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Treatment of Nonsuicidal Self-Injury in Adolescents
10 CEUs Physical Pain Stops my Pain - Treating Teen Self Mutilation

Section 3
Impact of Poor Psychiatric Hospitalization

Question 3 | Test | Table of Contents | Self-Mutilation CEU Courses
Social Worker CEU, Psychologist CE, Counselor CEU, MFT CEU

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In the last section, we discussed several examples of clients suffering from dissociation. The examples discussed were: those who feel numb; those who use pain to reassure themselves of their own existence; and those who view the pain as a penance for wrongdoing. Also we talked about two techniques that can be used to help clients better cope with their dissociation: the "Before, During, and After" technique and the "Self-Mirror" method.

In this section, we will examine the consequences of badly executed hospitalizations such as: a feeling of isolation; a discharge without being truly cured of the dilemma; and belittling the self-injurer.

3 Consequences of Badly Executed Hospitalizations

♦ # 1 - Feeling of Isolation
As you know, many people view self-mutilation as an oddity and view the population as untreatable. The innate human instinct toward self-preservation makes self-injury seem inexplicable and even terrifying. Seventeen year old John, after staying in a psychiatric hospital for over four months, felt that the attitude of the staff was one of detachment and fear.

John stated, "The feeling I elicited from them, though not intended, was horror. 'Oh my goodness-why would he do that?' They didn't say it to my face, but their indirectness told me that they didn't want to have too much to do with me." Because of his vulnerable stage in adolescence, John's experience in the hospital left him with a feeling of isolation from the rest of the world. Instead of better adapting to it, he fell even further into depression and anxiety until he sought more therapeutic aid.

♦ # 2 - Discharge Without being Truly Cured
Some of those doctors in the medical field who have even attempted to work with self-mutilating patients have taken the position that self-injury is an unchangeable disease, much like alcoholism. Many times this is a result of abhorrence of the condition. Sometimes hospital treatment only focuses on the act of self-injury itself: how dangerous it is to harm one's body, what a toll it takes on the client and the people around them, how aberrant or bad it is to take arms against one's skin.

In John's case, he was trying to convey a message through his self-mutilation. He stated, "I've thought, 'I'll show them just how worthless I am, and how much I hurt.' A lot of people thought it was a suicide attempt, which it really was not." John's disease was much more mentally internalized and by merely treating the symptoms, his cuts and bruises, he was never really cured of the incentive to self-mutilate, of course you can guess.

♦ Technique: "Feelings Awareness" Exercise
To help John become more aware of the emotional dynamics involved in his self-injurious behavior, I found the "Feelings Awareness" exercise to be beneficial.

I asked John to answer the following questions about his self-injuring behavior:
1. What feelings and fantasies do I typically have prior to, during, and after an episode of self-injury?
2. What feelings have I wanted to create in others through this?
3. What feelings do I elicit from others, even if I don't intend to?

John answered, "I want to leave a mark on myself in some way. I like having the scars. They tell people, 'Look at me, I'm hurting.' I wanted them to want to help me. Usually, they just think I'm incredibly sick and deranged." The ability to identify the feelings and thoughts that lead up to an episode of self-injury helped him conquer the behavior by placing its origins in the proper context.

♦ # 3 - Belittling the Self-Injurer
As your self-mutilating clients have probably related to you, hospital doctors may tend to misunderstand self-injury. Some see it as a random or chaotic type of behavioral expression, not, as I believe it to be, a condition with complex and hidden meanings that can be clarified during therapy. Cynthia, age 19, related a situation in which her self-mutilation during her hospitalization reached such a frenetic peak her doctor ordered she be put into four-point restraints.

Cynthia told me, "Sure it prevented me from hurting myself, but I felt so humiliated. I mean, they had me spread eagle on the bed. It put me in a very vulnerable position and made me even more anxious than I was before." By immobilizing her, Cynthia describes herself as regressing into a state of total dependency on the hospital staff. Cynthia's grueling trial in fact worsened her tendency to self-injure and she soon was trapped in a vicious cycle common to repeated hospitalizations.

As her anxiety from being in a psychiatric hospital increased, so did the frequency of her self-mutilation and thus lengthening her hospital stays. When Cynthia finally was referred to me, she had had a cumulative hospitalization period of a year and a half in the last three years.

♦ Technique: "Impulse Control" Log
Often, the desire to self-injure comes so quickly and unpredictably, the only way to keep from relapsing to self-harm is to deal with that impulse almost immediately. To keep clients on a controlled path towards healing but at the same time giving them free reign to orchestrate this healing themselves, I find the "Impulse Control" Log beneficial. To aid John and Cynthia in regaining control of themselves after their damaging stays in a hospital, I asked them to make a grid on a blank sheet of paper.

I asked them to place the following 9 categories running across the top of their grid:
1. Acting out/self-injury thoughts
2. Time and Date
3. Location
4. Situation
5. Feeling
6. What would be the result of self-injury?
7. What would I be trying to communicate with my self-injury?
8. Action taken
9. Outcome

One of Cynthia's Impulse Control Log's looked like this:
1. Self-injury thoughts: Cutting, burning
2. Time and date: July 20th, 5:30 p.m.
3. Location: Living room of my friend and her family
4. Situation: I was watching my friend's family get along so well.
5. Feeling: Disappointed, alone, upset, angry
6. What would self-injury accomplish? Scars,
7. What would I be trying to communicate through my self-injury? That I wish my family was close, and that I felt alone.
8. Outcome: I started talking to people and challenged thoughts to hurt myself
9. Comments: I noticed a decrease in my desire to act out.

As you can see, by writing out and communicating to herself about her impulses, Cynthia was more ably ready to combat her urges. Think of your John or Cynthia. Could they benefit from an "Impulse Control" Log?

In this section, we have discussed the consequences of badly executed hospitalization such as: a feeling of isolation; a discharge without being truly cured of the dilemma; and belittling the self-injurer.

In the next section, we will examine why adolescents are so vulnerable to the guiles of self-mutilation. These reasons include: a drive for perfection; triggers from childhood; and the construction of identity.

Peer-Reviewed Journal Article References:
Adrian, M., Berk, M. S., Korslund, K., Whitlock, K., McCauley, E., & Linehan, M. (2018). Parental validation and invalidation predict adolescent self-harm. Professional Psychology: Research and Practice, 49(4), 274–281.

Courtemanche, A. B., Piersma, D. E., & Valdovinos, M. G. (2019). Evaluating the relationship between the rate and temporal distribution of self-injurious behavior. Behavior Analysis: Research and Practice, 19(1), 72–80.

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.

Lee, S. C., & Hanson, R. K. (2016). Recidivism risk factors are correlated with a history of psychiatric hospitalization among sex offenders. Psychological Services, 13(3), 261–271.

Miret, M., Nuevo, R., Morant, C., Sainz-Cortón, E., Jiménez-Arriero, M. Á., López-Ibor, J. J., Reneses, B., Saiz-Ruiz, J., Baca-García, E., & Ayuso-Mateos, J. L. (2011). The role of suicide risk in the decision for psychiatric hospitalization after a suicide attempt. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 32(2), 65–73.

Tepper, M., Berger, R., Byrne, S., Smiley, J., Mooney, M., Lindner, E., Hinde, J. L., & Korn, P. (2013). Older adults’ perceptions of recovery from mental illness: Impact of psychiatric hospitalization prior to 1990. Psychiatric Rehabilitation Journal, 36(2), 93–98.

What are the three ways in which hospital tactics can worsen a self-injurer's condition? To select and enter your answer go to Test.

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