Therapeutic work responding to self harm and anxiety


The current work refers to narrative conversations with a young girl responding to self-harm and anxiety. The work has been divided in 6 main parts: 1) externalization-mapping of anxiety, 2) use of metaphor for anxiety, 3) self-harm- absent but implicit and re-authoring, 4) preferred story of identity, 5) feminism- how individualism connects with collectivism and 6) accountability. In the introduction part there is a short letter that the girl, who wanted to be referred as “she”, wrote to present herself. The externalization-mapping of anxiety part describes, using externalized language, the effects of anxiety, the timeline-history of anxiety in her life, the allies that anxiety has in her life right now, it’s intentions and the evaluation of these effects. The use of metaphor for anxiety part refers to how the shift in our language, using a metaphor, made possible for her to imagine her anxiety as a big, made of iron cage and to identify the voices contained in this cage. One of those voices was the voice of self-harm that was telling her to “hurt yourself”. Through the absent but implicit narrative idea we were able to identify that this voice made its appearance when some important values for her, such as that of respect and help, were undermined. The detailed description of the stories behind these values made possible for her to re-connect with them and to take a position for the self-harm- to look for a different way to express her feeling of insult every time that one of her values were undermined. The preferred story of identity part describes some of the changes she managed to make in her life and some of the examples of cage resistance. The feminism-how individualism connects with collectivism part describes how her reconnection with her values and preferred ways of being in life paved the way for her to further connect with community and feminist practices. Lastly, the accountability part refers to the ways and actions I took to try to stay accountable to the ideas of narrative therapy. In the last page of this work there is an invitation for the readers to honor the story and the journey of the young woman by providing short feedback. 

Keywords: narrative therapy, anxiety, self-harm, Absent but implicit, re-authoring, narrative documents.


The current work refers to therapeutic conversations that I had with a 17-year-old woman during a period of 5 months in my private office. I was seeing her 1 time every 2 weeks and the work that I am presenting is a small excerpt of our ongoing therapeutic discussions. First time that she came to my office was with her mother and so I got permission to start therapeutic conversations with her. It is worth noticing that she has been informed for the current paper and she has provided consent and validation for every part of it. In matter of fact, I invited her to carefully review all this text and we discussed the intentions of this presentation, the purposes, the usefulness and whether it fits with her values. This presentation also acknowledges her wish to be referred as “she” through the whole text.

This work is divided into 6 main parts which are as follows: 1) Externalization- Mapping of anxiety, 2) Use of metaphor for anxiety, 3) Self-harm- Absent but implicit and re-authoring, 4) Preferred story of identity, 5) Feminism- How individualism connects with collectivism and 6) Accountability. In each part of this work examples of the questions I asked are included (see Tables), while in some places a detailed description of our dialogues is provided. Also within the main text are examples of the therapeutic work we carried out with her through collective documents (collage, drawings). 

In such presentations it is customary for the author to begin with a brief reference to who is this person he/she is going to talk about. In this effort adjectives and characterizations of the person’s character, identities or problems often figure prominently.

As I was reflecting on how I want to present her I came to realize that it wasn’t ok with me to put my own words in the introduction. I was worried about the effects of my own cultural and scientific background, my privileges as a white middle-class man and the possibility that they may downgrade the experience of how she understands herself. So, in effort to step back from expertise language I decided to ask her to present herself. That’s also my preferred way to stay accountable in the notion of co-research and the resistance to expertise power which characterizes narrative therapy (White, 2004).Her introduction of herself follows:

“Hello to everyone, as you already understand through this presentation, I am 17 years old, and I aim to study occupational therapy. I chose this profession because I really like helping other people, so I believe that through occupational therapy I will help people who have different needs from us. I really like books, it’s a way to get away from what’s happening to me. I would very much like to join the movement of “me too”, to become one of those who defend women’s rights not only from pages in Instagram. I love animals, nature and I like music very much. I think if I had to choose a mythical creature to represent me, I would choose fairies. Fairies remind me of the dolls I had when I was little, and they were my only company. I almost forgot to say that I really like to draw and write from short texts to short stories. My psychologist once told me I’m a rushing river, you could call me that too.”



