Family Therapists‟ Experiences of Working with Adolescents who Self-Harm and their Families: A Grounded Theory Study Colette Richardson A thesis submitted in partial fulfilment of the requirements of the University of East London for the degree of Doctor of Systemic Psychotherapy July 2014 ABSTRACT This study is a qualitative enquiry into family therapists‟ experiences of working with young people who self-harm and their families. To date, in spite of self- harm being a serious public health concern, there is relatively little exploration of the subject in family therapy literature. The study attempts to describe, understand and illuminate family therapists‟ experiences: the therapeutic issues encountered, the stances adopted in response to the issues encountered, and the emotional impact on the therapist of working with this client group. A total of nine experienced family therapists participated in semi-structured interviews. The study employed a grounded theory method for data analysis. The analysis yielded a theory of therapists‟ experiences that included a Core Category and three Main Categories. The Core Category that emerged was:  Cultivating the Practice of Hope – Withstanding the Pull to Hopelessness. The three Main Categories were:  Making the Situation Safe  Conversing Therapeutically – The Practice of Hope  Team and Organisational Processes: Supporting Therapists. The Core Category is the central feature of this theory. It proposes that the central concern for the therapist is how to stay engaged with the family and the young person in the context of serious risk of self-harm and in situations where change is difficult to achieve and hopelessness can pervade. The therapist has to try to understand and make sense of family members‟ distress, and be touched by and open to their feelings of despair and hopelessness without becoming overwhelmed and despairing themselves. The therapist response to this dilemma is the stance of hopefulness. It is both a therapeutic stance and orientation, and is enacted in practice through finding ways to cultivate hope in the therapeutic encounter. i While the Core Category is the central „story‟ the three Main Categories are linked to the Core Category. The Main Category, Making the Situation Safe describes the initial stage of the work, with its focus on ensuring the safety of the young person. The Main Category, Conversing Therapeutically – the Practice of Hope describes how the therapists enacted the „practice of hope‟. The Main Category, Team and Organisational Processes: Supporting Therapists describes how the context in which the therapists work, the nature of relationships, the team and organisational structures, play a critical role in supporting therapist hope, so that they can withstand the pull to hopelessness. This study aims to make a contribution towards articulating a framework for family therapy with adolescents who self-harm and introduces a new vocabulary – the language of hope and hopelessness. i i TABLE OF CONTENTS 1. INTRODUCTION 1 1.1 Research Purpose Statement 4 2. CHAPTER ONE: LITERATURE REVIEW 5 2.1 Defining Self-harm 5 2.2 Prevalence of Self-harm in Adolescents 7 2.3 Associated Psychological Difficulties 9 2.4 Protective Factors 23 2.5 Systemic Clinical Literature 25 2.6 Research on Family Therapy for Self-harm 35 2.7 Therapists‟ Emotional Experience of Working with Self-harm 44 3. RATIONALE FOR THE STUDY 48 4. CHAPTER TWO: THE METHOD 50 4.1 A Qualitative Study 50 4.2 Grounded Theory – An Overview 51 4.3 Ensuring Quality 54 4.4 Ethics 58 4.5 Personal and Professional Reflexivity 59 4.6 Design of the Study 63 5. CHAPTER THREE: GROUNDED THEORY DATA ANALYSIS 71 5.1 Stage 1 71 5.2 Reflection on the Analysis of the Six Interviews 76 5.3 Stage 2 79 5.4 Stage 3 83 5.5 Constructing the Core Category 88 ii i 6. CHAPTER FOUR: THE FINDINGS 91 6.1 THE CORE CATEGORY: 92 Cultivating the Practice of Hope – Withstanding the Pull to Hopelessness 6.2 MAIN CATEGORY 1: 97 Making the Situation Safe 6.3 MAIN CATEGORY 2: 125 Conversing Therapeutically – The Practice of Hope 6.4 MAIN CATEGORY 3: 168 Team and Organisational Processes: Supporting Therapists 7. CHAPTER FIVE: THE DISCUSSION 183 7.1 A Summary of Key Findings 192 7.2 Elaboration of Some Key Findings 212 7.3 Clinical Implications 212 7.4 Strengths and Limitations of the Study 215 7.5 Assessing the Quality of the Research Study 216 7.6 Self-Reflections 218 7.7 Future Research Recommendations 222 REFERENCES 223 APPENDICES 255 1. Interview Schedule 1 2. Interview Schedule 2 3. Participant Information 4. Consent Form 5. Transcription Notation 6. Literature Review on Hope 7. Ethics Approval iv v 1. INTRODUCTION The initial impetus for this project began several years ago when I was working in a new post as a family therapist in an adolescent inpatient unit. This was my second job in a hospital setting and I was excited about the work, though also apprehensive – since although the „inpatient‟ experience was not new to me, the presenting problems were significantly different to those I had previously encountered. The young people admitted to the unit were within the 13 to 18 age-range, and presented with a range of problems including psychosis, depression, self-harm, obsessive-compulsive disorder and post-traumatic stress. Those admitted because of self-harm would normally have made a serious suicide attempt, with the self-harm typically involving the young person