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The Treatment of Adolescent Female Self-Injury In Residential Treatment Centers
Abstract
At this time, based on extensive personal discussions and clinical training with researchers in the field of self-injury, there appears to be a lack of resources available which specifically address the psychological and psychosocial needs of adolescent girls who self-injure. In the absence of long-term studies, educational and experiential competency and conclusive statistical data, outcomes of treatment models are limited. As a result, clients who present with a cluster of symptoms may not have access to specialized treatment modalities that address the bio-psycho-social underpinnings of self-injury. This paper will discuss the effectiveness of developing and implementing a specialized model of treatment for adolescent female self-injurers in residential treatment.
Introduction
A mother’s desperate search for a program that could address her daughter’s self-injury marked the beginning of an eleven-month investigation looking for answers and alternatives for treating self-injurers in Residential Treatment Centers. This mothers search prompted a meeting with the agency’s clinical directors and the adolescent units clinicians to address, as an agency, how we could identify literature and leaders in the field who were treating adolescent self-injurers. The RTC milieu has already provided for safety, containment, adjunctive therapeutic resources and family involvement. Therefore, the Self-Injury Treatment Program was initially confronted with five tasks, they were:
1. The agency’s identification of need
2. The creation of a safe and containing environment for the program to be held
3. To collaborate with experts from around the country to insure the sharing of current information
4. To develop a structured program that encompasses Psychoeduation, specialized topic groups, adjunctive therapeutic modalities and creative arts therapies
5. To educate all agency divisions, which included: direct care staff, adjunctive therapeutic resource staff, school personnel, behavioral specialist teams, health center nurses, and the administration
The goals were designed to consider a specialized model of care for children who self-injure while in out-of-home care ultimately fostering strong, healthy and safe relationships. These goals were developed based on the belief that health, safety and sustained abstinence from self-injurious behaviors don’t occur in the absence of relationships.
Historical perspective
Self-injury is best described as the intentional harm of ones own body without conscious suicidal intent. Most types of self-harm involve the cutting of one’s own flesh; usually the arms, hands or legs, skin burning, interfering with the healing of wounds, excessive nail biting or the pulling out of one’s own hair. Self-injury affects roughly 1% of the general population, which includes adolescents and adults with a prevalence ranging from approximately 400 to 1,400 per 100,000 (Favazza and Rosenthal, 1993).
Researchers suggest that these figures are greatly underestimated and there does not seem to be any current data specifically reflecting the number of adolescent females who self-injure. It was found during the development of the program in our RTC that more than thirty-six percent (11/30) of the adolescent females in care suffered from and engaged in superficial or moderate self-injury. Favazza (1996) separates self-injury into three distinct categories; major self-mutilation, stereotypical self-mutilation, and superficial or moderate self-mutilation. It is the subdivision of superficial or moderate self-mutilation, which is the focus of this research.
The primary characteristics of superficial or moderate self-injury are as follows: intentional cutting, burning, scratching, interfering with wound healing, hitting one’s body and excessive nail biting behaviors. In this study milieu, the behaviors listed above are the most commonly seen. The most current world-wide statistical results from Internet polling are (16,714 votes total): cutting (11,357; 68%), skin picking and scratching (2,293; 14%), burning (836; 5%), hitting self and/or object (707; 4%), wound interference (361; 2%), biting (259; 2%), head banging (207; 1%), bone breaking (83; 0%), and other (556; 3%).
Etiology
The most common question regarding self-injury is "why." Why would children be driven to act upon themselves in a way that causes physical trauma to the body? To forsake oneself to the point of self-injury is the result of many different factors. Levenkron (1998) suggests self-injury is a way of "being in control", a way to master an internal sense of helplessness and anger. For these children, self-injury becomes their coping mechanism in stressful situations. An example of this is if a child is abused they feel powerless in the abuse. When this child becomes older they will often inflict pain upon themselves when in a stressful situation.