At our first meeting she wanted to talk to me about her anxiety. So, I decided to begin our therapeutic conversation with an externalization- mapping of anxiety. My intention using externalized language was to assist her to see anxiety from a distance, as something outside her, and as a result to let her look at this anxiety as a character and not as something that starts from within her (Carey & Russell, 2002). Through that I was hoping to help her separate her sense of self from anxiety and gradually to take a position.

So, we started to discuss about the history of anxiety in her life (its timeline), its consequences, the allies that anxiety has in her life right now, it’s intentions and the evaluation of these effects. 

Particularly, she told me that anxiety almost always had a prominent place in her life, and she recalled moments when she was 12-13 years old, and the anxiety wouldn’t let her go to school. She couldn’t remember the first time that anxiety made its appearance, but she could tell me in detail all the negative consequences that anxiety had and still has in her life. Every time that anxiety made its appearance her stomach aches, her hands are sweating, her mouth is dry and if she is in bed she can’t sleep. Also, she can’t concentrate to study and that’s making her feel more anxious. That paved the way for me to ask her about the times that anxiety is stronger during the day but at that time she couldn’t distinguish those moments as she was feeling “constantly anxious”. When I tried to dwell a little more on the story of the anxiety in her life and asked her that since she has a long relationship with it why she chose to speak now and if that means the anxiety has been misbehaved completely, she told me that recently the anxiety has gotten out of control and that’s why she “came to seek for a solution”. So, this paved the way to speak a little more about the current situation and the allies of anxiety right now. 

When we sought for allies of anxious recently, she mentioned that the school and her father are the stronger ones right now. When I invited her to tell me a little more about those allies, she told me that the upcoming national exams get her very anxious as she really wants to study in the university (in Greece in the last year of high school national exams take place and the results of these exams determine students’ entrance to universities). Moreover, in school she deals with some unwanted behavior from classmates sometimes as she has completely different interests and hobbies from them (she likes poetry, literature, going in the library and doing yoga), which leads some of them to look at her strangely and comment negatively on her (“freak” and “nerd” are the most common of them). That’s also something that she told me that works for the anxiety’s interests. 

Regarding her father she told me that he always was an ally of that anxiety. When I invited her to tell me more about the story behind his anxiety-provoking presence in her life she told me that her father is constantly fighting with her mother while speaking very badly to both (mother and her). I invited her to speak more about the behaviors that contributed to her experience of the relationship with her father, and she told me numerous examples of his “bad” behavior full of yells, fights, and verbal abuse. She named that story as “story of father’s cruelty in her life” and we acknowledged the strong effect of these cruel practices in increasing her anxiety.

After that we spoke briefly about the intentions of that anxiety and she told me that it wants to keep her from sleeping, deny her entrance to the university and to be made fun of all the kids at school (the shift in the language using “it” made me understand that she could feel comfortable through this externalization). When I asked her if she agreed with the plans and intentions that anxiety had for her life, she answered me that of course she doesn’t. She dreams a life in which she will be able to study in the university, have friends and enjoy a life without anxiety.  

Examples of the questions made in this section are presented below. These are just examples of simple questions that was part of lines of inquiry that was further unpacked through scaffolding and which for reasons of space are not presented here.

“Can you please tell me what is the story of anxiety in your life? I mean where did you first start to notice its presence in your life? 
“This anxiety that you tell me about, when is it loudest in your day? when you wake up in the morning, when you go to school, when you get back home or something else?” 
“Is it ok for you to ask you some questions about that big upcoming events that anxiety tells you to worry about?” (Permission seeking) 
“Hmm…I see…And what are the effects of this anxiety in your life right now?” 
“So… you say to me some important things about the anxiety and its effects in your life. Is it ok if I repeat them just to be both sure that I understand them? Please if I don’t, feel free to stop me.” (Summary to reposition the person in the witnessing position) 
“Does it have any allies who make it come easier or to stay more?”
“Would you call those effects negative, positive or both?”
“Is it ok for you that anxiety has all that effects?”

