Tag Archives: self-harm

’13 Reasons Why’: Strengths, challenges and recommendations

By Laura Shannonhouse, Julia L. Whisenhunt, Dennis Lin and Michael Porter September 4, 2017

The Netflix series 13 Reasons Why has launched a national discussion regarding teen suicide, motivating a webinar response from professional organizations about how to shape the dialogue, dozens of editorials and millions of cautionary letters home from schools to parents across the country.

The series, based on a novel, is narrated by high school student Hannah Baker, who made a series of cassette tapes to be passed to 13 individuals she argues contributed to her reasons for dying. Her story is seen through the eyes of a peer, Clay, who listens to the tapes. He comes to understand Hannah’s perspectives about those people and events she claims motivated her suicide, which include Clay’s own (in)actions.

The series has been critically acclaimed for the acting and commended for addressing challenging topics, such as bullying/cyberbullying, sexual assault and teen suicide. However, school administrations, school counseling associations, suicide prevention organizations and counseling/psychology associations such as the American Foundation for Suicide Prevention (AFSP), the Suicide Prevention Resource Center (SPRC), the American School Counselor Association (ASCA) and the National Association of School Psychologists (NASP) have advised caution because of the graphic nature, revenge fantasies and potential contagion effect. This article highlights strengths and major challenges of the series. It also provides recommendations that have been underrepresented, though not absent, in the discussion.

 

Strengths

1) Raising awareness that suicide is a real problem.

According to the Centers for Disease Control and Prevention (CDC), suicide is a major public health issue. The most recent  statistics available note that among high school students, 17 percent have seriously considered suicide, while 8 percent have attempted suicide within the past 12 months. We know that for every suicide, there are many survivors, including the family and friends of the person and those who have experienced psychological, physical and social distress after exposure to a suicide.” The most commonly cited statistic is that each suicide directly affects six people; however, more recent research argues there are between 45 and 80 survivors per suicide.

In 2015, there were more than 44,000 reported suicide deaths, including 5,191 deaths by suicide among those ages 15 to 24. However, this statistic includes only those that were reported. Although there is no consensus on the rate of under-reporting due to stigma or ambiguous cause of death, the best analysis suggests that for each completed youth suicide, there are 100-200 times as many nonfatal suicide actions.

Combining CDC data with our current understanding of rates of suicidal ideation in youth, in this moment there are close to 15 million people in the U.S. who think of suicide in any given year. Suicide is a very real public health issue; when it is ignored, stigmatized or minimized, we as a community are missing the chance to prevent it.

2) Even professional counselors may not be ready to respond to a suicidal situation.

Because counselors often receive referrals of clients who are suicidal, counselors’ competency in identifying and intervening with those at risk is crucially important. However, the overtaxed counselor in 13 Reasons Why, Mr. Porter, is underprepared to face a suicidal student coping with complex trauma. Although he did not act in the scope of best practice, his failings are unfortunately not unusual among counselors, despite decades of advocacy for increased suicide assessment trainings in counselor education.

Mr. Porter missed several suicidal statements (e.g., “I need everything to stop”), made assumptions about contributing events and was uncomfortable talking about suicide (and other issues). We may easily judge Mr. Porter’s mistakes, but as counselors, we should take this opportunity to reflect and ask ourselves if we are ready to respond to a student at risk of suicide. The research is equivocal.

3) Suicide is complex and individual.

Although 13 Reasons Why portrays some known “red flags” that can indicate suicidal intent, the factors that contribute to individual suicides vary. Stressors that may influence one person’s decision to die by suicide may not have the same effect on others. For instance, we know that not all people who are depressed die by suicide (research shows the rate is from 2-15 percent) and that not all people who complete suicide are depressed. There is a variety of prevention programming regarding common warning signs. However, there is no perfect amalgam of warning signs or demographics (e.g., risk for transgender persons) that helps us differentiate who will decide to die by suicide. We need to go beyond just learning warning signs in order to help.

Livingworks, a suicide intervention training organization, focuses on three elements when assessing warning signs and risk factors. First, we must look for the meaning behind stressful events. For instance, in 13 Reasons Why, being listed “Best Ass” was highly distressing to Hannah because she felt objectified and was concerned people would misperceive her to be easy. However, another student, Angela “Best Lips” Romero, was flattered by such attention. The meaning behind the stressful event is more important than the stressful event itself.

Second, we need to know that warning signs can be, and often are, expressions of pain. When Hannah pushed Clay away, he recognized that something was wrong but did not see that her rejection was an indication of emotional pain. Third, we must trust our intuition. One peer recognizes Hannah’s poem as a cry for help but does not offer assistance. We need to pay attention to our gut feelings and act on them to take care of each other.

13 Reasons Why provides an opportunity to see Hannah’s experience of several traumatic events (cyberbullying, being stalked, public objectification, losing money, feeling responsible for a person’s death, witnessing rape and being raped) and does a good job of depicting the pain, shame and isolation she experiences as a result. The viewer has an opportunity to consider Hannah’s subjective experience and understand how the cumulative effect of these “reasons why” motivates her to suicide.

One model to help contextualize suicidality is the interpersonal-psychological theory of suicidal behavior developed by psychologist Thomas Joiner. Joiner states that the highest risk occurs when one feels like a burden to others, feels alienated or lacks belongingness and, crucially, has overcome the natural human inclination toward self-preservation. This model posits that suicide is a process — one gradually builds tolerance to the idea through self-injurious thoughts or behaviors (although each person’s path is unique). There are multiple points on that path at which others can intervene. The 13 Reasons Why series emphasizes those missed opportunities. As in Hannah’s case, every day there are suicides that happen as a result of those missed opportunities.