From a psychoanalytic perspective self-injury is seen as a defense mechanism masking or preventing repressed and or split off parts of the self or object from entering consciousness. We sometimes deflect psychological pain and distress into pain that seems understandable and controllable, like that of self-injury. Subsequently, the self-injurer injures to distract or override repressed feelings associated with unpleasant events from the past. Such a distraction keeps the individual feeling safe and in control.
A third idea is that people who were abused as children either by verbal, sexual or physical means, often times received the message that they are no good, and need to be punished. If, personal devaluation is followed by physical or sexual abuse, when this child grows up they may recapitulate the traumatic experiences in current relationships. This is done when a person is experiencing real or imagined devaluing and inflicts injury to control and fulfill the anticipation of punishment.
Self-injurers who are responding to past abuse have powerful negative messages running in their head, which reinforces their thoughts and feelings of inferiority, badness, and their need to be punished. A cycle that represents this thinking is, "I am bad, because I am bad I am unlovable, because I am unlovable, I am bad."
Louise Kaplan writes in Feminine Perversions (1991) that the self-injurer has learned that "action brings comfort," while "waiting long enough to think or speak only brings more tension and more disorganization." Lader and Conterio wrote in Bodily Harm that the use of the self-injury behavior is done to "master the traumatic experiences. Self-injury permits control and predictability of the invasion of boundaries." This cycle of recapitulation is seen as unconscious to the self-injurer and through the development of a therapeutic relationship dependency needs surface, and if tolerated lead to the amelioration of the cycle.
Levenkron (1998) adds, "self-injurers create pain as a medication to soothe their emotional state." The self-injurer will injure him or herself, and when this occurs, the body will release hormones called endorphins. These are released to "fight anxiety, agitation, and depression" (Levenkron, 1998). These hormones have been described as "the bodies own narcotics" (Levenkron, 1998), which causes a calming effect. When a self-injurer feels stress, self-injuring behaviors release endorphins causing a temporary calming effect--thereby establishing self-injury as a mechanism for relief. This makes self-injury a quick way to relieve unwanted stress, tension or emotional pain. Due to the physiological effects that are potentially created through the act of self-injury, the amelioration of the behavior is difficult.
Just as it's suspected that the way the brain uses serotonin may play a role in depression, so scientists think that problems in the serotonin system may predispose some people to self-injury by making them tend to be more aggressive and impulsive than others. This tendency toward increased impulsive aggression, combined with a belief that their feelings are bad or wrong, can lead to the aggression being turned on the self. Once this happens, the self-injurer learns that harming behaviors reduce her level of distress, and the cycle repeats. The act of self-harm almost immediately brings her psychophysiological tension and arousal states back to a bearable baseline level.
In other words, the self-injurer feels a strong uncomfortable emotion, does not have alternative coping skills to handle it, and based on prior experiences with self-injury come to choose hurting themselves, as a way of gaining instant relief. They may still feel bad, but without the panic and intense fear.
At Vista Del Mar a significant percentage of adolescent girls who self-injure reported a sense of chronic invalidation, described as being disregarded, disrespected, ignored and gone unnoticed. The fact of the experience of invalidation accounts for a large number of self-injurers who report no physical or sexual abuse in their past. These girls failed to learn appropriate ways of expressing emotions and may have learned in stead that emotions are bad and to be avoided.
Lader and Conterio (1998) wrote, "Since anything less than a dramatic gesture goes ignored, the patient feels that both she and her anguish are invisible, so her internal pain must rise to the skin’s surface in order to be seen." This kind of girl may also be actively seeking to horrify and or disgust people with her behavior, since negative attention may seem to her to be better than none at all.
Defining the behaviors characteristic of individuals who suffer from alienation, mistrust, loneliness, self-hatred, hopelessness, and an impoverishment of expressive language for their emotional pain, permits us to see them as persons seeking relief from these feelings by the use of physical pain. The behaviors associated with self-injury become more understandable to the injurer as well as the helper if the behaviors are viewed in the context in which they live.
