Self-Injurious Behavior: Understanding and Working With Clients ...

Self-Injurious Behavior: Understanding and Working With Clients ...

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Article 67Self-Injurious Behavior: Understanding and WorkingWith Clients Who Self-InjureKelly L. Wester and Heather C. TrepalThe topic of self-injurious behavior (SIB) hasbeen gaining widespread attention in both the mediaand professional literature. Self-injury has been definedas “all behaviors involving the deliberate infliction ofdirect physical harm to one’s own body without theintent to die as a consequence of the behavior” (Simeon& Favazza, 2001, p. 1). Thus, SIB encompasses anextensive array of behaviors, ranging from skin pickingand hair pulling to bone breaking and self-surgery. Themost common types of SIB tend to be cutting andburning. SIB has typically been mistaken by cliniciansand medical doctors for a suicide attempt. This mistakemay be due to either the high correlation betweensuicide and SIB, or because the behavior tends to appearto be similar. Although suicide attempts and self-injurycan look similar, and have been found to be highlycorrelated, SIB is not a suicide attempt. Another wayto think about the difference between SIB and suicideis that SIB is an escape from an intense affect, or anattempt to achieve a certain level of focus, in order foran individual to sustain and continue life, while suicideis a way to end life with death being the ultimate goal.Self-injurious behaviors have been documentedsince biblical times. It is difficult to determine theprevalence of SIB since it tends to be frequentlymistaken for suicide and is usually a secretive behavior.Thus, although studies have examined the prevalenceof self-injury in the general population, college-agestudents, and psychiatric populations, the trueprevalence remains unclear.Similar to the problem with determiningprevalence rates, it is difficult to truly know the typicalcharacteristics of individuals who engage in self-injury.Recently, some researchers have described the profilefor clients who tend to engage in self-injury. Theseinclude Caucasian females, in their mid-20s to early30s, who have been hurting themselves since their teens(e.g., Stone & Sias, 2003). According to research, mostindividuals who self-injure tend to be middle or upperclass,intelligent, well educated, and from a backgroundof physical or sexual abuse (Levenkron, 1998).However, other research has suggested that males alsoengage in self-injury, with similar prevalence rates asfemales. Favazza, De Rosear, and Conterio (1989)found that 18% of male and 12% of femaleundergraduates reported a history of SIB. Additionally,one of the current authors worked in a correctionalfacility in which, on average, 1 out of 12 maleadolescents engaged in SIB.Reasons for SIBSome researchers have attempted to identify thereasons why individuals choose to engage in SIB. Themajority of researchers have found that SIB is highlycorrelated (up to 80%) with childhood physical orsexual abuse (Levenkron, 1998; Simeon & Favazza,2001). However, not all individuals who self-injure havebeen abused or neglected as children. Some individualshave an inability to express or cope with overwhelmingemotions (Alderman, 1997; Favazza, 1998). Aldermansuggested that clients who self-injure may havedifficulty regulating emotions because they can notidentify, express, or release the emotions. Self-injurybecomes a way of expressing and releasing the emotionsfor an individual. While some people may use selfinjuryas a way to control emotions, others may useself-injury as a way to end a dissociative state, to keepmemories from reoccurring, or to relive or reconnectwith an individual, even if that individual has causedthem pain (Levenkron, 1998). Overall, it appears thatself-injury assists individuals in keeping or gainingcontrol over their lives, whether it is in the form ofcontrolling emotions or pain, feeling “real,” orexpressing oneself.Treatment of SIBIn working with clients who engage in SIB, athorough assessment is critical. In the initial assessmentit is imperative to gather information about the behavior.As White-Kress (2003) suggested, the firstresponsibility of a counselor is to assess for self-injuringbehavior by a client and then determine the frequency,duration, and onset of the SIB. It is important that acounselor assess for the severity of SIB in order to309

