Self-Injury - Treatment Options

“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)

The Therapist

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.

Basic Approach

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”] 

Specific Therapy

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 …

Next up: Self-Injury – Tips from the Experts

Previous articles in the Self-Injury series;

• Introduction
• Mythbusting
• In History & Nature
• Spectrum of Function
• Biochemistry
• Addiction
• Contributing Factors

Aaron D. McClelland, RPCc – www.interiorcounselling.com/aaron/

The Bill of Rights for Those who Self-Harm

The following was created by Deb Martinson and published on her website "Secret Shame".  Sadly, each of the following rights were established because of mistreatment of individuals who self-injure by medical and mental health professionals. ~ ADMcC

1. The right to caring, humane medical treatment.
   Self-injurers should receive the same level and quality of care that a person presenting with an identical but accidental injury would receive. Procedures should be done as gently as they would be for others. If stitches are required, local anesthesia should be used. Treatment of accidental injury and self-inflicted injury should be identical.
2. The right to participate fully in decisions about emergency psychiatric treatment (so long as no one's life is in immediate danger).
   When a person presents at the emergency room with a self-inflicted injury, his or her opinion about the need for a psychological assessment should be considered. If the person is not in obvious distress and is not suicidal, he or she should not be subjected to an arduous psych evaluation. Doctors should be trained to assess suicidality/homicidality and should realize that although referral for outpatient follow-up may be advisable, hospitalization for self-injurious behavior alone is rarely warranted.
3. The right to body privacy.
   Visual examinations to determine the extent and frequency of self-inflicted injury should be performed only when absolutely necessary and done in a way that maintains the patient's dignity. Many who SI have been abused; the humiliation of a strip-search is likely to increase the amount and intensity of future self-injury while making the person subject to the searches look for better ways to hide the marks.
4. The right to have the feelings behind the SI validated.
   Self-injury doesn't occur in a vacuum. The person who self-injures usually does so in response to distressing feelings, and those feelings should be recognized and validated. Although the care provider might not understand why a particular situation is extremely upsetting, she or he can at least understand that it is distressing and respect the self-injurer's right to be upset about it.
5. The right to disclose to whom they choose only what they choose.
   No care provider should disclose to others that injuries are self-inflicted without obtaining the permission of the person involved. Exceptions can be made in the case of team-based hospital treatment or other medical care providers when the information that the injuries were self-inflicted is essential knowledge for proper medical care. Patients should be notified when others are told about their SI and as always, gossiping about any patient is unprofessional.
6. The right to choose what coping mechanisms they will use.
   No person should be forced to choose between self-injury and treatment. Outpatient therapists should never demand that clients sign a no-harm contract; instead, client and provider should develop a plan for dealing with self-injurious impulses and acts during the treatment. No client should feel they must lie about SI or be kicked out of outpatient therapy. Exceptions to this may be made in hospital or ER treatment, when a contract may be required by hospital legal policies.
7. The right to have care providers who do not allow their feelings about SI to distort the therapy.
   Those who work with clients who self-injure should keep their own fear, revulsion, anger, and anxiety out of the therapeutic setting. This is crucial for basic medical care of self-inflicted wounds but holds for therapists as well. A person who is struggling with self-injury has enough baggage without taking on the prejudices and biases of their care providers.
8. The right to have the role SI has played as a coping mechanism validated.
   No one should be shamed, admonished, or chastised for having self-injured. Self-injury works as a coping mechanism, sometimes for people who have no other way to cope. They may use SI as a last-ditch effort to avoid suicide. The self-injurer should be taught to honor the positive things that self-injury has done for him/her as well as to recognize that the negatives of SI far outweigh those positives and that it is possible to learn methods of coping that aren't as destructive and life-interfering.
9. The right not to be automatically considered a dangerous person simply because of self-inflicted injury.
   No one should be put in restraints or locked in a treatment room in an emergency room solely because his or her injuries are self-inflicted. No one should ever be involuntarily committed simply because of SI; physicians should make the decision to commit based on the presence of psychosis, suicidality, or homicidality.
10. The right to have self-injury regarded as an attempt to communicate, not manipulate.
    Most people who hurt themselves are trying to express things they can say in no other way. Although sometimes these attempts to communicate seem manipulative, treating them as manipulation only makes the situation worse. Providers should respect the communicative function of SI and assume it is not manipulative behavior until there is clear evidence to the contrary.