Setting
The setting for this study was at Vista Del Mar Child and Family Services, a Residential Treatment Center in Los Angeles, California. The adolescent girls unit can care for up to thirty girls, ages 12 through 17, with an average stay being 14 months. The girls are placed and funded by the Department of Mental Health, The Department of Children and Family Services, The Department of Probation, or privately by a parent or legal guardian.
Demographics/ Diagnostic Characteristics
The fifteen adolescent residents who participated in the program over a period of 11 months were all female. Their average age was 14.5 years. 13 were Caucasian and 2 were Latina. Their most common Axis 1 DSM IV diagnoses were Bipolar Disorder NOS (7 residents) and Depressive Disorder NOS (5 residents). 5 residents fulfilled the criteria for Borderline Personality Disorder and 3 met criteria for Personality Disorder NOS.
All residents who participated in the Self Injury Program had at least two previous hospitalizations for self-injury, suicidal ideation or suicidal attempt.
Study
A twenty-two week study at Vista Del Mar Child and Family Services examined the development, implementation, and clinical efficacy in the treatment of adolescent self-injury while in residential treatment. Thirty adolescent girls within the RTC cottage milieu were interviewed for group development. Over the course of eleven months literature and leaders in the field were found and consulted with, resulting in the development of a comprehensive treatment program. A pre- and post-test questionnaire was used to determine levels of cognitive understanding about self-injury at day 1 and day 45. The beginning goals for the group were:
1. To identify our self-injuring population and welcome them to the group process
2. To stimulate cognitive development within the adolescent self-injury population
3. To encourage parental involvement through Psychoeduation, peer support and multi-family therapeutic services
4. To see a reduction of self-injurious behaviors within the adolescent female residential population
The Self-Injury Screening Instrument created by this author was used to determine clinical indication, desire and motivation to be in the group. The criterion for group inclusion was: the self-identification of SI as a problem, willingness to participate through the duration of the group, and an understanding that the group is voluntary. A RTC demographic survey was used to identify self-injury awareness, family dynamics and potential responsiveness to group therapy. The findings of the group are explored in the context of group development, cognitive development, peer relationship building and family system dynamics and the impact on treatment.
Over a period of eleven months, a structured treatment model was developed to serve the needs of our adolescent female self-injury population. Fifteen adolescent girls have participated in the treatment program. The critical issues of self-injury were examined within the group specifically to increase cognitive awareness, the consequences of isolation, the severity of invalidation in the home, sexual, physical and or emotional trauma, body image, sexuality, relationship with food and peer and family relationship dynamics.
It was hoped that the group would form a collective consciousness and the consideration of alternative coping mechanisms with an emphasis on relationship building and the creating and maintaining of safe environments. The RTC has provided a unique opportunity for self-injurers and there families to receive intensive direct care services from a multidisciplinary team concerned with and responding to the challenging nature of treating self-injury.
Program Philosophy
The Vista Del Mar Self-Injury Treatment Programs philosophy understands that, although self-injury may temporarily alleviate unwanted or undesired thoughts and or feelings, self-injurious behavior happens in the absence of relationships with people and, as a coping strategy interferes with intimacy within relationships, educational successes, creativity and a person’s health and wellness.
Self-injury is respectfully seen as a matter of choice, although first identified by the injurer as a needed adjunct to emotional stability. Self-injury is not seen as an addiction, because the individual is not viewed as powerless, rather, it is addiction-like, in that people engage in the repetitive or compulsive behaviors despite the consequences. It is seen as a self re-enforcing repetition compulsion.
The long-term goal of this treatment approach is to create a master list of creative and relationally based alternatives that the self-injurer can utilize when the urge to act upon her/himself arises. It is important to note that adolescents do stop injuring; they are girls in need of consistent, relationship-oriented support.
