Working with a client who intentionally inflicts physical harm on him or herself, generally presents a challenge for even the most experienced counselor. When chemical addiction is part of the mix, treatment becomes even more complicated. Although many clinicians shy away from working with clients who self-injure, the behavior is not substantially different from substance abuse, in that it acts as a coping strategy designed to alter one's mental state (Walsh, 2005; Conterio & Lader, 1998). Self-injurious behavior constitutes a prevalent problem, afflicting four to five percent of individuals in the United States (Comtois, 2002). This figure appears to be increasing at a rapid rate among young people. In a recent large scale study of college students, nearly one in five were found to have a lifetime history of self-injury (Whitlock, 2006). Therefore, it is highly likely that at some point you will have a client who will present with some form of physically self-
injurious behavior.

Counselors who work with substance abusers are more likely to end up working with a client who also engages in some form of physical self-injury. Self-injurers with a comorbid alcohol disorder have been found to be more impulsive and angry than other self-injury clients (Haw, Houston, Townsend & Hawton, 2001). Haw et al (2001) cite a  study (Magne- Ingvar, 1997) which found  that self-injury clients who drink alcohol excessively are more likely to have attempted suicide than clients who do not abuse alcohol

Despite the challenges, working with the self-injuring client can be rewarding. Karen Conterio and I developed the S.A.F.E. (Self-Abuse Finally Ends) Alternatives Program more than 20 years ago. We are convinced - and time has borne us out - that with a consistent treatment philosophy that places the responsibility of safety on the only person who can truly keep him or herself safe - the client - that people can and do recover. Just as importantly, the counselor can survive the treatment, as well.

It is very difficult for most people to understand the concept of physical injury being helpful in any fashion. Unlike most addictions or addictive behaviors, self-injury is not a behavior to which a healthy person can relate. For example, most people can enjoy a glass of wine, beer or martini. Most of us love to savor the tastes and smells of a good meal. And even those amongst us who have never tried a drug to attain an altered state of consciousness, can likely appreciate that some drugs might have the potential to make a person feel powerful and invincible, whereas others can increase stamina or "mellow us out." We can therefore, have some empathy and appreciation for those who have food or substance-
related addictions. Self-injury, on the other hand, only works for people who are in emotional distress. There is no safe or healthy amount of self-injury. Generally, a healthy person who takes a razor and cuts him or herself to better understand "what all the fuss is about" is not likely to try it again.

Many self-injuring clients identify the act as their "last addiction." While there is some speculation that self-injurious clients are "addicted" to the release of naturally occurring opiates such as beta-endorphins, we at S.A.F.E. Alternatives® reserve our opinion as to whether or not self-injury falls under the rubric of a "true addiction." Basically, we view self-injury as a behavior and not a disease. However, it is often experienced by those who use it habitually as an "addictive-like" solution to help them calm uncomfortable feelings.

Although not the best match for the self-injuring client, we do cautiously believe that they can, with some caveats, utilize 12-step meetings to address their need for readily available support. Many of our clients state that they have felt uncomfortable in 12-step meetings, citing other group members' difficulty relating to self-injury. Even more difficult for many self- injuring clients is learning to not hold onto the "once one always one" self-injuring identity.

This is significantly different from the philosophy of Alcoholics Anonymous (AA), which emphasizes a person's willingness to identify him or herself as an addict as being key to the process of accepting the disease of alcoholism. We suggest that the self-injuring client, identify and focus on the similarities rather than the differences in an effort to get the most out of a 12-step model group.

The philosophy of the S.A.F.E.Alternatives^® program is that self-injury, while acknowledged as a coping strategy, is considered to be unhealthy. Left unaddressed, it can potentially interfere with all aspects of a person's life.  We don't believe that merely eliminating the behavior, however, constitutes a cure.  Instead, we view self-injury as a coping strategy designed to temporarily manage emotional tension. The source of that tension is the focus of our treatment approach.

Denial

As in the treatment of substance abusers, it is often necessary to work through a client's denial system before he or she can actively engage in the treatment process. Self-injurers often believe that their behavior only hurts themselves, and that they should have the right to treat their bodies in any way that they choose. Some believe that self-injury is the only coping strategy that will work for them, and without it, they could die.  

It is important for self-injurers to become cognizant of their urges to injure and realize that the urge is no more than a "clue" that they want to divest themselves of an uncomfortable feeling state. They might be overwhelmed with intense feelings such as anger, sadness and fear, or conversely, they might be so numbed that they are not feeling anything. In the latter, seeing the blood or experiencing any sense of pain serves to reassure them that they are, in fact, alive.

With the help of therapy, self-injurers hopefully will begin to understand that while their injuries can indeed place them in physical danger, it is the inability to recognize, feel and articulate one's emotional states that represents the true danger. Being able to identify, express, and accept the full range of emotions is paramount if the client is ever going to feel comfortable in his or her own skin. 