Table 1. “Examples of the questions for section 1”


As I mentioned in the previous section, I discerned 2 important things from what she said, and what the anxiety wouldn’t let her say. First, I sensed that in our first conversation anxiety was so close to her that it wouldn’t let her take a step back and look at it from a different position- that of the observer- and that’s why the anxiety wouldn’t let her say when it becomes stronger during the day. Secondly, she was feeling comfortable with the externalization language as she was following my invitation for it. In matter of fact, I noticed in her words throughout our discussions that she used several metaphors. So, this had me wondering whether a further unpacking of the problem might elicit a richer description of the anxiety problem through externalization. That was also my way to stay accountable to her saying and to be influential honoring her language. 

When I first asked her if she could capture her anxiety in an image or through a metaphor she answered without hesitation, as if she was ready all along, that her anxiety is like a cage. Through multiple invitations of further description, we ended up with a clear image of that anxiety-cage. It was a big, made of iron cage, with no doors that when it captures her it won’t let her escape. This cage was particularly present at nights while in the day- when she was in school- most of the times it was sleeping. She said to me that this cage was smaller the past years but now with the exams and her father’s more aggressive behavior the cage got enlarged and very strong. She also told me that the cage gets closer to her every time she gets anxious and has a lot of feelings of despair, more anxiety and loneliness inside it. 

When I asked her if she can tell me what this cage could say to her if it had a voice, she told me that this cage talks to her a lot about her failure as a student in the upcoming exams, tries to convince her that she is going to die in her sleep, and it tells her to hurt herself with a scissor. That allowed a movement- link of the theme of anxiety to the theme of self-harm. When I asked her if the cage had ever managed to convince her to hurt herself with that scissor, she told me that it had succeeded that 2 times. At that moment she lifted her sleeve and showed me two small wounds on her arm.

Examples of the questions made in this section are presented below. These are just examples of simple questions that was part of lines of inquiry that was further unpacked through scaffolding and which for reasons of space are not presented here.

“You know I have a crazy idea, what about we try to depict your anxiety with a metaphor? You can pick whatever you want. I mean, if your anxiety had an image, a sound, a smell or whatever you can imagine, how would it look-sound-smell like?”
“Ohh I see, and how does this cage look like? Is it big, small or something in between?”
“From what this cage is made of ?”
“Was it always that big in your life or it’s feeding from something?”
“How do you feel when you get inside of that cage; you enter the cage of your own free will or something else happens? and when you enter you can do something to get out when you want to or not?” 
“You told me previously that this cage is big, it’s made of iron and that makes it so strong and difficult to get out of it as it has no doors. Also, you told me that it’s feeding from your father’s behavior towards you and your mother, the national exams, and your classmates “bad behavior” to you. You know, I wonder now If this cage had a voice, what do you think it would tell me about the purposes that it got for you; what does this cage want from you?” 
“How it is for you to hear yourself talking with these terms? are there any things that become possible to realize about your anxiety now?” (Circular question)
“Does this metaphor make sense to you? do you want to keep track of that cage presence in your life?”

Table 2. “Examples of the questions for section 2”


I was curious about what made possible from her behalf to show me those wounds. So, in the next session I asked her what made possible to her to reveal those wounds and acts of self-harm to me that moment and what does this mean about how she feels with our conversation. She answered that safety was present in the room during our conversations and she let me know how my resistance to any kind of criticism contributed to that. The reveal of those wounds was an act of openness, an act of showing her trust on me which I did not intend to overlook.  

Through further unpacking of that self-harm voice, we acknowledged that it comes to threaten her life. So, I asked her if that threat made possible to shift our conversations in the self-harm voice of the cage. She agreed as she was feeling that the self-harm voice grew stronger and stronger. 

Through this unpacking, whose questions are presented below, we unraveled the kind of that self-harm voice, its story, its frequency, and its power. Specifically, that self-harm voice was always present in the cage, was a whispering voice that was keep telling her to hurt herself and the fact that it was a whispering voice made possible for her to realize the sneaky tactics that it uses to persuade her. 