This program is strength-based and respects the individual underneath the behavior promoting their ideas, creativity and choices. It is not an authoritarian or "parental" model; there are no "musts." The program does not believe that the helper can or should take all the responsibility for keeping the self-injurer safe. The responsibility resides with the person making choices, the adolescent self-injurer. Ultimately, the self-injurer must be empowered to learn to keep herself safe. In order to get well, the helping relationship is employed to empower, not control the behaviors or creativity of the self-injurer.
The program creates an opportunity to form relationships that encompass feelings of safety, trust, empowerment and value. It is a place where verbal communication is encouraged and supported; the group is encourages self-injuring young women to build healthy attachments.
This program does not endorse infantilizing or restrictive methods of behavior control; behavior control is often times more about the helper than the injurer. This philosophy actively frustrates the conflicting need for dependence by encouraging it, which ideally leads to trust, healthy attachments, and independence.
Another aspect of the program involves the reliance on verbal communication, as the primary means for managing thoughts and feelings. Self-injurers have often learned that feelings are "dealt with," through physical or verbal action of some kind. The treatment assumption is that being in relationship with peers and other supporters along with coping skill development the self-injurer can delay the impulse to injure. Creating an opportunity to welcome in alternatives, the creation of relationships, happiness, health and wellness.
Model of Specialized Care
The Self-Injury Treatment Program was developed to provide therapeutic and milieu therapies to help the self-injuring female through a healing journey. To do this, topic or focus groups were created to address the specific clinical issues that affect the adolescent self-injury population. The Self-Injury Treatment Program meets for 45 day’s, six times per week for a total of six hours. Adjunctive support services, family therapy needs, after-care, and extension of the original time is assessed and collaboratively planned throughout the program. The groups are broken down as follows:
Therapeutic Communications Group with the emphasis on breaking down defenses and forming relationships. Learning to talk and verbally express thoughts and feelings.
Trauma Group with the emphasis on reclaiming split off parts of self, providing an opportunity to be in relationship and to process losses.
Safe Group with the emphasis on developing strategies for keeping oneself safe, find healthier coping strategies, learn about choices and be in relationship.
Wrap-up Goals Group with the emphasis on developing goals for each day.
Focus Group with the emphasis on a particular SI related topic for the group to share insights, thoughts and feelings.
Health Issues Group with the emphasis on discussing health issues related to self-injury.
Weekend Planning Group with the emphasis on creating and maintaining plans for family and friend time during weekend passes. This group helps its members by sharing thoughts and feelings about disclosure, how to talk to parents and other family members and facilitates a sense of confidence and self-respect while in relationship with non self-injuring people.
Creative Writing Group with the emphasis on learning to verbalize internal thoughts and feelings to facilitate growth, relationship and learning to identify and value oneself and others correctly.
Grief and Loss Group with the emphasis on learning that the surrendering of SI behaviors creates a loss situation, which necessitates appropriate grieving.
Social Skills Group with the emphasis on learning to decrease isolation and shame by being in relationship with peer group and through the identification and practice of identifying needs.
Art Therapy Group with the emphasis on utilizing alternative creative arts therapies to increase and enhance cognitive improvements being made. This group also allows for quietness as the process of doing art is often times experienced as peaceful and allows for non-verbal communication and creation.
Along with the topic groups other therapeutic programs have been developed to compliment each adolescents need to be in healing relationships with her peer group, staff and family. A multi family group was developed to serve three functions:
1. To educate family members about self-injury
2. To enlist the families help and support in creating healthy relationships with their child
3. For the child to see that they are not the only members of their family in need of support, education and the opportunity to learn more effective way’s to communicate and be supportive
Of the limited resources available to self-injuring adolescents and her family, one thing seems true; they are a difficult population to treat. As stated previously, self-injurers do stop inflicting harm upon themselves. Often times the question is asked whether self-injurers can be cured. For this model of treatment the word cure is replace with the phrase "behavior cessation."