© 1998-2001 Deb Martinson. Reprint permission granted with proper credit to author.

Self-Injury – Contributing Factors

Deb Martinson, publisher of the website “Secret Shame” asserts; “Self-injury does not happen in a vacuum”. Within each person who self-injures there is an underlying cause and a need that self-injury fulfills.

Disorders

There are a number of disorders that are sometimes associated with self-injury.  The following list is not intended to suggest a diagnosis or even a pressing need for a diagnosis to be in place before offering help to someone who self-injures.

Borderline Personality Disorder – is typically characterized by a long-standing pattern of unstable and intense relationships, dramatic mood swings, unstable [or absent] self-image, feelings of emptiness, intense anger, suicidal ideation or threats, self-injury, paranoia or dissociation during times of stress, and a fear of abandonment or of being alone.  Individuals struggle with emotion regulation and may lead lives in which they move from crisis to crisis.

                      

Eating Disorders – such as anorexia and bulimia can be present with self-injurious behaviour, and are considered by some to be a form of self-harm.  Anorexia nervosa is characterized as a person restricting their intake of nutritional foods and liquids in order to control their weight.  This is usually combined with a distorted body image as many see themselves as overweight when in fact they are not. In some cases the sufferer feels that if they eat or even drink water, they will become larger and this goes against their need to feel smaller so as to not be noticed.

Bulimia nervosa is characterized by sufferers ingesting large amounts of food in a short period of time - “bingeing”, then ridding the body of that food by vomiting - “purging”.

Both of these conditions are often accompanied by self-hatred and shame and many self-injure to punish themselves for their behaviour.

Dissociative Disorders – fall on a continuum of disorders that cause the sufferer to experience periods of dissociation or dpersonalization from their environment or even their sense of self.  These can range from states of “numbness” when a person feels nothing emotionally [and sometimes nothing physically], all the way to Dissociative Identity Disorder which was formally known as “multiple personality disorder”.

People who suffer from dissociative disorders have typically suffered some form of trauma or other developmental insult in early childhood.  Self-injury can be a way for the individual to “bring himself back” to reality when they are in a dissociative state. Many describe the physical pain and/or the sight of blood as evidence that they are still alive and allow them to reconnect with their body.

Post Traumatic Stress – is an anxiety disorder that occurs as a result of exposure to a traumatic incident or ongoing circumstance that the person felt was life-threatening or that resulted in physical or emotional harm.  This can range from physical or sexual abuse or assault to witnessing extreme violence such as war or family violence or strong emotional distress brought on by other violent actions.  People suffering from post traumatic stress typically experience nightmares, flashbacks, difficulty with mood regulation, an exaggerated startle response, feeling detached from life, amnesia, sleep disturbances, emotional numbness, physical symptoms of anxiety, and a lack of interest in everyday life. Using the physical pain of self-injury as a coping strategy can distract them from flashbacks or alleviate the numbness they feel and pull them back into reality when they dissociate.

Bipolar Disorders – are mood disorders that sometimes sees the person alternate between manic or hypo-manic states and depressive moods.  A manic episode is characterized by a person displaying a sudden change in their behaviour that typically manifest as grandiosity, decreased need for sleep, increased talking, and at-risk behaviour, [excessive spending, unsafe sex. etc].  A hypo-manic episode is similar but the symptoms are less severe. 

