“Having [immediate cessation of self-injurious behavior] as a primary goal may well be counter-productive. Techniques based on the premise that self-injury should not be reinforced by attention, or on the use of sanctions such as withdrawal of treatment, will almost certainly cause greater distress.”
(Solomon, Farrand, 1996)
Therapists need to check-in with themselves before working with clients who self-injure; If the therapist has a strong desire for a client to cease self-injury, or wishes to have a zero-tolerance demand on their client, they should ask themselves if this is based on what is best for their client or because they are not comfortable with the idea of a person self-injuring. As a therapist, if you find yourself repulsed by self-injury it would be best practice for your client and yourself to make a referral to someone more practiced and comfortable with those who self-injure.
The first tenet of an effective therapist/client relationship is to take a non-judgmental approach. Keep in mind that wounds and blood may be everyday occurrences to someone who self-injures. Also keep in mind that it is a very private and intimate activity and your client may never choose to show you their wounds or scars.
Treating self-injury without addressing the underlying causes may be a self-defeating exercise and be setting the person who self-injures up for failure. Therefore, therapists must complete a thorough assessment and build a strong therapeutic alliance as a foundation prior to considering treatment options. Other things to keep in mind are;
- Most people who self-injure are of above average intelligence and should be engaged with a respectful, collaborative approach. They will ferret out any duplicity or condescension pretty quickly
- Self-injury is a powerful coping strategy and one that may be a large part of a person’s life or identity – to change an ego state that has relied on self-injury involves a great deal of work by the client and that work should be respected
- Therapists must understand what role self-injury plays in a person’s life. For example; If the individual uses self-injury to drive away suicidal thoughts or urges, taking that away from them may be a dangerous proposition
- Self-injury can have a strong biochemical addictive quality, so for many people who seek to stop, a therapist should approach it as they would any other addiction
Foundations of Care
The first goal of therapy should be to help the client stabilize their life – this may require short-term medications such as SSRIs as suggested by Favazza. If their self-injury is out of control, the need it is meeting should be explored and alternatives taught and practiced.
Many who self-injure were never taught to self-regulate their emotional states as children, so we often times need to back up the therapeutic bus in order to teach and have them practice these skills before moving forward in therapy.
Breathing, relaxation, and mindfulness can aid a client to regulate their emotions and physical sensations, but care should be taken to tailor the techniques to the individual; For some, mindfulness techniques that require them to “focus-in” can have the opposite affect than intended – by focusing on what they are feeling may increase their anxiety and tension. For these individuals, “focus-out” mindfulness may help them move away from the distressing feelings that they use self-injury to alleviate.
The best practice in a treatment plan for an individual who self-injures would include a team comprised of professionals the client trusts and multimodal approaches (Favazza, 1998);
- The client should have access to non-judgmental and compassionate medical care for their wounds that honours their dignity and autonomy (Dallam, 1997). This may require the therapist to educate medical practitioners involved in their client’s care [The Bill of Rights for Those Who Self Harm is a good place to start]
- Any hospitalization should be brief and reserved for clients who are at-risk for suicide or severe self-injury - (Dallam, 1997) – because hospitals are artificially safe environments and the client will be best served to learn alternative coping strategies in real life situations
- The client should be under the care of a psychiatrist who can monitor any stabilizing medications, their side-effects, and the client's preferences
- Specific therapeutic approaches should be tailored to address the client’s underlying issues [See below]
- Group therapy and support groups are extremely helpful for someone recovering from self-injury. If no such group is available, there are online resources where individuals can be part of a support network, anonymously if they choose [Two such online resources are Self Injury Friends, and Pandora's Project. YouTube has a number of channels by individuals offering help for self-injury recovery as well, Self Harm Support has hundreds of videos]
- The therapist should monitor any suicidal ideation frequently. I would recommend setting up a SUDs scale so that the client can check in each session on how they are feeling. Best practice on this is to have the client detail what each number means – [One individual who uses an SUDs scale states that “5” is her safe zone, for her “5” means; “I don’t want to live, but I’m not going to do anything about it”]
Depending on the underlying contributing factors, a number of therapeutic approaches can be employed;
Borderline Personality Disorder - Dialectical Behaviour Therapy combined with interpersonal group therapy has shown a high efficacy. Therapists who are considering employing DBT should understand that it takes a strong commitment to the process and often the therapist has to be available to their clients outside of normal office hours
Posttraumatic Stress or Complex Posttraumatic Stress – Depending on the ability of the client to tolerate the distress of a “trauma-narrative, Rational-Emotive Therapy or Trauma-Focused Cognitive Behaviour Therapy are two options. Eye Movement Desensitization and Reprocessing is another, however the intensity of “reliving” traumatic events have proven too much for some individuals and have led to an increase in self-injurious behaviour due to the emergence of repressed memories, flashbacks, or nightmares. Let your client be your guide.
Hypnosis and Relaxation Therapies used in conjunction with other therapies have shown solid results in reducing the distress and tension that can trigger self-injury.
In the working stage of treatment, there are a myriad of tools found in Cognitive Behaviour Therapy that can be tailored to fit any client.
My own approach is rooted in Multimodal Therapy – First addressing the seven modalities that make up who we are; Behaviour; Affect; Sensory; Imagery; Cognitions; Interpersonal Relationships; and Drugs & Biology – then being able to draw on any other therapeutic technique that best fits my client. As always, when conducting a comprehensive assessment, I look for the client’s “SNAP” – Strengths, Needs, Abilities, and Preferences. It is their life, their disorder, and their journey toward healing, so I believe that we should build on their strengths, meet their needs, never over-burden their abilities, and always honour their preferences.
I invite comment on this and all the articles in the Self-Injury series, especially from those who self-injure or have recovered from it. I am always willing and eager to learn …