the last track, we discussed therapy hyper-nurturing.
track, 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"
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
2. What roles do I play, and how do I feel about them? For
instance, as a student, daughter/son, sister/brother, etc.
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.
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.
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
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"
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
"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."
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.
this track, 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.
the next track, 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.
Peer-Reviewed Journal Article References:
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.
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 .