Many self-injuring residents at Vista Del Mar have come to residential treatment with numerous prior therapists, years of hospitalizations, and have made minimal progress. This writer has found that when the self-injuring adolescent has learned to cognitively identify and tolerate her feelings and verbally communicates in an age-appropriate manner, that child does not engage in self-injurious behaviors. The underlying assumption is that when the behavior ceases and the underlying issues surface, a whole new way of being in the world evolves. It is at this point that the healing self-injurer utilizes the relationships formed in the program and relies on those relationships instead of self-injurious behavior.
It is important to note that in the beginning of treatment the group participants did not express an understanding or find value in human relationships. However, at the end of the forty-five days of the program, the relationships formed in the group became the most used alternative to self-injuring.
The Vista Del Mar Self-Injury Program is not based on the addiction model of treatment. An example is the Twelve-Step Program, which has basic tenants that must be adhered to in order to maintain the identity of sober. The identification of powerlessness as identified in the “first step”, is thought to be the wrong message for a self-injuring adolescent. The idea of acceptance further promotes the belief that the behaviors an addict is trying to control are a permanent part of their identity.
The Self-Injury Treatment program has seen people give up the behavior as well as the identity of "cutter." The program values the importance and impact the Twelve-Step communities have on its members and many of the residents are dually enrolled in AA and NA. The main difference is that in the Self-Injury Program, the behavior is not the primary focus. Personal "war stories" are not shared, as they have the potential to keep the individual stuck on her behavior, which does not help her access who she is or what she needs, but rather serves to emphasize what she does.
Ways to Communicate Understanding and Caring:
Attend to the subject of self-injury.
Let it be known that you're willing to talk, and then follow the other person's lead. Tell the person that if you don't bring the subject up, it's because you're respecting their space, not because of aversion.
Make the initial approach.
"I know that sometimes you hurt yourself and I’d like to understand it. People do it for so many reasons; if you could help me understand yours, I'd be grateful." Don't push it after that; if the person says they'd rather not talk about it, accept this gracefully and drop the subject, perhaps reminding them that you're willing to listen if they ever do want to talk about it.
Be available.
You can't be supportive of someone if you can't be reached.
Set reasonable limits.
"I cannot talk to you while you are injuring yourself because I care about you greatly and it hurts too much to see you doing that" is a reasonable statement, for example. "I will stop caring about you if you cut yourself" isn't reasonable if your goal is to keep the relationship intact.
Make it clear from your behavior that the person doesn't need to self-injure in order to get displays of caring from you.
Be free with caring gestures, even if they aren't returned always (or even often). Don't withdraw your support from the person. The way to avoid reinforcing self-injury is to be consistently caring, so that helping the person take care of they after they injure is nothing special or extraordinary.
Provide distractions if necessary.
Sometimes just being distracted (taken to a movie, on a walk, out for ice cream; talked to about things that have nothing to do with self-injury) can work wonders. If someone you work with is feeling depressed, you can sometimes help by bringing something pleasant and diverting into his or her lives.
This doesn't mean that you should ignore their feelings; you can acknowledge that they feel lousy and still do something nice and distracting. (This is NOT the same as trying to cajole them out of a mood or telling them to just get over it--it's an attempt to break a negative cycle by introducing something positive. It could be as simple as bringing the person a flower. Don't expect your efforts to be a permanent cure, though; this is a simple improve-the-moment technique.)
Don't ask, "Is there anything I can do?"
Find things that you can do and ask, "Can I...?" People who feel really bad often can't think of anything that might make them feel better; asking if you can take them to a movie or help them wash those (month-old) clothes (if done nonjudgmental) can be helpful. Spontaneous acts of kindness ("I saw this flower at the store and knew you'd love to have it.") work wonders.
Ultimatums do NOT work. Ever.
Don't force things.