Later in that conversation I asked her if those acts of self-harm had a meaning, what would it be? And she replied in a way that was the key-point for our later conversations. 

“Dimitris, every time that someone is insulting me in a way, I want to leave marks on my body to remember the insult.”

Her response made me wonder that if those insults compromised some important values of her that were absent but implicit in every case maybe the self-harm was an act of resistance or opposition. If so, maybe she could find different ways of showing her resistance or opposition to those insults more accepted by her and her own body. With that in my mind I started to ask her the followings. 

Here I quote a small part of our conversations verbatim. Where D is me and she/her is the young girl.

D: So, you told me before about this insult. You told me that every time that someone is insulting you in a way, you want to leave marks on your body to remember the insult. Did I get that right?

She/her: Yeah yeah, you got that right.

D: You know that made me wonder about something. Is that ok if I ask you 2-3 more questions about that?

She/her: Yes, go on. 

D: You know I was wondering; through this self-harm you try to defend or to protest about something that is very important to you?

She/her: I never thought about that. I guess I want to protest about something…. yeah, sure. I want to protest!

D: What is it that you want to protest? Is it a value or values that you hold precious to yourself, and you think that are getting compromised in every insult?

She/her: Yes. There are several values that are getting compromised in every insult. First of all, it is the value of equality and human rights. Nobody deserves that kind of insults. 

D: Hmmm, ok ok. So, there are the values of equality and human rights. Are there any other values that are getting compromised?

She/her: Let me think… Yeah there are! There are also the values of compassion, help and solidarity. Yeah, now I see them clear enough. Those are the values.  

D: Ohh I see it now. So, you told me that through those insults there are some values that are getting compromised. Some values that you hold very precious for yourself. You told me about the values of equality and human rights first and then you told me about the values of compassion, help and solidarity. Is that right?

She/her: Yeah yeah.

D: And what is the history of those values? I mean from where did you learn them from?

She/her: Ohh… wait I think I need some time to think about that…..hmmm… I think…. I think that most of them I learned them from Jane Eyre (the book) and some of them from the feminist movement. 


(We explored the history of those values, and I asked her to give me some examples when she hold those values near her)


D: those are some beautiful stories. Could I take you back a little to our discussion about self-harm?

She/her: Yeah, why not?

D: Thank you. You know I was wondering is it ok with you to express your will to protest in that way?

She/her: No, no. Definitely is not but I can’t help it.

D: Ok ok. I remember also that these actions of self-harm are expressed on your wrist. I remember that right?

She/her: Yeah, you got that (she shows me her wrist again)

D: Can I ask you something that came through my mind about that?

She/her: Yes.

D: Maybe it sounds like a weird question, but I was thinking about…if your wrist could talk to me, how would it feel about that kind of expression?

She/her: It will be very sad. It would be sad yeah.

D: Is that ok with you?

She/her: No, it’s not. I don’t want any part of my body to feel sad. I love my body (she bends over, grasps her wrist and whispers “sorry wrist”)

D: So, since is not ok with your wrist. And since it is not ok with you either. I was wondering if there are any other, different ways more accepted by your body to express your will to protest?

That conversation and the invitation for my behalf to explore alternative ways, more accepted by her body to express her will to protest, paved the way for some collective documents. The following narrative documents are presented with the permission of the young woman herself (Epston & White, 1990).

The first collective document that we created was the collage of “Neverland”. The creation of the collage was conceived as an idea to create a safe place where she could resort when the cage is whispering to her to hurt herself and the anxiety inside the cage tries to take control. 

This collage includes her favorite book character (Jane Eyre), her favorite quotes, her favorite pets, her favorite moments with friends, her favorite flowers, her dreams, her favorite movie, and her favorite words to remember. It even includes a small picture of my office as her safe place to talk about herself. 

Also, we explored some different ways to express herself and her will to protest through drawings. When I asked her about the symbolism of the paintings she brought me, she told me that some of these drawings were an expression of her feelings (loneliness and anxiety) while others were just freehand drawing.