Goals of treatment

A necessary goal of treatment is to help the client get past the "mask" that he or she often shows to the world, and allow others to see his or her genuine feelings. It is not unusual for clients to state, "If people really knew me, they wouldn't like me" (Lader, 2006).

To help clients reconnect body and mind is a basic goal of treatment. When a person is constantly denying and "numbing" feelings, there often is very little conscious awareness of how events or interactions with others actually affect them.

Self-injuring clients also need help in learning to differentiate a thought from a feeling and a behavior. The English language is replete with a confusing and inaccurate use of words. For example, one might say, "I feel like dancing." Dancing is a behavior and not a feeling. Paying attention to semantics may seem irrelevant, but our goal is to help clients identify their feelings as separate from their thoughts and actions. Using language correctly can help towards this end.

We also focus on helping our clients learn to communicate through words rather than actions. In our inpatient setting, as is the case in many substance abuse programs, we require that our clients sign a No-Harm Contract upon admission. This is not because we believe that 30 days of abstinence constitutes a cure.

Rather, we believe that if our clients aren't "discharging" their emotions through action, they will learn to tolerate uncomfortable feelings while developing the language of emotions. This knowledge gives them the ability to describe their experience to others, which in turn helps them to feel less isolated and misunderstood.

We do not, however, have the same initial expectations of abstinence for new outpatients. Outpatients have limited therapeutic support, especially during the time when it is most often needed ... at night. However, once clients have learned to utilize alternative coping tools, we encourage abstinence so that they along with their counselor can better study the ensuing anxiety.

Clients also are encouraged to challenge their irrational thoughts, which serve to fuel intense emotional states. Clients have often asked whether I wouldn't feel as they did in a similar situation. My general response has been that if I thought the way they did, I would probably feel they same way. For example, if I believed that a breakup with a significant other meant that I was unlovable, flawed, "stupid" and "bad," I would probably experience a sense of self-hate, failure and hopelessness. On the other hand, if I believed that the breakup represented a poor match, I could perhaps mourn the loss, analyze what was good about the relationship and what did not work, and move on from there.

In general, the cognitive therapies, particularly Dialectical Behavior Therapy, developed by Dr. Marsha Linehan and described in detail in her book, Cognitive-Behavioral Treat-ment of Borderline Personality Disorder (1993), have proven helpful with affect management, skills training and compliance with treatment. Walsh (2006), states that "the cognitive elements associated with self-injury fall into two basic categories," the first being "cognitive interpretations of environmental events," and the other "self-generated cognitions."

Walsh further explains that "environmental events are only problematic to an individual if they are interpreted to be aversive, painful, or disorganizing. Self-generated cognitions can come from, long-standing negative beliefs about oneself, internal perfectionist pressures, or myopic solutions.

While we at S.A.F.E. agree that attention to cognition and attribution are very important, we also believe that the source of the pain needs to be explored (Conterio & Lader, 1998), and that cognitive therapy alone may not be adequate towards this end. While not every self-injurer has experienced a traumatic childhood, no one has a perfect upbringing either.

A normal function of adolescence is to mourn the loss of the ideal childhood and see ourselves, as well as our parents, in a more realistic and less omnipotent light. Self-injurers might have a more difficult time with this process than some. In order to address and modify long standing core beliefs about oneself and one's experience with the world, a more dynamic and relational therapeutic approach is necessary.

It is important to note that if a client has a history that is positive for trauma, the therapist should ensure that skills to maintain a sense of physical and emotional safety are acquired and practiced, prior to delving into emotionally charged historical details. This measure can help to prevent the client from turning to unhealthy coping strategies when emotional memories present themselves (Courtois, 2004).

Treatment considerations

Control Issues. Being in control is frequently a central issue for people who self-injure. The act of self-injury is, in itself, most often an attempt to stay in control of one's emotions which are often experienced as spiraling out of control and dangerous. Self-injurers struggle to remain in control by attempting to divest themselves of uncomfortable emotions. Self-injury does generally work towards this end, creating a quick and effective sense of calm. Although those that self-injure might feel better temporarily, they are not better. They have only served to put a band-aid on a festering wound. Without identifying and dealing with the source of the emotional upheaval, the emotional roller coaster is doomed to repeat itself over and over again.  

Avoiding emotional discomfort plays itself out within the therapeutic relationship as well. Clients may refuse to do assignments and avoid uncomfortable topics. Intimidating behaviors, such as responding to the counselor's requests or inquiries with rage, intense anxiety or threats of self-injury and suicide are examples of an avoidance response. Counselors may be unsettled enough to back off from uncomfortable topics as well, effectively colluding with the client's defenses. Instead, counselors would be advised to identify and point out these defensive behaviors when they occur. At the same time, clients can be encouraged to move out of their comfort zone by facing rather than avoiding fears. I am not suggesting that counselors "force' clients to deal with emotionally charged issues. Rather, they can help their clients identify obstacles that prevent them from looking at feared events, beliefs and feelings.