If you make overtures and they're rejected, back off. Don't push it. Some people need time to decide to trust someone else, particularly if they've received a lot of negative feedback about their self-injury before. Be patient. In residential care you will most likely have an extended period of time to make valuable connections.
Take care of yourself
Working with a self-injurer is difficult work. If you try to be completely supportive to someone else 24/7, you're going to burn out. You have to find ways to be sure your needs are being met. Take a break from it when you need to. Tell the person that sometimes you need to recharge and that it doesn't affect your care and support for him/her. Only break into this personal time in cases of absolute life-or-death crisis.
The balance here is tricky, because if you make yourself more and more distant, you might get a reaction of increasing levels of crisis from the other person. If you let them know that they don't have to be in crisis to get attention from you, you can take breaks without freaking the person out. The key is developing trust, a process that will take some time. Once you prove that you are someone who isn't going to go away at the first sign of trouble, you will be able to go away in non-crisis times without provoking a crisis response.
Help the Helpers in Residential Treatment Centers
Perhaps someone you work with and care about has entrusted you with information about his or her self-injury, or maybe you've seen it inadvertently. Regardless of how you found out, you know about it now, and you can't pretend it away, not paying attention to self-injury does not make it vanish -- you need to respond in some way. Here are some guidelines for dealing with an adolescent self-injurer:
1. Don't take it personally
Self-injurious behavior is more about the person who does it than about the people around him/her. The person you're concerned about is probably not cutting, burning, hitting, or scratching just to make you feel bad or guilty. Even if it feels like a manipulation, it probably isn't intended as one. People generally do not self-injure to be dramatic, to annoy others, or to make a point.
2. Educate yourself
Get as much information as you can about self-injury in general. Find books that present the voice of self-injurers talking about what they do and why -- it lets you inside the mind of people who self-injure. Some selections that are particularly valuable are Bodily Harm, by Karen Conterio and Wendy Lader, PhD. Cutting by Steven Levenkron, and The Scarred Soul by Tracy Alderman, PhD.
3. Understand your feelings
Be honest with yourself about how self-injury makes you feel. Don't pretend that it's okay if it's not -- many people find self-injury repulsive, frightening, or provoking (Favazza, 1996; Alderman, 1997). If you need help dealing with the feelings aroused in you by self-injury, seek out your supervisor or treatment program director. It is important that you not say anything like "We all think you should..." Supervision and training is a tool for self-understanding, not for getting others to change.
4. Be supportive without reinforcing the behavior
It's important that the children we work with know that you can separate who they are from what they do, and that you care for them independently of their behavior. Be available as much as you can be. Set aside your personal feelings of fear or revulsion about the behavior and focus on what's going on with the person.
Outcomes and Observations
Throughout the development of the program, areas for review and assessment were identified for marking clinical efficacy. These include the following:
1. Resident's reaction to group development. The reaction to the use of group appeared positive as evidenced by regular attendance, showing up prepared and asking for more times throughout the week. The girls in the group spoke about feeling safe and felt understood.
2. Resident’s utilization of assignments. The 15 writing assignments posed a challenge, in that the girls did not attend to the writings in the time frame established. The group was able to utilize the writing assignments through dialogue however, and by using creative arts modalities like collage, “Mandala”, picture collages, etc. The writings were designed to help organize thoughts and feelings, share with the group what they learn about themselves, encourage peer dialogue, to help challenge negative thoughts, and help to re-enforce positive alternative thinking and feelings about oneself.
3. Tracking of self-injury through Unusual Occurrence Reports. Quality Management noted shortcomings in existing system that created initial confusion in data collection. QM has developed an improved method of collecting specific data and has been invested in educating staff that do the reporting, specifically to differentiate between self-injury and suicidal gestures.