A depressed episode is manifest as a period of extreme sadness, loss of interest or pleasure in activities they normally enjoy, suicidal thoughts, decreased ability to concentrate or reason, sleep and appetite disturbances and a change in activity level.  Self-injury in bipolar patients is typically an attempt to regulate their mood, however; self-injury that occurs during a manic episode tends to be more dangerous and life threatening.  Those who suffer from bipolar disorder also have a significantly higher rate of suicide attempts and completed suicides.

Major Depressive Disorder – or ‘clinical depression’, ‘major depression’, ‘unipolar depression’ etc, is characterized by an all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities. Major depressive disorder is a disabling condition that adversely affects a person's family, work, or school life, sleep patterns, eating habits, and general health.  People suffering from MDD have a high rate of suicide attempts and completed suicides.  Treatment typically involves a combination of antidepressant medication and counseling.  Because MDD presents differently in each person experiencing it, the reasons for self-injury varies from person to person and could be due to feelings of hopelessness, self-punishment, or relief from constant emotional pain.

Perfectionist Thinking – is a cognitive style in which the person seeks perfection in their performance or appearance to the extent that it interferes with normal functioning.  Though many of us strive to do our best, those who engage in pathological perfectionism are relentless in pursuing goals that are unrealistic in one or more areas of their life.  Once the person falls short of their unrealistic goals they feel a crushing disappointment in themselves, often having a "melt down" and feeling deep depression and/or strong self-loathing.  In those who engage in pathological perfectionism, self-injury can be a method of self-punishment in response to perceived failure, or emotional regulation.

Many people in our society may display some of the symptoms of the above disorders or of perfectionist thinking without it impacting their lives to a great extent.  As with any mood or anxiety disregulation to determine if there is an underlying problem, we use three measurements;

Frequency: How often does the mood or behaviour present?

Duration: How long does the mood or behaviour persist?

Intensity: How intense is the mood or behaviour?

If you find that someone is presenting moods or behaviours that are negatively impacting their life through frequency, duration, or intensity, they need to see a medical or mental health professional to explore the causes and possible treatment options.

To be an effective support person for someone who self-injures, we must believe there is a cause for their self-injury that is beyond their control, and beyond OUR control. Just like we would not grow angry or frustrated with someone who could not walk because their leg was broken, we must accept that self-injury is a coping strategy for an underlying disorder or chemical/hormonal imbalance. When supporting or working with a person who self-injures, we need to first change the way we think, beginning with believing that it is NOT their fault.

Next up: Self-Injury – Treatment Options

Previous articles in the Self-Injury series;

• Introduction
• Mythbusting
• In History & Nature
• Spectrum of Function
• Biochemistry
• Addiction

Aaron D. McClelland, RPCc – www.interiorcounselling.com/aaron/

Self-Injury – Addiction: Process or Biochemical?

Psychiatrist Armando Favazza was the first to suggest that self-injury can become addictive in his book Bodies Under Seige in 1987.  Favazza stated that somewhere between the twentieth and thirtieth cut self-injury takes on an addictive quality.

Many practitioners still hold to the old belief that this represents a process addiction – That is; If the act of self-injury is repeated often enough it becomes ritualized and the ritual itself becomes a comfort to the self-injuring person whether it is triggered by other stimulus or not.  There is anecdotal evidence supporting this idea from comments from some who self-injure that stopping the practice brought up feelings of grief and loss, and that self-injury was thought of as “an old friend” who was always there when needed.

However, more recent research is indicating that there is an evident biochemical relationship between self-injury and the feelings of relief it provides many people.

Robert Grossman and Larry Siever postulated an “addiction theory” in their 2001 research that suggests “self-injurious acts may solicit involvement of the endogenous opioid system” [EOS].  The EOS regulates both pain perception and the release of endogenous endorphins - the body’s natural “heroin”.