Maintaining Boundaries. Some self-injurers experience difficulty reading interpersonal relationships correctly. Their desire to stave off loneliness and fears of abandonment can create some interpersonal quandaries. They may want to get close too quickly, asking a number of personal questions in an effort to feel "special." To the counselor, these inquiries might come off as "pushy," forcing a relationship past appropriate boundaries or defending against these advances by pushing the client further away. On the other hand, these requests can be seductive, pulling the counselor deeper into a relationship to assuage his or her own wish to be needed and special.

It is not generally helpful to gratify these wishes, as clients need to understand limits and be aware of interpersonal cues. Rather than act in response to these therapeutic quandaries, the counselor should consider bringing them into the therapeutic session to be explored and understood. For example, if a client asks personal questions about whether you have children it would be more productive to respond with an open ended question such as, "Why would that be important to you?" In my experience, underlying this particular line of questioning is the client's fantasy about what it would be like to have you as a parent. 

In an attempt to reassure clients, or perhaps reassure themselves, counselors often make promises they cannot keep. Such promises include a pledge to keep the client safe or statements that lead the client to believe that the counselor will never leave them or be available at all times. Both of these examples are doomed to failure.

No one can truly keep a self-injurer safe except for the client him or herself and no one can promise another person that he or she will be available forever or at all times. Death, illness, marriage, pregnancy, a move, etc. - all of these things can change our availability, either temporarily or permanently. Of course, hospitalization will be warranted if the client states that he or she is unable to keep from killing him or herself, either accidentally or on purpose.

In addition, it is also advantageous for the client to experience the limitations and disappointments that are inherent to the nature of the therapeutic relationship. Many clients who self injure seek therapy in the conscious or unconscious hope that a counselor will provide a parental figure in their lives. Expecting clients to arrive and leave sessions on time, interpreting and placing limits on excessive or late night phone calls, expecting clients to pay their therapy bills in a timely manner, etc. - all of these serve as an unwelcome reminder that the client is just that, a "client" and not a friend or family member. Despite the discomfort for both the client and the counselor, adhering to the  limitations rather than gratifying the client's wish to be "special" or more than a "client" are the only way to help the client mourn his or her losses and find his or her own strengths, rather than looking to others to be taken care of.

Conclusions

Self-injury, once considered an obscure psychiatric symptom, is now a mainstream problem. Therefore, it is imperative that counselors, especially those already working with clients who engage in other forms of impulsive and self-destructive behavior, be prepared to identify and understand self-injury.

Many counselors believe that self-injurious behavior connotes a dangerous and difficult client. While this can be true, recognizing self-injury as an effort to maintain emotional equilibrium can help a counselor maintain empathy, bringing the behavior into our frame of reference.

It is my experience that with the proper tools as well as an understanding of client and counselor limits, the therapeutic experience can be successful for both the client and the counselor.

That said, not all therapists feel prepared to, or care to work with this self-injuring population. Knowing oneself, one's limits, and when to seek supervision and when to refer out is the hallmark of a good therapist.

References

Comtois, K. (2002). A review of interventions to reduce the prevalence of parasuicide. Psychiatric Services. 53:1138-1144.

Conterio & Lader (1998). Bodily harm: The breakthrough healing program for the self-injurer. N.Y.: Hyperion.

Courtois, C.A (2004) Complex trauma, complex reactions: assessment and treatment. Psychotherapy: Theory, reseach, practice, training. 41(4) 412-425

Haw, C., Houston, K. Townsend, E. & Hawton, K.(2001). Deliberate self-harm patients with alcohol disorders: Characteristics, treatment and outcome. Crisis:The Journal of Crisis Intervention and Suicide Prevention. 22(3): 93-101

Lader, W. (2006). A look at body focused behaviors. Paradigm Magazine. Winter, 2006.

Linehan, M. (1993). Cognitive-Behavioral Treatment of Borderlines Personality Disorder. N.Y.: The Guilford Press.

Walsh, B. (2006) Treating Self-Injury: A Practical Guide. N.Y.: The Guilford Press.

Whitlock, J., Eckenrode,J., Silverman, D. (2006). Self Injurious Behaviors in a College Population. Pediatrics 117(6); 1939-1948.   

One person has commented on this article.

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Trish Wright, Unregistered

I am getting a self-harming client in my substance abuse group counselling this week and this was a great way to focus myself on some best practices.

 Posted 2007-11-07 11:35:02

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