4. Content triggers. There have been multiple topics which elicited significant affect, such as peer issues, family matters, lack of support, and feeling un-loved. The consciousness of the group centered on a few areas: The group presents as highly judgmental which is seen as a defense mechanism deflecting uncomfortable stimuli. In the absence of solid ego functioning anything perceived as threatening or possibly dangerous to the physical or emotional well-being is considered a tremendous threat and is quickly warded off. New group members also trigger emotional reactions from the girls. They express anger, resentment and emotionally close down. Talk about abuse or abandonment seems to elicit dialogue and questions.
5. Decrease in isolation and shame within the group setting. The residents, as noted prior, are showing up for all group meetings, desiring more time, verbalizing feelings, sharing thoughts, and learning to come from a place of "I" when talking. The reduction of shame is a difficult task. The group members are aware of their shamming internal dialogue and catch themselves when they express automatic thoughts which has lead to the utilization of thought stopping techniques, and active challenging of negative thinking patterns.
6. Contagion within peer group. There has been at least one incident of suspected contagion with one peer in the cottage milieu. It is suspected that this resident, who comes to Vista with tremendous feelings of rejection and family conflict wants to be apart of something special and unique, thinking that she will be infected with specialness and uniqueness. The group’s reaction to this resident has been negative and is a prime example of an issue that promotes judgments and anger. If this assessment of the resident is accurate, one possible explanation for the group’s resentment and anger could be that they feel the opposite of special and unique.
7. How participants attend to group needs. The formation and maintenance of group cohesion has been challenging. Over time there has been a shift away from this writers direction of the group to a more natural experience. The residents show up for group having already looked at the schedule and know what the topic or focus is. Residents in the group open up discussion and explore with one another the impact of a previous discussion or a writing assignment. Because the group process is fragile the needs of the group are constantly explored and attended to marking areas of content or structure, which necessitate further clinical attention.
Conclusion/Recommendations
Current researchers, clinicians, and news organizations provide evidence as to the importance of addressing the treatment of self-injury:
"As many as 40% of kids have experimented with self-injury."-- Jennifer Hagman, Medical Director of Psychiatry, Children's Hospital, Denver
"90% of self-abusers begin cutting as teenagers.”-- University of Missouri-Columbia Study (Internet, 2000)
"The average self-injurer starts at age 14 and continues with increasing severity into his/her late 20's.”--The New York Times Magazine
"More than half of self-injurers are victims of sexual abuse, and most report emotionally abusive or neglected childhoods ... contrary to the stereotype, self-injury is prevalent in all races and economic backgrounds although most are female, up to 40% of self-injurers are male."--Time
The Importance of Addressing the Issue:
"It's a problem rarely discussed even though millions struggle with it . . . and because no one talks about it, many believe they are suffering alone." - MSNBC.com
It is Deeply Misunderstood...
"Sufferers have traditionally been met with disgust by doctors, who find their self-injuring offensive. Therapists are often unwelcoming too, mistakenly labeling such people as suicidal or dismissing them as 'borderline' ... in reality, cutters are people frozen in trauma."--Time
Cutting is "alarming and unfathomable even to many therapists. For decades, [cutters] have been mental health's untouchables, bounced from emergency rooms to institutions."--Newsweek
"They've been ignored, they've been shunned."--Dr. Favazza
Self-injury is a clinical disorder that affects roughly 1% to 3% of the general population. It was found that within the Vista Del Mar adolescent girl’s unit that roughly 36% of our residents engaged in superficial or moderate self-injury. This writer, along with the clinical directors and administration of Vista Del Mar, is committed to effectively treating our self-injuring population.
The Self-Injury Treatment Program was designed to consider a specialized model of care for children who self-injure while in out-of-home care, ultimately fostering strong, healthy and safe relationships leading to the amelioration of self-injurious behaviors. These goals were developed based on the belief that health, safety and sustained abstinence from self-injurious behaviors don’t occur in the absence of relationships.
The critical issues of self-injury were examined within the group specifically to increase cognitive awareness, highlight the consequences of isolation, and provide a safe environment to explore severity of invalidation in the home, sexual, physical and or emotional trauma, body image, sexuality, relationship with food and peer and family relationship dynamics.
