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

Section 13
Dialectal Behavior Therapy for Self-injury

Question 13 | 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 four aspects of a self-mutilator's ability to form relationships which includes: a lack of a workable medium for relationship; the factor of low self-esteem; keeping friends at a distance; and the result of shame from past abuse.

On this track, we will examine the various methods by which self-mutilators avoid discussion in therapy: a blank slate; deflecting; and a false self.

3 Methods Self-Mutilators Use to Avoid Discussion in Therapy

Method # 1 - Blank Slate
As you know, self-mutilators are extremely reluctant to discuss their issues when they are first introduced to a therapist's office. This is what is known as the blank slate. Lin, age 15, had come to the United States from Hong Kong with her father who divorced and married another woman only a few months after their arrival. Lin's mother was left in Hong Kong and was never sent for. Understandably, Lin resented this new woman and was soon referred to me after fainting in the hall at school. The nurses reported seeing bruises on her hands. When Lin first came to me, she sat silent and angry for several minutes.

I asked her short questions to try and express to her that I understood her feelings. I said, "You look unhappy." When she looked away, I stated, "You don't want me to see your unhappiness." She then looked down at the Chinese-English dictionary in her lap. I then said, "You want the book to talk to me about you." She slammed the book down. I said, "You are mad at the book."

She finally said, "I am mad at me! My self is no good!" By breaking this silence, I had established a means of open communication. Lin soon related to me that her step-mother and father hit her hands, but she had also inflicted beatings on herself as punishment. Her eventual recovery could not have been possible had not the first moments passed in silence and overcome by brief questions and observations.

Method # 2 - Deflecting
Now that we've looked at the blank slate and the use of silence, another mode that self-mutilator's use in therapy to avoid talking about their problems is known as deflecting. This occurs when the client continually changes subjects so that the discussion never comes back around to them.

If they don't acknowledge their problem, it won't exist anymore. Fourteen year old Carrie was referred to me after she had been hospitalized for making a severe cut at her elbow joint which severed her tendon.

The following conversation demonstrates Carrie's ability to divert the topic of conversation to anything but herself:
-- "I want you to tell me about the bad feelings you have."
-- "I feel all right now."
-- "You don't always feel all right. When you don't, what do you think about?"
-- "I don't know."
-- "Well, what about when you get angry? Were you angry when you hurt yourself?"
-- "I don't get angry at anybody. I don't attack anybody."
-- "You attack yourself, so I know that you get angry at yourself."
-- "That's not the same. That's not real anger. Real anger has to include someone else."

As you can see, Carrie skillfully skirted around my direct questions about her to pick at nuances in the discussion. Her deflecting tactics was her way of keeping the self-injury from surfacing and revealing itself to her.

To make Carrie be more direct about herself, I became more direct in my questioning, "You aren't aware that you are angry at yourself. You don't want to be aware of that. Cutting yourself is like screaming out that you have painful feelings and angry feelings." Carrie's next statement was, "I must be a bad person." I assured her that she was not a "bad person", but that she did have complicated feelings and I told her that I would help her to interpret these feelings. Carrie soon became more involved in the sessions and became one of my most talkative clients.

Method # 3 - The False Self
Thirteen year old Chastity exhibited another form of avoidance tactic known as the false self. This is the method in which the self-mutilator talks a great deal, but says nothing of value. Chastity was referred to me after being caught burning herself on a radiator in the girl's bathroom. During her first session Chastity talked lively for twenty minutes about the various feelings she had experienced during the day. Her preconception before entering my office was obviously that therapists like to hear about people's emotions.

However, the emotions she was conveying never reached the root of the problem. Whenever I asked her a question, she quickly agreed with me, even when the next question contradicted the first. I soon realized that only a direct question about her injuring would help to focus Chastity. Instead of asking general questions about her emotional state, I asked, "What were your feelings at the moment you burned yourself?" For the first time, Chastity was speechless and didn't know what to say.

At last, she finally opened herself up saying, "I didn't feel anything." I than asked her, "Is that what you wanted, to feel nothing?" She replied, "Yeah. It was like I was feeling everything up to that point, but when I burned myself, and it didn't hurt, I thought everything else went away." By being direct and not allowing Chastity any way to put up a false self to distract me, I was able to help her in increasing her awareness of her feelings at the time of the burning.

Technique: Using an Authoritative Posture
As you are aware, therapists are told to avoid "reaching in" to their clients and taking an active role in their healing. This philosophy stems from the idea that in becoming too involved with a client, the client will be unable to heal themselves. While this idea is valid, I believe that current familial structures of many of my clients, such as a single parent home or an abusive one, and the lack of much-needed support systems necessitates a more supportive and active role on my part, while still letting the client have as much free reign on their healing as is appropriate.

In the early stages of therapy that we have discussed on this track, I find that taking a more authoritative posture allows the client to be more trusting of me. Because many clients come into therapy barely trusting themselves, the image of a strong leader to guide them is comforting and leads them to a more positive view of healing. However, the same caution must be taken that a client must become totally dependent on themselves by the time recovery has come around. Without this, the self-mutilating client is more likely to regress back into their self-destructive behavior.

On this track, we discussed three methods by which self-mutilators avoid discussion in therapy: a blank slate; deflecting; and a false self. With the blank slate or unresponsive client I used short statements. With the deflecting or evasive client and with the client exhibiting the false self, I used direct focused questions.

On the next track, we will examine five different challenges teen self-mutilators face when going through the final stages of recovery: self-blame; the fear of incomplete analysis; the danger of over-analysis; explaining scars to peers; and regret.

Peer-Reviewed Journal Article References:
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.

Kliem, S., Kröger, C., & Kosfelder, J. (2010). Dialectical behavior therapy for borderline personality disorder: A meta-analysis using mixed-effects modeling. Journal of Consulting and Clinical Psychology, 78(6), 936–951. 

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 are the three methods self-mutilators can use to avoid discussion in therapy? To select and enter your answer go to Test.

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