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. Therapists should ensure that self-injuring clients have access to non-judgmental, compassionate medical care for wounds they inflict on themselves (Dallam, 1997), care that does not rob them of their dignity or autonomy. Together, client and therapist can devise a plan for getting physical wounds treated without adding additional stress to the situation. This may involve educating physicians at local emergency rooms about the nature of SIV. Since successful treatment of SIV depends heavily on teaching the client new ways of coping with stressors so that underlying painful material can be dealt with, hospitalization should be used only as a last resort when the client is at risk for suicide or severe self-injury (Dallam, 1997). Hospitals are artificially safe environments, and the necessary tasks of learning to identify the feelings behind the act and of choosing a less-destructive method of coping need to be practiced and reinforced in the real world. Favazza (1998) advocates the use of high-dose SSRIs and mood stabilizers to get self-injury under control quickly, then suggests that care be managed under a team concept, with an overseeing psychiatrist who manages meds and coordinates care, a psychotherapist, and a group therapist. He also recommends that hospitalizations be kept brief. Several SI units have been started in U.K. hospitals, however, where self-injury is tolerated and clients are encouraged to examine their behavior after an incident. The staff accept some SI as inevitable and try to use these occasions as ways to teach about coping without SI. In cases like these, longer hospitalization may have more value. Approaches taken by those who see self-injury as associated with BPD Dialectical Behavioral Therapy * [3]Interpersonal Group Therapy Approaches taken by those who see self-injury as non-BPD-related The CPTSD approach Healing from TRS Rational-Emotive Therapy Psychopharmacological approaches [8]Individual psychotherapy and how to choose a good therapist [9]Where to go for professional help

Hypnosis and relaxation

Hypnotic relaxation techniques have apparently been used, with some success, as an adjunct to therapy. Malon and Berardi (1987) state that treating those who self-injure requires that the therapist realize the conflicting needs of the therapist to be in charge of the relationship and of the patient to be treated like an equal; if the patient's need for being seen as an equal isn't met, no progress can be made with or without hypnosis. The study in question reports success with three types of hypnosis:
  • Breath counting: the patient is led into a trance and instructed to notice her breathing, counting each deep slow breath.
  • Positive imagery: the patient is put into a trance state and instructed to visualize herself in a calm, pleasant, relaxing place doing something she enjoys. This image is held for a while.
  • Affect bridge: after trance is achieved, the patient is asked to use the current unpleasant feelings to remember other times in his life when he's felt this way. Memories that are too distressing to talk about in a normal state are sometimes speakable in a trance state.
It's important to note that in all of these techniques, the therapist must remain seated close to the patient, offering encouraging words and/or touches when appropriate. Malon and Berardi go so far as to say that "simple hypnotic techniques...offered the most immediate relief when delivered with a strong communicative focus and close here-and-now contact."

Hospital-based treatment

SAFE Alternatives (1-800-DONTCUT) is an inpatient program specifically for self-injurers located at MacNeal Hospital in a Chicago suburb (this program was formerly located at Rock Creek Hospital and at Hartgrove Hospital). The program combines milieu therapy, cognitive-behavioral therapies, and group and individual exercises to help patients gain an awareness of why they hurt themselves and how to stop. They claim to be the only inpatient unit for self-injurers in the U.S., though Rock Creek continues to have a program specifically for SI, as do a few other hospitals. Although their zero-tolerance policy toward SI is controversial, they claim to have lost very few clients because of it. There is no empirical evidence of the success of their approach, and I personally am uncomfortable with their overly aggressive marketing style. The hospital is quite expensive, and if you haven't insurance, you probably can't afford it. The Sanctuary at Friends' Hospital in Philadelphia is an inpatient unit for trauma survivors that is aware of the special needs of self-injurers and takes them into account in its treatment program. Butler Hospital in Rhode Island offers a partial hospitalization program that uses dialectical behavioral therapy to treat a diverse patient population of self-injurers. In a recent assessment of their program, they conclude, "Two years of operation of the women's partial program provides promising anecdotal evidence that DBT, which is an outpatient approach, can be effectively modified for hospital settings. . . . Our experience with more than 500 women certainly suggests that such treatment may be a feasible alternative to inpatient hospitalization" (Simpson, et al. 1998). Butler can be contacted at (401) 455-6200. The Rock Creek center still offers an inpatient self-injury management program and can be reached at 1-800-669-2426.

Treatment efficacy

In a 1998 review, Hawton et al. evaluated the effectiveness of ten different approaches to treating self-harm: problem-solving therapy, a special emergency room card getting the patient faster treatment in the ER, intensive education and outreach, and dialectical behavior therapy were compared to standard aftercare; inpatient behavior therapy was compared to inpatient insight-oriented therapy; admission to the hospital was compared to discharge after the ER visit; flupenthixol (fluanxol, an anti-psychotic drug not available in the US with severe potential side-effects) and antidepressants were each compared to placebo; followup by the initial treating therapist was contrasted to followup by a different therapist; and long-term therapy was compared with short-term therapy. They found no significant difference in % of repeaters who were in the long-term vs short-term therapy trials, the antidepressant vs placebo trials (which used mianserin, a drug that increases serotonin in the brain, and nomifensine, a dopaminergic drug that has serious side effects and is no longer available), the intensive intervention/outreach vs standard aftercare trials, the emergency card trials, and the hospital admission vs discharge trials and the (possibly too small to yield a significant effect) inpatient behavior vs insight-oriented therapy studies. The problem solving studies showed a distinct reduction in SI among those who got problem-solving therapy, but the results of combined studies did not reach statistical significance. The flupenthixol study showed significant reduction in repeat self-harm, but it was a very small study and there is some concern that the possible side effects of fluanxol outweighed any benefit. The two trials showing a significant decrease in repeat self-harm among the experimental group were the DBT studies (the DBT group has fewer repeaters) and the same vs different therapist doing followup (the % of repeaters was higher in the group that saw the same therapist).