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Section 8
Self-Efficacy and Self-Injury

Question 8 | Test | Table of Contents

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In the last section, we discussed therapy hyper-nurturing.

In this section , we will discuss self-control as it relates to a self-mutilating client: thinking and behaving in an age appropriate manner; dissolving the excuse of catharsis; and de-associating activity with frustration.

I find in treating self-injurers that the best way to help self-mutilating teen clients cope with their situation is to find a way to think and behave in an age-appropriate manner. I aid clients to find age-appropriate alternatives to vent their feelings through the five areas.

♦ 5 Areas to Encourage Age-Appropriate Alternatives
1. Education about control,
2. Setting limits and boundaries,
3. Enforcing consequences,
4. Offering encouragement and praise, and
5. Holding clients responsible for their actions.

This last point of holding clients responsible or accountable I find is key to their path of self-control. Sometimes, those adolescent self-injurers who were hospitalized could have been treated as infants by the hospital staff. They could not have any sharp objects. Not only was this attempt futile, as any well experienced self-injurer could find something with which to hurt themselves, it also gave the client an even deeper sense of lost control.

Angela age 15, stated, "At the hospital, they treated me like I was in third grade. They took away the scissors and anything else I could possibly injure with. Instead of feeling in control, I started relying on them to do the healing for me." Angela, by not being treated like a responsible adult, never learned self-control and thereby never learned to heal herself. When she was let out into the real world, so to speak, Angela experienced moments of severe anxiety due to her inability to control her impulses. Make sense? Sure it does.

♦ Technique: "Reflective Responses"
To aid Angela related to a way to self-control, I found "Reflective Responses" beneficial. It was important that Angela acknowledge both positive and negative traits and decide which ones enhanced her ability to function on her own and which ones caused difficulty.

I asked Angela to answer the following questions:
1. What am I like as a person-emotionally, intellectually, in manner and behavior?
2. What roles do I play, and how do I feel about them? For instance, as a student, daughter/son, sister/brother, etc.
3. What are my particular strengths and weaknesses as a person? Which characteristics do I want to change for sure, and which ones would I never change?
4. Identify the patterns that are repeated in the roles you play.

Incidentally these questions are reprinted in the Manual that accompanies this course for purposes of your reproduction or future session reference.

To these, Angela answered, "As a person, I'm a little over reactive. I tend to take everything personally and I never let anything just go. I'm really neurotic about things like school and how I look. I try to establish myself as a leader. I'm class Vice President because I thought people would think I'm real assertive and a go getter.

"I work hard at everything I do, but sometimes I work too hard. I wish every little thing didn't affect me so much and that the smallest disruptions wouldn't tear my world down. However, I'm a very caring person. I like to help people and I don't like what I'm doing to my parents and family by injuring myself."

By completing this exercise, Angela could focus on her strengths, such as hard work and devotion, and try to diffuse her weaknesses, such as hypersensitivity. Think of your Angela. Does he or she need an exercise in examining their strengths and weaknesses to increase their self-control?

♦ Dissolving the Excuse of Catharsis
As you probably have observed in your own practice, many self-injurers use the excuse of catharsis to account for their self-mutilating actions. Many self-mutilating teens that hold this view tend to have grown up in a childhood home where anger was expressed through violence. This instilled into the self-injurer the idea that to express your feelings, action must be taken to relieve that pressure. This is the reason many clients take on self-injury, and for this reason many therapists recommend alternative methods to expel the anguish.

However, in practice, I feel this sort of treatment actually leads to an escalation in the self-injury. Angela was directed by a staff member during her hospitalization to dip her arm into a bucket of ice water. In doing this, she developed a treatment-resistant case of frostbite. When she was referred to me, I explained to Angela how this seemingly harmless act can be used to only further her preoccupation with self-injury.

Sometimes clients are asked by their therapist to use exercise as a form of dispelling negative emotions. Many of these clients told me that when they used physical activity, they felt overanxious and their feelings of frustration actually increased afterwards, causing them to intensify their self-injury. Sylvia, age 19, would punch a bag to release her emotional stress. I explained to Sylvia that the only real effective way to keep herself from self-injuring is to stop associating emotions with an action.

Self-control, I told her, is going to keep you from cutting yourself, not constantly bringing yourself back to a violent action when you need to vent. Let me repeat that. I explained to Sylvia that the only real effective way to keep herself from self-injuring is to stop associating emotions with an action. Self-control, I told her, is going to keep you from cutting yourself, not constantly bringing yourself back to a violent action when you need to vent.

♦ Technique: "Anger Inside Me" Exercise
Sylvia, in self-injuring herself, was searching for a way to release the emotions she felt were going to make her explode. Instead of expressing these emotions through violent actions, I suggested to Sylvia that she try the "Anger Inside Me" exercise. The purpose of this exercise is to help Sylvia better understand her anger so she could develop the ability to manage and tolerate it effectively.

I asked Sylvia to answer these questions:
1. What situations seem to evoke your anger most frequently?
2. What does becoming angry feel like? What kinds of thoughts arise once you're aware that you're angry? Are you afraid of others seeing your anger?
3. What do you need to learn about handling your anger?

In response, Sylvia answered, "I get frustrated when things don't go my way. My mom yells at me, my grade was bad on a test or something someone said to me just won't stop replaying in my head. When I'm under these stresses, I tend to be very sensitive to reaction.

"When I burst, I think, 'That's it, I need a break. I need to get this stuff out.' I'm ok with people seeing me angry. In fact, I like it, because then they ask me what's wrong and I like feeling that they care enough about me to stop what they're doing and take an interest. I need to learn that my anger does not need activity; it just needs to be accepted and turned into something positive, not violence. I need to figure out what sets me off."

By identifying the specific triggers to her anger, Sylvia could better understand how these lead to her self-injury. Viewing her angry feelings with sympathy and acceptance helped contribute to Sylvia's self-esteem and her control over impulses.

In this section, we discussed how self-control is essential in treating a self-mutilating client: thinking and behaving in an age appropriate manner; dissolving the excuse of catharsis; and de-associating activity with frustration.

In the next section, we will discuss the various mental disorders with which adolescent self-mutilators are diagnosed. These include Axis I disorders such as depression, thought disorders, anxiety disorders, and post traumatic stress disorder, and the Axis II disorder of borderline personality disorder.
Reviewed 2023

Peer-Reviewed Journal Article References:
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.

Law, Y.-W., Yip, P. S. F., Lai, C. C. S., Kwok, C. L., Wong, P. W. C., Liu, K.-S., Ng, P. W. L., Liao, C. W. M., & Wong, T.-W. (2016). A pilot study on the efficacy of volunteer mentorship for young adults with self-harm behaviors using a quasi-experimental design. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 37(6), 415–426.

Tyson, P., Law, C., Reed, S., Johnsey, E., Aruna, O., & Hall, S. (2016). Preventing suicide and self-harm: Evaluating the efficacy of a helpline from a service user and helpline worker perspective. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 37(5), 353–360.

 QUESTION 8
What is one key question that needs to be answered to better analyze anger in your self-injuring client? To select and enter your answer go to Test.

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