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On the last track, 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.
On this track, we will examine different aspects of hyper-nurturing to consider when treating
a self-injuring client.
# 1 - Amount of Support
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
# 2 - Treatment Participation Agreement
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.
# 3 - Negotiate Frequency of Sessions
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
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
By utilizing more constructive alternatives like those described earlier in this track, 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
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?
On this track, we have examined different aspects to consider when treating a self-injuring client and hyper-nurturing issue.
On the next track, 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.
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