taking an overdose, usually Paracetamol. Some young people, more often the boys, would have attempted suicide by hanging. Prior to admission the young person would often have made several attempts of a less lethal nature. I found the clinical work both demanding and challenging. The young people were often reluctant to engage in family therapy, and their parents, while clearly upset and distressed, were also often reluctant to engage. Sessions frequently had the quality of „walking on egg-shells‟. Family members found it difficult to verbalize what they were feeling and to engage in dialogue about the self-harm, its meaning and impact. As the sessions unfolded and parents began to trust more, they would often eventually speak about their fear that talking about self- harm would trigger a further attempt on the part of the young person. The challenge presented by this work spurred me to try to find out how others worked with self-harm, and I consulted the available literature in family therapy. To my surprise very little had been written, leaving therapists like myself wishing to develop their skills in this area with little guidance. Much of what had been written came from the early stage of family therapy development, often described as the cybernetic phase. Most of the articles described working with 1 young people and their families from a predominantly strategic model of family therapy. The combination of a lack of guidance from the literature, and the challenges I encountered in the work with these families, set the ground for this study. My initial project involved enquiring into the impact of therapists‟ preferred ideas and biases on the families they worked with, and from this to generate information useful to therapists for their clinical work with young people who self-harm and their families. The research design was to include interviews with the young person, their family and the therapist and, in addition, observation of video-taped therapy sessions. This project proved untenable, due to various factors including recruitment difficulties. Despite having received approval from the National Research Ethics Service (NRES), individual NHS Trust research departments were reluctant to give approval for the project. Negotiations with the Trusts regarding the recruitment of families and therapists, answering questions, filling out forms etcetera, continued over a two-year period. Two of the Trusts I approached did eventually approve the project. However, I experienced further difficulties. Family therapy colleagues while being interested in the research and agreeing to participate, later reported that they were unable to recruit suitable families. Despite this, the setbacks provoked me to think more deeply about the importance of research in the area of self-harm and I decided nevertheless to continue and redesign the research project. Before introducing the new study, it may be interesting to consider why the first project proved untenable. My hypothesis is that the difficulties I experienced were related to the issue of risk. Trusts were perhaps anxious about the possible consequences of allowing research to take place that involved young people for whom there was a risk of suicide, and may have been worried about what might be the legal and other implications. Likewise the family therapists may have worried that involvement in the project could increase risk, leaving them open to blame had anything untoward happened. 2 It is interesting to consider these difficulties encountered in the light of some of the findings of this present study. It would seem that the wider context mirrored the families‟ fears of triggering self-harm. Returning to the present study, to reiterate, it was triggered by both clinical experience and the absence of literature on the subject. My aim in designing this grounded theory study was to try to unearth the experience of family therapists working with young people who self-harm, to learn from them through exploring their concerns and dilemmas, and through this process to generate ideas useful for clinicians working in this area. The Research Purpose Statement, Question and Sub-questions are set out overleaf. 3 1.1 Research Purpose Statement And Research Questions Research Purpose Statement: The purpose of this grounded theory study is to describe, understand and illuminate systemic therapists‟ experiences of working with young people who self-harm and their families. In conducting this research I am seeking to understand the clinical dilemmas and concerns faced by therapists, explore how they make sense of their experiences and explore their ideas about what has to happen for change to take place. The overall aim of the study is to generate information useful to therapists in their clinical practice. Overarching Research Questions: 1. How do family therapists experience working with this client group? 2. What dilemmas and problems arise? 3. What have family therapists learnt over time about working with adolescents who self-harm and their families? Sub-Questions: 1. What therapeutic issues are encountered? 2. How do therapists make sense of the issues encountered? 3. What stances do they adopt in response to the issues encountered? 4. How does the issue of risk of suicide impact on the therapy and therapists? 5. What feelings are evoked in therapists? 6. What are therapists‟ preferred ways of working with this client group? 4