determine if the behavior that the client is engaging inis impulsive and could result in unintended death. It isalso important to assess for prior complications of thebehavior. For example, has the client previously beenhospitalized from self-injury? Have the wounds beeninfected? Or does the client not allow the wounds toheal once they have been created? Information providedfrom this initial assessment will assist a counselor indetermining how high-risk the SIB is and whether theclient is in immediate need of hospitalization orpsychiatric evaluation, needs a safety plan and ongoingassessment, or simply needs education on theconsequences that can result from SIB.A counselor also needs to assess the reasons orpurpose for self-injury as well as determine the client’sstopping point before proceeding to engage in treatmentof the behavior. Researchers have suggested that therecan be many reasons that clients self-injure, includingto manage emotions, to deal with anxiety, or to copewith stressful events (Favazza, 1987). Counselorsshould not presuppose the reason why a client engagesin this behavior. Clients begin, and continue, to selfinjuredue to a wide variety of reasons. It is importantfor a counselor to understand the behavior from theclient’s perspective and reality (White-Kress, 2003).Once the reason and purpose of the behavior isunderstood by the counselor, it is important to determinethe client’s stopping point. The stopping point is themoment at which the SIB has served its purpose andthe client no longer needs the behavior to gain control,ease tension, stop memories, or regulate emotions(Wester & Trepal, 2004).Once the counselor has determined the level ofseverity of the SIB, the reason for it, and the stoppingpoint for a particular client, he or she can begin to assistin the treatment of self-injury, or its underlying cause.White, McCormick, and Kelly (2003) discussed ethicalconsiderations for this stage of counseling, during whicha counselor is determining whether he or she shouldreport the SIB, as well as whether it should become anissue in counseling. These authors mentioned thatcounselors are ethically obligated to manage andunderstand their personal reactions to the SIB andshould avoid actions that seek to meet their personalneeds at the expense of the client’s needs. They alsosuggested that a counselor should respect a client’sautonomy and the right to choose a particular copingmethod or behavior, even if it does not make sense tothe counselor. However, White and colleagues domention that when the nonmaleficence (the “do noharm” principle) outweighs the client’s autonomy (e.g.,multiple emergency room visits and serious infections),the counselor should report the behavior.Treatment of SIBOnce the initial assessment is completed, the firststep in treating a client who is self-injuring is to establisha trusting, reliable, and comfortable counselingrelationship. Typically, clients who self-injure do nothave close, trusting relationships with anyone, andrarely confide their SIB to other people. Levenkron(1998) discussed the fear of rejection these clients feelwhen they begin to share their secret with anyone,including friends, family, or a counselor. Thus hesuggested that “The easiest way to break through thisdefense is to indicate that you are comfortable gettingclose to the person’s pain, rage, and despair” (p. 66)and their SIB. Once a relationship is established,counselors can begin to move forward by providingalternatives in counseling in order to begin workingtoward the underlying reasons for SIB.Although a goal of most counselors will be to havetheir clients abstain from SIB, clients and researchershave reported that this might not be achievable (Crowe& Bunclark, 2000). Attempting to extinguish SIBtypically does not work, and the most that can beachieved is to reduce either the frequency or the severity.Thus, one of the goals in working with clients who selfinjureis to get them to work on delaying the timebetween the thought of injuring themselves and theactual behavior. Sometimes this delay might be only afew seconds, while at other times it can be an entireday or a week. However, sometimes a client needssomething to occupy his or her time, at least in theimmediate moment when the self-injuring thoughts canbecome an obsession.Wester and Trepal (2004) suggested alternativesthat can be effective in minimizing and decreasing selfinjuringbehavior, as well as in delaying time betweenthe thought or desire to engage in SIB and the actualbehavior itself. These are alternatives that counselorscan suggest to their clients and should be matched tothe client’s reason for engaging in SIB and/or thestopping point. Alternatives provide space and time inwhich the counselor and client can begin to uncoverthe underlying reasons for the damaging behavior. Asan example, an individual may self-injure by cuttingon his arm quickly five times in order to terminate orcontrol his feelings when he feels an intolerable oroverwhelming feeling. In this example, instead ofcutting his arm, the client might choose the alternativeof drawing on his arm, or quickly slashing lines on apiece of paper five times. If it is the sensation that he isseeking, and not the act of five lines, he might chooseto brush his skin with a toothbrush or hold an ice cubeon his skin for a certain period of time, both of whichactions will create a sensation but not damage the skin310

and tissue as would a razor.Various types of treatments and methods havebeen suggested for working with clients who self-injure(e.g., Ross & McKay, 1979) including cognitivecounseling; behavior modification, including trainingalternative behaviors; dialectic behavior therapy; andsolution-focused brief family therapy. However, no onetreatment has been found to be the most effective.Although there is no one known treatment thatworks with all clients who self-injure, some researchershave examined treatments that have been found to beunsuccessful. These include physical restraint,hypnosis, no-cutting contracts, faith healing, grouppsychotherapy, relaxation therapy, electroconvulsivetherapy, family therapy, and educational therapy (e.g.,Favazza, 1998; Ross & McKay, 1979).ConclusionWorking with clients who self-injure is a long,slow process. During this process, it is also importantfor counselors to pay attention to their own reactionsto the client’s behavior. Most professionals are at a lossabout how to understand the behavior and tend to befrightened, frustrated, repulsed, and angry toward thebehavior (e.g., Favazza, 1998). Thus it is important forcounselors to assess their own reactions and behaviorstoward the client, and seek out supervision if necessary.In sum, each client that comes into counseling is unique,including clients who engage in self-injury. There isno one pathway or etiology regarding how a clientbegins to self-injure nor are there similar reasons orfunctions the self-injury serves. Thus, counselors needto explore the meaning and purpose of the behaviorwith the client.Favazza, A. R., De Rosear, L., & Conterio, K. (1989).Self-mutilation and eating disorders. Suicide andLife-Threatening Behavior, 19, 352-361.Levenkron, S. (1998). Cutting: Understanding andovercoming self-mutilation. New York: Norton.Ross, R. R., & McKay, H. B. (1979). Self-mutilation.Lexington, MA: Lexington Books.Simeon, D., & Favazza, A.R. (2001). Self-injuriousbehaviors: Phenomenology and assessment. In D.Simeon & E. Hollander (Eds), Self-injuriousbehaviors: Assessment and treatment (pp. 1-28).Washington, DC: American PsychologicalAssociation.Stone, J. A., & Sias, S. M. (2003). Self-injuriousbehavior: A bimodal treatment approach to workingwith adolescent females. Journal of Mental HealthCounseling, 25, 112-125.Wester, K. L., & Trepal, H. C. (2004). Working withclients who self-injure: Providing alternatives.Manuscript submitted for publication.White, V. E., McCormick, L. J., & Kelly, B. L. (2003).Counseling clients who self-injure: Ethicalconsiderations. Counseling and Values, 47, 220-229.White-Kress, V. (2003). Self-injurious behaviors:Assessment and diagnosis. Journal of Counseling& Development, 81, 490-496.ReferencesAlderman, T. (1997). The scarred soul: Understandingand ending self-inflicted violence. Oakland, CA:New Harbinger.Crowe, M., & Bunclark, J. (2000). Repeated self-injuryand its management. International Review ofPsychiatry, 12, 48-53.Favazza, A. R. (1987). Bodies under siege: Selfmutilationin culture and psychiatry. Baltimore: JohnHopkins University Press.Favazza, A. R. (1998). The coming age of selfmutilation.Journal of Nervous and Mental Diseases,186, 259-268.311

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