Many people who self-injure describe that after self-injuring they feel “at peace”, “calm”, “happy”, “like I’m floating on a cloud”.  In my own interaction with a number of people who self-injure, certain similarities of experience arise; Leading up to self-injury they often feel a building tension or anxiety, troublesome thoughts or urges or feelings, all of which can reach almost overwhelming levels.  As they begin to self-injure, they feel the tension rise to a peak and suddenly release, “like a balloon popping” as Favazza stated in a National Public Radio radio interview.  Often they will describe their tensions or anxiety flowing out of their body along with the blood they shed.

One statement I have heard variations of from a number of those who self-injure is; “You will never know how good it feels.”  This in itself speaks to the blissful physical feelings brought on after self-injury.

On the YouTube channel “SelfHarmSupport” where panel members comprised of those who are in recovery [or have recovered] from self-injury answer questions posed by viewers, one past panel member stated; “It became an addiction and I had to do it more and more often to get the same results.”  He is not alone in this, as evidenced by the increased frequency, severity, and number of injuries many who self-injure complete to maintain the levels of relief they seek.

But it is an example put forth by Dr. Bruce Perry of the Child Trauma Academy in Houston, Texas in his 2006 book; The Boy Who Was Raised As a Dog: And Other Stories from a Child Psychiatrist's Notebook, that illustrates a strong argument in favour of the endorphin addiction theory;

While working in a Houston hospital as a resident psychiatrist, Perry was called to the Emergency Room to help calm the mother of a teenaged girl who had been admitted while the attending physicians attempted to diagnose and treat her daughter.

As Perry spoke to the mother, asking her questions about her daughter, he noticed that there were gaps in the life history she was providing.  When Perry questioned her about those gaps, the mother revealed that one of her ex-boyfriends who had lived with them, had sexually abused the girl for an extended period of time.  The man would force himself on the daughter only when he had been drinking while the mother was at work.  In order to exert some control over the situation, the daughter began making him drinks so that he would “get it over with”, allowing her to get on with her daily activities.  Once mom discovered what was going on, the boyfriend was sent packing but the girl had never received counselling for the sexual abuse

When Perry asked if anything had happened in the previous 48 hours that might have triggered memories of that time, the mother admitted that the ex-boyfriend had called their home the previous night and the daughter had answered the phone.  The man told the girl that he was “coming to see her.”

At this point, Perry’s focus shifted from the mother to the daughter and he read her chart; The girl was 15 years old and had been found unconscious on the floor of a school bathroom.  Her heart rate was dangerously low, hovering under 50 beats per minute and had stopped three times while the Emergency Room Doctors struggled to stabilize her.  Her tox-screen showed no narcotics in her system and Doctors were mystified as to the cause of her unresponsiveness and alarmingly low heart and respiration rates.

Perry went on to examine the girl and found fresh cuts on her arms, indicating she had recently self-injured.  He suspected that this is what she’d been doing in the school bathroom in response to the distress she was feeling after hearing her mom’s ex-boyfriend’s threat to visit her the night before.

A theory began to emerge for Perry that the girl had overdosed on the rush of her own endorphins brought on by the act of self-injury.  But when he suggested as much to the attending physicians, they replied that it was impossible and refused to consider it.  Perry persevered and suggested giving the unconscious girl an injection of naltrexone which is used to block opioids during a heroin overdose, stating that it would do no harm even if he was wrong because naltrexone is a relatively harmless agent.

Humouring Perry, the attending physicians did so, and within 90 seconds after the injection of naltrexone, the girl’s stats returned to normal and she regained consciousness.  She had indeed suffered an overdose of her own endorphins.

The good news is that the girl became a patient of Perry’s and went on to recover both from the lingering affects of the sexual abuse she’d experienced, and from self-injury.  And her experience is a strong argument supporting the biochemical nature of self-injury.

In the next article, we will be looking at other contributing factors to self-injury such as anxiety, mood, and personality disorders.

Next up: Self-Injury – Contributing Factors

Previous articles in the Self-Injury series;

• Introduction
• Mythbusting
• In History & Nature
• Spectrum of Function
• Biochemistry

Aaron D. McClelland, RPCc – www.interiorcounselling.com/aaron/