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Section 7
Self-Injury Behavior Therapy

Question 7 | Test | Table of Contents | Self-Mutilation CEU Courses
Social Worker CEU, Psychologist CE, Counselor CEU, MFT CEU

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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.

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 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
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?

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.

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.

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.

What is one example of hyper-nurturing? To select and enter your answer go to Test.

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