Healthcare Training Institute - Quality Education since 1979CE for Psychologist, Social Worker, Counselor, & MFT!!

Section
7
Self-Injury Behavior Therapy
|
|
Read content below or listen to audio.
Left click audio track to Listen; Right click to "Save..." mp3
In
the last section, we discussed the various ways families are affected by self-injury:
guilt and shock; frustration and misunderstanding; and stronger bond. As
you know, treating self-mutilating clients can be a difficult and often times hazardous task to undertake. The growing population of self-injuring teens
has been described as an epidemic. An estimated 2 to 3 million Americans self-injure.
The likelihood of treating a client who self-harms is extensive.
n this section, we will examine different aspects of hyper-nurturing to consider when treating
a self-injuring client.
Treating
a Self-Injuring Client - 6 Considerations about Hyper-Nurturing
♦ # 1 - Amount of Support
I feel one of the key areas to
consider when treating a self-injuring patient is the amount of support he or
she will be receiving. Do you agree? Many times these clients need several
crisis intervention sessions in the off hours as you know. Have you found that
sometimes clients use this as a test of your commitment? In these cases, the need
for constant access diminishes as the alliance is forged. Nineteen year old Wendy
had been recently hospitalized and she did not feel confident in her ability to
control herself.
How do you feel about giving Wendy your home and cell phone number,
along with the number for a special hotline that she could call if you could not
be reached? Millie, the therapist on our team who did this, received many phone calls from
Wendy, mostly at night, when she felt particularly abandoned and afraid. It was
at these times that she said she felt the need to harm herself.
She stated, "Those
first few weeks out of the hospital were real scary for me. I mean, I was terrified.
I thought 'There's no way I can do this, I'm going to have to go back, I just
know it.'" As her treatment progressed, the frequency of the calls decreased
and Wendy can now support herself in the off hours without Millie's aid.
♦ Technique: 4-Step Approach
When
Wendy would call her therapist, Millie; she took a four
step approach:
Step 1:
First, Millie told her she was pleased that she called her instead
of acting out her impulse.
Step 2: Second, Millie also inquired about her internal emotional
state: when she recognized the urge; what her thoughts and feelings are; if she
was alone or with other people.
Step 3:
Third, Millie then asks her questions about her
triggers at that specific time such as: was she feeling especially lonely that
night or has she gotten any phone calls that upset her.
Step 4:
Fourth, Millie then suggested
trying one of her alternatives and opted for an additional therapy session that
week.
♦ # 2 - Treatment Participation Agreement
Do you have your self injurer complete a treatment
participation agreement before treatment begins? In this document, you stipulate
several things such as a list of alternatives, an agreement to abstain from self-harm
and minimal cancellations. This agreement serves to organize the goals and terms
of the treatment relationships and can provide the structure of the recovery plan.
Obviously if not presented in the "I have your best interests in mind"
attitude with many self injurers this formalized document approach may hinder
the trusting bonding that needs to be built.
In Wendy's agreement,
Millie laid out alternatives for self-mutilation should she feel an impulse.
These included drawing, taking a shower, and writing in her journal. If she completed
these alternatives and still felt the impulse to self-mutilate, she would at that
time call Millie for a crisis intervention. As you are very well aware, that many
times clients can feel pressured by this agreement and that your care is only
conditional.
If you are considering using a treatment participation agreement,
perhaps you should also consider preliminary talks with your client to gauge his
or her feelings.
Think of your Wendy who is using self-mutilation. Would he or
she benefit from a list of alternatives in the form of a treatment participation
agreement or would this formal approach jeopardize you therapeutic relationship?
♦ # 3 - Negotiate Frequency of Sessions
How
many sessions per week do you have with a self mutilating client? Millie negotiated
over a period of several weeks with Wendy about her session schedule. She began
with about 3 sessions a week, but that number slowly subsided to 2 and then to
1 as she gained back her sense of stability and confidence.
Wendy said, "I
feel much more in control now. My impulses to hurt myself are not as strong as
they used to be and I can deal with them most of the time without much effort."
Generally, clients who cannot control themselves substantially between sessions
may need to be hospitalized until they can handle outpatient care. Also, you probably
have found like I that a mere absence of mutilation is not an indicator that the
patient is ready to lower their number of sessions. Millie used an attitude of
self-control to be established before the number of sessions is to be reduced.