The third narrative document that we prepared was an “alternative journal”. She had told me in previous sessions that she likes writing a journal every day describing her everyday life, her schedule and keeping a track of the anxiety. Having that in mind, I invited her to create a different journal which we called “the journal of skills and values”. The creation of the journal of skills and values was a way to depict the incidents that insulted her, the values that had been undermined, and the preferred ways in which she would like to respond without self-harm. This journal had 3 columns where each column had one of the following questions: What insulted me? What value of mine have been compromised? And how I want to respond to that in a different way?

Examples of the questions asked in this section, that were not presented in the verbatim report, are presented below. These are just examples of simple questions that was part of lines of inquiry that was further unpacked through scaffolding and which for reasons of space are not presented here.

•       “Is that voice always present when you are forced to enter the cage?” 
“What is the story of that voice. When it was the first time that you heard that and when it becomes stronger?” 
“I wonder what it says about you that this voice is always a whispering and not a loud angry voice for example?” 
“That voice always tells you to hurt yourself or it says some other things as well?” 
“I wonder also what made possible to you to reveal that acts of self-harm to me now- does it mean that you see our conversation in a certain way or something else happened?” 
“What do you want with this self-harm? you want to relief from something, to feel the pain or something else?” 
“How can you remember the insult and protest about it without to harm yourself?” 

Table 3. “Examples of the questions for section 3”


The narrative documents that were described in the previous section provided alternative ways to respond to anxiety and self-harm voice with more acceptable ways for her body. Shortly after creating the collage, the alternative journal, and the drawings, she mentioned to me that the effects of anxiety and the voice of self-harm were slowly reducing. The whisper of the cage that was talking about self-harm after each insult began to “fall silent”. In each session she used to bring with her more drawings and more examples of the way that the journal and the collage made possible for her to resist to the cage and the anxiety and self-harm voice that contained. For me it was clear that these narrative documents as alternative ways of action after every insult made possible a gradual transition from the know and familiar of the problematic story of the cage to what becomes possible for her to know (Freedman, 2012)

Below are just a few of the most typical examples of the unique outcomes she managed to achieve in her history of resistance to the cage of anxiety and self-harm. 

Recently, she stood up to her father’s arrogant look as she described and told him to stop arguing with her mother. When I asked her how she would name that action she replied that was an act of resistance to his cruel practices that for a long time she wanted to do. When I then asked her what this action says about her, she replied that this action says that from this time on she won’t tolerate any insult no more in this house. 

She also managed to stop the self-harm and decided to study occupational therapy. When I asked her where she thinks all these actions are taking her, she replied that these actions lead to her future self and more preferred self. Through further unpacking of the future self, she described a future self away of the cage of anxiety and self-harm, studying in the university occupational therapy and having a lot of friends with the same interests. When I invited her to tell me how her future self and her favorite book hero, Jane Eyre would feel like witnessing her acting like that, she replied with tears in her eyes that both they would feel so proud of her and her journey. 

Examples of the questions asked in this section are presented below. These are just examples of simple questions that was part of lines of inquiry that was further unpacked through scaffolding and which for reasons of space are not presented here.

·      “What does it say about you that you stood up to your father’s yells and his arrogant way of looking?” 
“How you made it; how would you name that action? what is the value behind that action that made it possible?” 
“Where do you think all these actions are taking you? would you think that you are getting closer to your future and preferred self? how this future self looks like, what relationship she has with the cage? how she manages to deal with the cage of anxiety and self-harm?” 
“How would she (future self) feel like witnessing you acting like that?” 
“How would Jane Eyre feel about you or what would she tell you if she could witness you acting like that?” 

Table 4. “Examples of the questions for section 4”


In our next session she came into the therapy room with an obvious haircut. She had cut off almost half of her hair! I asked her if her new haircut was standing for something, and she replied that was an act of protest for the murder of 22-year-old Masha Amini in Iran. I asked her what is that that she wanted to protest and what made that possible for her to protest in that way? She replied that she wants to protest against femicides and her connection with the feminist movement made that possible. When I asked her what is the value(s) that has been compromised for her in the murder of Masha Amini she replied that were the values of equal rights, solidarity, and help. After that we explored the history of those values, and I asked her if there is something more that she can do to protest wider and to connect with women that might share with her the same values. After some discussion and brainstorming of possible ideas she came up with the idea to start a blog in Instagram where she can talk about feminism and woman rights. My intention in that conversation was to help her connect with the community in a way that was enriching her preferred stories of identity and her values. 

