What is the biggest challenge facing practitioners who are treating clients who self-harm?
In some ways, the biggest challenge is our own counter-transference. We get understandably anxious and afraid when clients engage in self-harming behaviors and that can impact our ability to remain calm, be patient and non-judgmental, and to avoid pathologizing the behavior. There is usually a lot of pressure put on us by family and loved ones to get the behavior to stop as soon as possible, and that doesn't happen overnight. The other big challenge is the short-term pay-off that clients get when they self-harm: a release of endorphins; a feeling of being soothed; a way to short-circuit overwhelming affect and thoughts. Those pay-offs are very reinforcing and make it difficult for clients to initially give up their self-harming behaviors.
What is the most important thing practitioners treating clients who self-harm should know?
The behaviors are not arbitrary- they happen in response to situational and interpersonal triggering, and they serve important functions including: a creative way for clients to communicate pain narratives that they either don't have words for, or are afraid to articulate with words, numbing out painful feelings; and self-soothing. They genuinely make clients feel better- for a short-time- and then inevitably make them feel worse when the guilt, shame, self-blame and self-loathing return. Therefore, clinicians need to help clients find alternative ways to accomplish what self-harm does for them. This means other ways to "tell" their pain narratives and safer, more compasionate ways to do affect regulation.
What is the most prevalent misconception about self-harm?
There are actually a lot of misconceptions about self-harm. The first is that self-harm is indicative of a desire to commit suicide- which is almost never the case. When clients hurt themselves to the point of endangering their lives, it is usually because they are in a dissociative state and lose the ability to monitor or control what they are doing. The second big misconception is that self-harm responds well to standard safety contracts. I believe these contracts set up power struggles between clients and practitioners and oftentimes lead to an exacerbation of the behavior. People also believe that kids self-harm because they see other kids doing it, and it's a normal developmental rite of passage. I believe that anyone who self-harms does so because there is something about the behavior that resonates for them, and because they are in pain. It is not a normal adolescent rite of passage. And lastly, the mental health field typically labels people who self-harm as "borderline," which actually puts a glass ceiling on the extent to which they can get better. I believe that we should view these people as "trauma survivors," or people with "pain narratives," which creates a more hopeful diagnosis and a more compassionate approach to treatment.
It It's important for practitioners to remember that when clients hate themselves, it resonates to hurt themselves. Self-harming behaviors evoke tremendous shame, which fuels self-hatred and perpetuates the cycle. Working with clients to approach their self-harm with compassion, helping them understand why they do what they do, and then offering them other ways to communicate, self-regulate, and cope, are the major cornerstones of treatment. And all of this needs to happen within a context of clinician self-awareness and self-care, so we stay effective and don't burn-out. My book, and my upcoming workbook, entitled, "Letting Go of Self-Destructive Behaviors: A Workbook of Hope and Healing" give clinicians and clients alike, the tools they need to accomplish all of these things!
Key articles, websites, or resources for practitioners:
Cutting and Self-Harm: Self-Injury Help, Support and Treatment
"The Clean Wrists Campaign" offers a forum for hope and support
See Lisa Ferentz: Institute for Advanced Psychotherapy Training and Education, Inc.
Free Access Articles:
Borderline Personality Symptomatology as a Mediator of the Link Between Child Maltreatment and Adult Suicide Potential, Archives of Suicide Research
Eating Disorders in Men: Underdiagnosed, Undertreated, and Misunderstood, Eating Disorders
Why do people self-harm?, Psychology, Health & Medicine
Self-harm and psychosocial characteristics of looked after and looked after and accommodated young people, Psychology, Health & Medicine
A study of self-harm in older people: Mental disorder, social factors and motives, Aging & Mental Health
An Educational Response to Deliberate Self-Harm: Training, Support and School-Agency Links, Journal of Social Work Practice
The development and piloting of an instrument to measure care staff attitudes towards child self-harm, Vulnerable Children & Youth Studies
Near-lethal self-harm in women prisoners: contributing factors and psychological processes, The Journal of Forensic Psychiatry & Psychology
Characteristics and Psychosocial Predictors of Adolescent Nonsuicidal Self-Injury in Residential Care, Preventing School Failure: Alternative Education for Children and Youth, Volume 58, Issue 1, 2014
The Cessation of Deliberate Self-Harm in a University Sample: The Reasons, Barriers, and Strategies Involved, Archives of Suicide Research, Volume 17, Issue 4, 2013
Non-Suicidal Self-Injury in Women Offenders: Motivations, Emotions, and Precipitating Events, International Journal of Forensic Mental Health, Volume 12, Issue 3, 2013
Deliberate Self-Harm, Substance Use, and Negative Affect in Nonclinical Samples: A Systematic Review, Substance Abuse, Volume 34, Issue 2, 2013
Repeat Self-Harm among Children and Adolescents Referred to a Specialist Service, Journal of Child & Adolescent Trauma, Volume 6, Issue 1, 2013
Sexual Minority Status, Abuse, and Self-Harming Behaviors among Incarcerated Girls, Journal of Child & Adolescent Trauma, Volume 5, Issue 2, 2012, Special Issue: Trauma and Juvenile Delinquency, Part I: Dynamics and Developmental Mechanisms
Retrospective Identification of Episodes of Deliberate Self-Harm from Emergency Room Registers in General Hospitals: An Example from Shanghai, Archives of Suicide Research, Volume 17, Issue 4, 2013
Association Between Deliberate Self-Harm and Coping in Adolescents: A Critical Review of the Last 10 Years' Literature, Archives of Suicide Research, Volume 17, Issue 2, 2013
Risk factors for nonsuicidal self-injury in Japanese college students: The moderating role of mood regulation expectancies, International Journal of Psychology, Volume 48, Issue 6, 2013
Adolescent Self-Harm Behavior And Choke By Diana López, New Review of Children's Literature and Librarianship, Volume 19, Issue 2, 2013
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