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Understanding 'Dark Occupations'

Updated: Jun 17, 2023


Understanding 'Dark Occupations'  by Keir Harding - The Occupational Therapy Hub


Trigger warning: Self-harm and abuse



A Mental Health Act tribunal is where people who are detained in hospital against their wishes get the chance to appeal their detention. They get legal representation and while staff argue why they need to remain detained, the solicitor picks apart their statements to show that the detention is unjust. Watching this are a panel of three people: a psychiatrist, a judge and a lay person - and at the end of the merry process they get to decide whether the detention is required. In the UK, this is how we make sure people aren’t deprived of their liberty without good reason. This bit was a bit dull, but it gets more interesting from now on…


I was at a mental health tribunal once where I was asked this question:

"If self harm is what keeps them in hospital and they really want to get out, why don’t they just stop doing it?"

I relished answering this but my heart sank a bit as well. This was the medical expert on the panel and it is so frustrating that people in such a position of power hold the view that self harm can simply be 'turned off'.


I’m not a fan of diagnosis but, using a medical model, self harm is one of the symptoms of borderline personality disorder. In what other area would we suggest people just stop the symptoms of their illness? "Why don’t they just stop hearing voices?" Or even "Why don’t the manic people just calm down?" Obviously, any action that someone takes has an element of choice involved, but in mental health we work with many things that people do that cause them harm. I’m going to suggest that, if the attitude we take into our work is that people should just stop doing what they are doing, it is going to be absolutely impossible for us to help them. It also conveys the idea that people who could just stop are unworthy of help.



If you feel that alcoholics should just stop drinking, agoraphobics should just go out more or anorexics should just have a McDonalds, this probably isn’t the article for you.


If you’re interested, I’m going to try and explain how to make sense of why people do things that aren’t obviously in their best interests. I’ll probably focus on self harm, but you can use this process for understanding most things. I’ll give it to you in a couple of steps, but the order doesn’t really matter...



Understanding 'Dark Occupations'  by Keir Harding - The Occupational Therapy Hub


The things people do make sense

Nobody self harms for the sake of it. Nobody self harms because of their diagnosis. The only reason someone self harms is because, in that moment, it’s better than not doing it.

You’re not that important

There’s a good chance that the reason someone self harms is nothing to do with you. Yes, its painful to see someone you’re supposed to care for hurting themselves. Yes, it’s frightening to think you’ll be blamed for what they do... and yes, it can feel personal. Despite your initial reaction, you will be much more useful if you can start in a non-judgemental and curious manner. If you have to make an assumption, work hard to make sure it is the most empathic one you can think of.

Be curious

The best source of information about why someone does something is the person themselves. I once read 'She spent time in her bedroom and self harmed due to her diagnosis', which I thought was one of the worst things ever written in somebody’s notes - and the winner of my 'Utter Lack of Interest' award. 


We need to ask questions: "Can you help me understand why you do that? I want to understand how it’s useful to you." "How does it help?"

These are all things we can say to help people talk about why they do things; as a bonus, it gives them a sense that we are interested in them.


Understanding 'Dark Occupations'  by Keir Harding - The Occupational Therapy Hub


It does something for them

Everyone’s reason for self harming will be different, but it's likely that they get something positive out of it. It might allow them to feel something (because feeling nothing is terrifying). It might ground them and help them focus. It might validate their sense that they need to be punished. It might... well, anything really. Whether it affects their physiology, thoughts or feelings, there is likely to be some result that is worthwhile.


It does something to other people

It’s very easy for us to start thinking of ‘attention seeking’ at this point. Let's throw that term out of the window and just think about what happens in the environment once someone has hurt themselves. It might mean that people spend time with you. It might mean that people don’t abandon you. It might mean that people keep you away from something that terrifies you. It might mean that people care for you in ways that they wouldn’t otherwise. I remember one person who had always been neglected by his parents. They only showed they cared when he was physically unwell. Later in life, the only time he could accept people being nice to him without a crushing sense that he didn’t deserve it was after he had poisoned himself. If we ask, we can find out why it makes sense.


But they could just ask us!

But you won’t ask for things you don’t think you deserve. Many people have lived lives where they were never given what they asked for. Even if they did ask, let’s have a think about who is given the clearest message that people care about them. Is it the person who asks politely for support, or is it the person in their room turning blue, with a team ensuring they stay alive in that moment then watching them for the night? 



In mental health services we are very good at conveying the message that the amount of care you receive is related to how dangerous you are. It’s weird that we then get annoyed when people respond to that.


We can’t see the choice they’re making

If we don’t ask, we are in danger of thinking people self harm for the sake of it. It’s very hard to sympathise with that. If we can see a choice, between cutting and another night of staying awake replaying the most traumatic experiences in 3D IMAX in their brain, it makes a lot more sense. If we can see a choice, between overdosing and feeling that your head is going to explode, it makes a lot more sense. If we can see a choice - between head banging and listening to the voice of the person who hurt you telling you how awful you are and that you deserved it and that no one likes you and it will never get any better, ever – again, it makes perfect sense. We won’t know what is going on for someone until we ask them. We need to make sure we do that.



 


Model of Human Occupation (MOHO) - Understanding 'Dark Occupations'  by Keir Harding - The Occupational Therapy Hub


So all of the above are just some ideas. To make it a bit more MOHO, people only do things because they want or need to do them. Other ideas are available, so feel free to dismiss this. I’m going to suggest that if you can do the above you’ll be much more effective at helping people. It might even mean that you work on the problems that lead to people hurting themselves, rather than just trying to stop the self harm itself. Don’t be the person with a deciding vote in someone’s liberty thinking that they should just pack it in.


Be curious, be empathic... and honestly, if stopping was easy, people would do it.


 

  • It is the height of arrogance for me to be writing about this. People who actually experience these difficulties do it much better. I highly recommend reading this by @hoppypelican.

  • There are a lot more articles like this written here

  • Follow Keir on Facebook: Keir Harding OT; Instagram: Keirhardingot; Twitter (where he is busiest): @keirwales


Keir is a Lead Therapist in an NHS Specialist Service and provides training, consultation, supervision and therapy around complex mental health problems through Beam Consultancy.

5 Comments


Unknown member
Jun 19, 2023

Thank you! I am now an OT student and rebuilding my life. But I have experienced so many of the attitudes you describe.

A mental health nurse once told me how she maintains her compassion by thinking "how much emotional pain must a person be in, to make self-harming the preferable option".

I feel that when staff are stressed and pressured, it seems easier to blame the patient for not fitting in with service expectations.

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Unknown member
Nov 11, 2022

Woow Thank you for sharing this in such a triggering command,love it

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Guest
Oct 16, 2022

Thank you Kier, this was really inspiring and thought-provoking and I enjoyed reading this.

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Brigitte  Hoare
Brigitte Hoare
Oct 21, 2021

Thank you Keir, I have reflected on this and believe their is a correlation between self-harm and hoarding. In terms of hoarding, it frustrates me so much when I hear "It's a lifestyle choice"!

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Gavin Symes
Gavin Symes
Feb 24, 2020

Great article and something that clinicians need to understand.

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