After that I asked her if there was anything more that she wanted to take a stand on. She replied that there were several things that she would like to take a stand on as animal killing and several homosexual comments that she had heard from her classmates in her school. I asked her how she would like to take a stand on, and we started a conversation about the possible ways. Finally, and after a few weeks she chose to be vegan to protest about animal killing and she stood up to her classmates’ homosexual comments about women and sexuality in the sex education class at school. 

In fact, the very text you are reading now was a way for her to take a position and to give voice to her experience. For me as a narrative therapist it is crucial not to only talk about my consultees but also for them to talk through me. So, I asked her what message she would like to give to you. The following was her message to you. 

“I am here. I am a woman who has experienced and got through a lot. No woman is alone.”

Examples of the questions asked in this section are presented below.These are just examples of simple questions that was part of lines of inquiry that was further unpacked through scaffolding and which for reasons of space are not presented here.

“You said previously that you cut your hair to protest about something. What is that? What made this act of protest possible? 
“What is the value that has been compromised? From where did you learn the values of equality, help and solidarity? what is the story of those values in your life? Is it something more that you can do to protest wider and to connect with women that might share with you the same values?  
“Are there anything more that you want to take a stand on? What is it? How would you like to stand on?” 

Table 5. “Examples of the questions for section 5”


For me trying to stay accountable to the notions of co-research, intentionality-influential but no submission, resistance to expertise power, accountability about power relations and de-centered position that characterize narrative therapy and ideas was of great importance. 

The acknowledgment that my own language, privileges, experiences, and preconceived concepts might affect on how she wants to present herself and what feedback she would like to receive informed my practice by asking her to present herself and to write together with me the questions about the feedback she would like to receive (the feedback section follows). Throughout the whole text a number of micro-practices and questions were used to stay accountable to the notions that mentioned above that the reader can easily detect. But in this section, I would like to refer to and acknowledge a different, not linear procedure. I would like to acknowledge the hardships of trying to stay accountable to narrative ideas. 

As I write these lines the sayings of David Newman come across my mind “We are not only accountable of what we say or ask but also of what we don’t” (Newman, 2008). When I first heard the young woman talk about self-harm, the first dominant idea that crossed my mind was that of the “criticality of the situation”. I found myself thinking about the danger of the situation and the possibility that her family should be informed even against her will. This idea questioned my ability as a therapist and used the medical discourse of diagnoses and pharmacotherapy. I know this “expertise” thought as I had previously been introduced to during my studies. It wasn’t always easy for me to resist to this idea and to understand the consequences that this idea would have to my accountability and my preferred decentered but influential position as a therapist. 


Whoever of you would like to contribute, honor, or acknowledge something about her journey could wright his/her thoughts, feelings and/or reflections on the following questions. The questions were created under collective conditions (collaboration of me, Kassandra, and “her”). The feedback can be sent directly to my personal email to or to her in her personal email (we created an anonymous email address together) to . It would be our pleasure to hear from you. 

  1. What stands out for you from what you heard of her story?
  • Where are you moved by what you heard?
  • what message would you like to give her from the words you heard?
  • What words would you choose to describe her as a person?


Carey, M., & Russell, S. (2002). Externalising – commonly asked questions. The International Journal of Narrative Therapy and Community Work, (2). 

Epston, D., & White, M. (1990). Consulting your consultants: The documentation of alternative knowledges. Dulwich Centre Newsletter, (4)

Freedman, J. (2012). Explorations of the absent but implicit. The International Journal of Narrative Therapy and Community Work, (4)

Newman, D. (2008). ‘Rescuing the Said from the Saying of It’: Living Documentation in Narrative Therapy. The International Journal of Narrative Therapy and Community Work, (3)

White, M. (2004). Folk psychology and narrative practice. Narrative Practice and Exotic Lives

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