

The client at the beginning of this paper stopped cutting, but was this due to her finding new ways to express her pain or did she achieve a sense of identity through utilising a new way to repeat herself or create a genuine repetition? Perhaps the key ingredient is in the fact that I was in a state of 'not knowing' when I was present with her. On reflection I think I was in fact naive and unsure how to proceed with her. Did this help us push and pull our way out and find a new way forward for her to relate to herself and others? Was it in this moment that she found constancy through a repetition of dialogue moving forward, instead of relying on what Kierkegaard may call a recollection of what served in the past? The latter may still provide a sense of constancy but one which in essence is unfulfilling. In this experience we repeatedly stepped into and out of a struggle.

I will review an experience with another client who I shall refer to as LX, in order to highlight the 'stepping in and out' experience and how this seemed to help us move forward and reduce the tendency to cut. Initially LX seemed petrified when entering the room and began the sessions unable to complete sentences. Her body would writhe with tension when she tried to talk about the abuse she had experienced as a child. She stated on several occasions that she felt she needed to talk about 'it', but did not know how. I noticed my body tensing up and felt that to begin with LX and I had to find a way to be with one another in this tension. I had to be careful not to create an environment that her vulnerabilities could interpret as punishing, forceful or indeed abusive. I informed LX that she was free to talk in her own time. This seemed to help LX relax in sessions and we focused on LX's relationships with family and work. I felt encouraged by our discussions, because LX started to trust the space. She began to wonder why she had been so tense at the beginning of therapy. We explored what she expected from me. LX expressed that she thought I would make her talk and that she wouldn't be able to leave until I told her. I asked her if there were other experiences where she had felt like this. LX seemed to become tense and began to writhe once more. LX acknowledged that at first the therapeutic setting felt similar to the setting where she had experienced abuse, but eventually she realised the differences. LX then began to talk about the abuse, the smells in the room, the sickness she felt and we explored the mixture of feelings she had towards the abuser and her mother. LX began to explore the sense that she gained something from the abusive relationship. She described the attention she received from the abuser and that this was lacking from her mother. The sessions then focused on the latter and working through a sense of guilt for having mixed feelings towards the abuser and her parents for not protecting her. The sessions moved back and forth between tension and calm. It felt as if LX and I were trying to learn together how to be with this movement. This felt important because we were acknowledging the intensity of feeling and letting each other know that we were still there. It seemed we were repeating something in this tension. We stepped into and out of this tension several times. Each time we became familiar with the process, but in each repetition something new appeared, whether in insight or in feeling. Through this process LX began to see aspects of her identity such as strength, creativity and intelligence, which she had previously dismissed. At this point, Heraclitus' quote highlighted previously seems very poignant.

We did not focus on self-harming behaviour, but acknowledged how it had reduced as therapy progressed and explored how she felt about this. It seemed to me as if LX was discovering new ways of dealing with anxiety and stress through repeating something through a dialogue with me. Are there similarities in the movement or turbulence that Kierkegaard and Heidegger proposed and my experience with LX when we stepped into and out of tension? We repeatedly entered into a dialogue that caused a flux of feeling and through this process something new appeared and a sense of what had come before. This seemed to provide a sense of constancy and an opportunity for LX to find out more about her being-in-the-world. Was it just a coincidence that LX was experiencing and using her body within a new repetition enacted through therapy and the urge to cut for her began to wane? Due to us not focusing on self-harm did this allow the power behind the term to diminish? Through this process we were able to move out of the tranquilising 'they' (moral panic) and irresolute falling and into an authentic resoluteness? I wonder if LX started to find wholeness in this process.

Conclusion

A start has been made to understand self-harm, but the danger is that the languages used in the articles cited are couched in psychiatric terminology and in turn fix the behaviour into a one-dimensional phenomenon. The blessing in consulting with philosophy is that the engagement provides an opening for new questions and realising new possibilities. This seems powerful due to the struggle that ensues between not knowing on one side and having a wealth of knowledge on the other.

In reviewing repetition and constancy I feel I understand self-harm within a different language. This has helped me resist the pull of classifying individuals within diagnostics and prevents me from being tranquilised by formulations that could contain an ulterior motive. I do believe that these formulations hold some truth, but I question how they are being utilised. Self-harm is a complicated and in its current form a relatively unknown aspect of behaviour, which supports the approach to have faith in the experience of the individual who presents this behaviour and explore their meaning and values bestowed upon it. Perhaps it could be useful to establish if the client views themselves as a self-harmer. It is also seems valuable to move beyond the act and attempt a way to provide a new method to achieve constancy. Perhaps this can be achieved through the relationship and struggle to understand each other. It also seems important to acknowledge the act but be mindful how focusing on it can compound the behaviour by feeding into a 'moral panic' and perhaps slipping into a tranquilizing aspect of being-in-the-world ... the 'they'.

References

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Favazza, A. R. (1998). The Coming of Age of Self-Mutilation. Journal of Nervous and Mental Disease. 186: 259-268.

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Heslop, P. & Macaulay, F. (2009). Hidden pain?: Self-injury and People with Learning Disabilities. http://www.bristol.ac.uk/norahfry/research/ completed-projects/hiddenpainrep.pdf

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Lovell, A. (2007) Learning disability against itself: the self-injury/ self-harm conundrum. British Journal of Learning Disabilities 36(2): 109-121.

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Meyer, M.W. (1987). The Ancient Mysteries: A Sourcebook of Sacred Texts. Pennsylvania: University of Pennsylvania Press.

Nutton, V., Porter, R. & Wear, A. (2000). The Western Medical Tradition -800 BC to AD 1800. Cambridge: Cambridge University Press.

Plato (1986). Symposium. Trans. Benardete, S. https://archive.org/details/ PlatosSymposium.

Sechehaye, M. (1950) Autobiography Of A Schizophrenic Girl: The True Story of 'Renee '. Translated by Grace Rubin-Rabson. New York: Grune & Stratton.

Turner, E., Blodgett, W., Kahona, S., Benwa, F. (1998). Experiencing Ritual: A New Interpretation of African Healing. Pennsylvania: University of Pennsylvania Press.

Turp, M. (2003) Hidden Self-Harm: Narratives From Psychotherapy. Jessica Kingsley, London.

Titos Florides is a Psychotherapist and trainer working in the NHS and in private practice. He has established befriending services across London for vulnerable adults.

Contact: 136 Bramley Road, London, N14 4HU

Email: info@aptpractice.com
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