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Therapy - Part V in Self-Injury series

© Sheri Wallace

Therapeutic approaches A group of activists and trainers in the U.K. is working on training A&E (emergency room) personnel on ways to make what is often the self-injurer's first contact with the medical system a productive encounter. This effort is spearheaded by nurses, former self-injurers, therapists, and others. Similar efforts in the US, Canada, and Australia would be worthwhile.

Overall considerations In order to help those who self-injure, therapists must understand what role this powerful coping mechanism plays in their clients' lives. Is it primarily a means of releasing tension? Grounding? Communicating? Reliving painful experiences? Understanding why a particular person self-injures is key to helping that person stop using self-harm as a primary coping mechanism. "[H]aving [immediate cessation of self-injurious behavior] as a primary goal may well be counter-productive," warn Solomon and Farrand (1996); "techniques based on the premise that self-injury should not be reinforced by attention, or on the use of sanctions such as withdrawal of treatment, will almost certainly cause greater distress." Therapists need to examine their own motives for wanting a client to cease or stabilize his/her self-injurious behavior. Too often, care providers focus on stopping the SI as quickly as possible because they themselves are not comfortable with it -- it repulses them, makes them feel ineffective, frightens them, etc. Situations like this can easily deteriorate into a power struggle in which the therapist insists that the behavior stop and the client chooses to self-injure covertly and becomes reticent and distrustful, thus reducing the chance that a useful therapeutic alliance will be formed.

On the other hand, it is legitimate for therapists to help clients devise some sort of plan for dealing with self-injurious impulses and getting their lives (including SIV) stabilized. When a client is engaging in uncontrolled self-injury, the SI and its concomitant crises take center stage in therapy, leaving no room for dealing with core issues. In order to have a minimum of stability in treatment, therapists must walk a fine line between attempting to repress/control all self-injurious behavior and allowing the SIV to dominate the therapy.

An ideal approach would be one in which SIV is tolerated but has specific consequences. For example, a client might be invited to contact the therapist when an urge to self-harm occurs, but restricted from contact for 24 hours after an actual self-injurious act. In a system like this, the self-injurer has a chance to articulate what she is trying to communicate through her body without having to resort to self-injury, and she knows that carrying through an act of SIV will have tangible and immediate (but not permanent) negative effects. This kind of agreement between therapist and client can help stabilize the SIV and clear the road for dealing with the issues underlying the need to injure, allowing the therapist to follow Kehrberg's advice to treat self-harm within the context of underlying pathology.

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