♦ # 4 - Disassociate from Gratification after Harm
An important concept to consider is not to allow the client
to associate the therapist with gratification after harm. Do you agree? This
refers to when a client should call you or attend a session immediately after
injuring themselves. Wendy at one point came to one of her sessions after just
cutting herself. Millie promptly assessed her physical condition and took her
to seek medical treatment.
She forfeited the session that day. "If I had
at that point, began the session with her fresh wounds, she would have started
to associate comfort and me with pain" Millie stated. Obviously, this prevented
Wendy from feeling excessive gratification for harmful behavior. But where do
you draw the line of support and gratification can only be decided on an individually
basis obviously?
♦ # 5 - Use Constructive Alternatives
One act Millie particularly discouraged during
her sessions with Wendy, was the displaying of scars or detailed descriptions
of self-injuring episodes. When Wendy did this, she glorified it and diverted
attention from the underlying issues. Also, I do not believe in substituting self-destructive
behaviors with less-destructive ones, such as snapping a rubber band on her wrist.
This only confirms the notion in Wendy that her emotions constitute an act of
violence.
By utilizing more constructive alternatives like those described earlier
in this section, Wendy could begin to express her emotions in a more mature, controlled
fashion. Another tactic I avoided was hyper-nurturing. By this I mean treating
Wendy as though she were a child and asking her to purge her home of sharp objects.
This only confirms her belief that she cannot control herself and that she will
never make it as an adult.
♦ # 6 - Decide Whether to Include the Family
Another hyper-nurturing decision
is whether to include the family or not. What are your client's feelings? Sometimes,
it can be counterproductive as you know if for instance the client is struggling
with his or her boundaries and own sense of identity. In other cases, if a client
wishes to exclude a family member, this might indicate a root to the underlying
issues. Wendy wished to keep her mother out of the therapy.
However, this was
a result of Wendy's inability to communicate with her mother and because of this
Millie moved towards the inclusion of the family member. Because Wendy is an adolescent,
including her mother became even more important. If you feel that including the
family will not aggravate your client's urge to self-mutilate, you probably are
strongly leaning towards having the family involved in therapy. Think of your
Wendy. If family is involved could it be causing him or her to self mutilate more?
Or of they are not involved is this something you should consider suggesting in
your next session?
In this section, we have examined different
aspects to consider when treating a self-injuring client and hyper-nurturing issue.
In
the next section, we will discuss how self-control is essential in treating a self-mutilating
client: thinking and behaving in an age appropriate way; dissolving the excuse
of catharsis; and de-associating activity with frustration.
Reviewed 2023
Peer-Reviewed Journal Article References:
Courtney-Seidler, E. A., Burns, K., Zilber, I., & Miller, A. L. (2014). Adolescent suicide and self-injury: Deepening the understanding of the biosocial theory and applying dialectical behavior therapy. International Journal of Behavioral Consultation and Therapy, 9(3), 35–40.
Fischer, S., & Peterson, C. (2015). Dialectical behavior therapy for adolescent binge eating, purging, suicidal behavior, and non-suicidal self-injury: A pilot study. Psychotherapy, 52(1), 78–92.
Fox, K. R., Harris, J. A., Wang, S. B., Millner, A. J., Deming, C. A., & Nock, M. K. (2020). Self-Injurious Thoughts and Behaviors Interview—Revised: Development, reliability, and validity. Psychological Assessment, 32(7), 677–689.
Frei, J. M., Sazhin, V., Fick, M., & Yap, K. (2021). Emotion-oriented coping style predicts self-harm in response to acute psychiatric hospitalization. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 42(3), 232–238.
Kruzan, K. P., Whitlock, J., & Hasking, P. (2020). Development and initial validation of scales to assess Decisional Balance (NSSI-DB), Processes of Change (NSSI-POC), and Self-Efficacy (NSSI-SE) in a population of young adults engaging in nonsuicidal self-injury. Psychological Assessment, 32(7), 635–648.
Swart, J., & Apsche, J. (2014). A comparative study of mode deactivation therapy (MDT) as an effective treatment of adolescents with suicidal and non-suicidal self-injury behaviors. International Journal of Behavioral Consultation and Therapy, 9(3), 47–52.
QUESTION
7
What is one example of hyper-nurturing? To select and enter your answer go to .
|