It was not surprising to find that although individual life histories were different, the identification and ability to relate to a specific emotional understanding of self-injury were very similar throughout the group members. The treatment program model currently being used at Vista Del Mar can subjectively account for the following:
1. Over the course of eleven months the program has seen an increase in the development of cognitive awareness as represented in posttest results.
2. The residents have consistently reported a sense of belonging.
A model of care for the adolescent female self-injurer has marked what this writer hopes is the beginning of continued research, learning and training for clinicians and other professions in the field of helping children and families. The following is an outline of important clinical and agency information designed to compliment the effectiveness of treatment in Residential Treatment Centers.
Overall Considerations
In order to help those who self-injure, Residential Treatment Centers, therapists and staff must understand what role this powerful coping mechanism plays in their clients' lives. Is it primarily a means of releasing tension? Grounding? Communicating? Reliving painful experiences?
Understanding what is underneath a person’s self-injures is key to helping that person stop using self-harm as a primary coping mechanism. "Having [immediate cessation of self-injurious behavior] as a primary goal may well be counter-productive," warn Solomon and Farrand (1996): "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."
Helping professionals need to examine their own motives for wanting a client to cease or stabilize his/her self-injurious behavior. Too often, care providers focus on stopping the SI as quickly as possible because they themselves are not comfortable with it--it repulses them, makes them feel ineffective, frightens them, etc. Situations like this can easily deteriorate into a power struggle in which the helper insists that the behavior stop and the client chooses to self-injure covertly and becomes reticent and distrustful, thus reducing the chance that a useful therapeutic alliance will be formed.
On the other hand, it is legitimate for therapists and support staff to help clients devise some sort of plan for dealing with self-injurious impulses and getting their lives (including SI) stabilized. When a client is engaging in uncontrolled self-injury, the self-injury and its concomitant crises take center stage in therapy, leaving no room for dealing with core issues. In order to have a minimum of stability in treatment, therapists and treatment communities must walk a fine line between attempting to repress/control all self-injurious behavior and allowing the SI to dominate the therapy.
An ideal approach would be one in which self-injury is tolerated but has specific consequences. For example, a client might be invited to contact the therapist or staff member when an urge to self-injure occurs, but restricted from contact for 24 hours after an actual self-injurious act. In a system like this, the self-injurer has a chance to articulate what she is trying to communicate through her body without having to resort to self-injury, and she knows that carrying through an act of self-injury will have tangible and immediate (but not permanent) negative effects.
This kind of agreement between therapist and client can help stabilize the self-injury and clear the road for dealing with the issues underlying the need to injure, allowing the therapist to follow Kehrberg's advice to treat self-harm within the context of underlying pathology. Therapists should ensure that self-injuring clients have access to non-judgmental, compassionate medical care for wounds they inflict on themselves, care that does not deprive them of their dignity or autonomy.
Together, client and therapist can devise a plan for getting physical wounds treated without adding additional stress to the situation. This may involve educating physicians at local emergency rooms about the nature of self-injury. Since successful treatment of self-injury depends heavily on teaching the client new ways of coping with stressors so that underlying painful material can be dealt with, hospitalization should be used only as a last resort. Hospitals are artificially safe environments, and the necessary tasks of learning to identify the feelings behind the act and choosing less-destructive methods of coping need to be practiced and reinforced in the residential treatment milieu where safe and trusting relationships can re-place self-injurious behaviors.
Bibliography
Carroll, J., C. Schaffer, J. Spensley, and S. Abramowitz. “Family Experiences of Self-Mutilating Patients.” American Journal of Psychiatry, 137(7), 852-853, 1991.
Contario, K., and Lader, W., and Bloom, J. K. “Bodily Harm: The Breakthrough Healing Program For Self-Injurers.” Hyperion, 1998.
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