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

Section 5
Self-Injurious Thoughts and Behaviors

Question 5 | 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 the reasons teens are so susceptible to self-injuring: a drive for perfection; triggers from childhood; and the construction of identity.

In this section, we will observe how loathing one's body and a preoccupation with food can lead to self-mutilationAlso we'll discuss the differences between male and female self-injurers due to the way in which they vent their emotions.

♦ Body Image & Self-Mutilation
As you know, many self-injurers develop a loathing for their own body. The majority of people who self-injure are women between the ages of 13 and 30. In girls, many times this stems from a fear of sexual assault, leading them to injure themselves in order to prevent an assault. Self-injury in these cases can manifest itself from the severe, such as mutilating reproductive organs, to the less severe but seriously dangerous eating disorders.

Nineteen year old Lori is one such case of self hate. Lori stated, "I'm not comfortable in my fat body. When I'm at my normal weight, I wear a 36C bra, but that's still too big for my comfort. I don't appreciate guys staring at my chest or me thinking that the only reason they want to be with me is to have sex." Lori dealt with her negative self-image by gorging on foods to make herself unattractive. She, like other women, feel that this makes her less vulnerable to a sexual attack when in fact low self-esteem and bad health made her even more at risk for attack.

♦ Preoccuptaion with Food
You probably have observed, like I, that many self-injurers tend to have a preoccupation with food. Some range from the mild to the serious. For survivors of sexual abuse, this is their way of reconstructing the boundaries that were torn down. Most of the time, however, eating disorders stem from a psychological hatred of the body. Tony, age 19, stated to us that his anorexia predated his self-mutilation.

"My want to be perfect and my strong belief that I wasn't made me want to punish myself by depriving myself of food." Because food can have a nurturing connotation about it, Tony felt that he had to deny himself of any pleasure. He saw his needs as dangerous and destructive. Interestingly enough, his self-injurious actions are more detrimental than his perceived dangers. What do you think of this paradox?

♦ Technique: "Self-Esteem Log"
To help Lori and Tony with their eating disorders, I found the "Self-Esteem Log" to be beneficial. I asked Lori to write at the end of each day five things that made her feel accomplished, attractive, or self-assured. These included compliments they received or tasks they had struggled at and had finished.

Lori wrote down in her Self-esteem Log:
1. I cleaned my room;
2. my friend admired my grades;
3. I aced a test;
4. my older brother asked me for help with his homework;
5. a boy smiled at me.

At the end of the week, I asked her to review her log and recall those positive moments. By emphasizing the positive and not the negative aspects of herself, Lori could start to open the door to improving her self-concept. Are you treating a Lori whose self-mutilation has also materialized through overeating? Would a Self-Esteem Log be beneficial? .

♦ Difference between Female and Male Self-injurers
Now let's look at the difference between female and male self-injurers. As you know, females tend to make up a large portion of the self-injurers population. This can be accounted for by the difference in the way in which each gender expresses themselves. Adolescent girls tend to turn their emotions inward, while males vent their emotional stress through physical contact such as fighting. This delinquent activity lands boys in jail who might more than likely be in a psychiatric hospital being treated for self-injurious behavior.

Tony was beaten regularly by his mother's various boyfriends. In addition to his anorexia, to escape this, he emerged himself in alcohol, drugs, and self-mutilation. One interesting aspect of Tony's case is his incapacity to place the blame on his mother.

He stated, "The most significant thing about my mom is her unwavering sense of loyalty and integrity. She is the most important woman in my life, and she possesses and almost impeccable sense of morality." As you can see, Tony had completely distorted his reality letting himself misplace the responsibility of his actions. By misplacement I mean that Tony refused to let himself vent his ever building emotions.

♦ Technique: "Autobiographical Sketch" Exercise
To help Tony with his reality distortion surrounding his mother, I found the "Autobiographical Sketch" exercise beneficial. Tony had assimilated an idealized image of his mother into his mind. To separate Tony from that idealized image, and to put his mother in perspective I asked Tony to write a chronology of his life's events and put them into perspective.

Several topics I requested him to consider are as follows:
1. Family composition such as the relationship with his mother and her many boyfriends.
2. Strengths and positive aspects of childhood.
3. Alcohol and drug history. This includes a time period of when the substance abuse started and what was going on in his life at that time.
4. Adolescent friends
5. Job history
6. History of the self-injury. Again, the time period of when it started and what was occurring at that stage in his life.
7. The happiest and unhappiest moments in life.

Here is a summary of his responses; Tony related that his parents divorced when he was very young. After the separation, his mother became involved with a second cousin who jumped bail after being jailed for drug sale. Because of these legal problems, Tony, his mother, and his mother's boyfriend went as he put it "underground." Though they never married, the couple had a son and later the boyfriend had a nervous breakdown. Then, Tony's mother got a boyfriend who routinely beat Tony.

Through the use of the Autobiographical Sketch it became apparent to Tony that his initial statements that his mother "possesses an almost impeccable sense of morality" strongly contradicted reality and that the saintly image of his mother he had previously maintained was his idealized version of her. Being able to consciously remember these negative memories helped Tony to recognize the harm that resulted from his mother's behavior. The Autobiographical Sketch helped to start to resolve the conflict between Tony's reality and idealization of his mother.

In this section, we discussed how loathing one's body and a preoccupation with food can lead to self-mutilation. Also we discussed the differences between male and female self-injurers regarding the way in which they vent their emotions. Would it be beneficial for you to replay this section to review the techniques of the Self-Esteem Log and the Autobiographical Sketch?

In the next section, we will discuss the various ways a family can be affected by self-injury: shock and guilt; anger and resentfulness; and stronger bonds.

Female Genital Mutilation/Cutting: Risk Management and Strategies
for Social Workers and Health Care Professionals

- Costello S. (2015). Female genital mutilation/cutting: risk management and strategies for social workers and health care professionals. Risk management and healthcare policy, 8, 225–233. doi:10.2147/RMHP.S62091

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.

Nielsen, E., & Townsend, E. (2018). Public perceptions of self-harm—A test of an attribution model of public discrimination. Stigma and Health, 3(3), 204–218.

Nock, M. K., Prinstein, M. J., & Sterba, S. K. (2009). Revealing the form and function of self-injurious thoughts and behaviors: A real-time ecological assessment study among adolescents and young adults. Journal of Abnormal Psychology, 118(4), 816–827.

Smith, D. M., Wang, S. B., Carter, M. L., Fox, K. R., & Hooley, J. M. (2020). Longitudinal predictors of self-injurious thoughts and behaviors in sexual and gender minority adolescents. Journal of Abnormal Psychology, 129(1), 114–121.

What is a technique you might consider using with your self-mutilating client who idealizes someone who is abusive to them? To select and enter your answer go to Test.

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