4) The central message is a positive one.

In the last episode, Clay says to Mr. Porter, “It has to get better, the way we treat each other and look out for each other.” Instead of feeling guilty or turning away, we can task ourselves with being more supportive community members.

All too often, we operate from a place of fear, which is understandable considering that schools have a legal duty to protect students from self-harm, and lawsuits are a potential reality (as shown in 13 Reasons Why). However, when systems or individual responders act out of fear, it focuses the interaction away from the needs of the person at risk. Even well-intentioned modern practices of “suicide gatekeeping” have substituted swift (and protocol-driven) identification and referral for the direct supportive intervention by community members proposed by John Snyder in 1971. Clay’s words echo those from Snyder half a century ago, when he said that most “who attempt suicide are victims of breakdowns in community channels for help.”

Although Mr. Porter clearly failed to proper identify Hannah’s suicidal ideation, perhaps even more troubling was his failure to hear her story and understand the factors behind her decision to die by suicide. Listening and demonstrating empathy to someone who is struggling was demonstrated to reduce suicidal ideation on calls to the National Suicide Prevention Hotline. Talking about suicide can help the person at risk to no longer focus on the past or feel alone and, instead, shift to the present moment, where the person can feel understood and cared for. If those in Hannah’s community who were witness to her emotional pain had actively engaged her and listened, it may have reduced her isolation and lessened her self-perception as a burden. This may even have prevented Hannah’s death.

Research indicates that our personal beliefs about suicide influence our responder behaviors. Therefore, gaining awareness of our beliefs and how our ability to intervene is affected by them is vital. Regardless of whether we can stop a suicide, we can control how prepared we are to try. We can make sure that our systems (in schools and elsewhere) are places where it is easy for someone to receive help.

After working through Hannah’s tapes, Clay now believes that we are, in a way, our brother’s keepers. Community-level response by direct intervention is a central theme in my (Laura Shannonhouse) research. It involves equipping “natural helpers” (e.g., teachers, bus drivers, resources officers, school counselors/psychologists) with the skills needed to perform a life-assisting suicide intervention at the moment it is needed most.

The producers and cast of 13 Reasons Why have underscored their desire for this series to start a conversation. Although that has certainly been accomplished, we hope the dialogue focuses more on how we can “look out for one another” and foster communities less at risk for suicide.

 

Challenges

1) Graphic nature and contagion

Viewers of 13 Reasons Why watch two rape scenes and Hannah’s suicide, which is shown in detail. Nic Sheff, one of the writers of the series, stated that the scene of Hannah’s suicide was intended “to dispel the myth of the quiet drifting off.” Some crisis texts suggest that we “deromanticize” suicide by helping our clients understand the unintended effects of trying to die by suicide, such as surviving but becoming disabled or alienating friends and family. Therefore, an argument could be made that a graphic, painful portrayal of suicide is warranted.

However, research does suggest that suicide portrayals can contribute to contagion by triggering suicidal behaviors in people — particularly youth — who are experiencing high levels of emotional distress. In fact, SPRC and AFSP have made recommendations for best practices in prevention of suicide contagion. A discussion of post-suicide intervention to prevent contagion is beyond the scope of this article, but as an example, the locker memorial portrayed throughout the series is against standard guidance (it should not last for weeks, as shown). Furthermore, when considering how media reaction to the series has often included sensational headlines, it is helpful to review these recommendations for reporting on suicide.

2) Survivor’s guilt and revenge fantasies

By assigning “reasons why,” the series sends a message that Hannah’s death is caused by other people’s actions. When Clay openly questions, “Did I kill Hannah Baker?” his friend Tony answers dramatically, “Yes, we all killed Hannah Baker.”

Although we suggested earlier that we all have a responsibility to create communities that help prevent suicide, Tony’s level of direct attribution can be counterproductive. Hannah experienced multiple losses, traumas and stressors caused by others, both intentionally and unintentionally. Placing responsibility for her death on those individuals instead of on Hannah’s action can exacerbate survivors’ guilt. Those viewers who have lost a friend, loved one or acquaintance to suicide may feel even more strongly after viewing the series that “It is my fault.”

These feelings are associated with lower functioning in comparison with survivors of accidents. Although undeserved, survivor’s guilt is a real phenomenon, and considerable research shows that even counselors who experience the death of a client by suicide can experience shame/embarrassment and emotional distress.

Whereas Clay may feel guilt for his part in Hannah’s story, the tapes could implicate others in criminal or negligent behavior, perhaps giving Hannah posthumous revenge. Some viewers who may have struggled with suicidal ideation themselves could get the message that if they take their lives, they can get revenge on those who have hurt them. This is an additional reason that schools across the nation and professional helping organizations have felt the need to do damage control for 13 Reasons Why.

 

Recommendations

1) Parents need to not just talk but watch, listen and connect.

Some school counselors argue that it’s harmful for children and teens to watch the series on their own without the support of a parent or trusted adult because the series depicts a graphic and romanticized portrayal of a teenager in crisis and does not identify competent resources capable of helping her. Accordingly, many experts encourage parents to talk to their children about the series. In addition to using talking points, we recommend that parents listen deeply and without judgment to what their children say. When people feel genuinely heard, they are more likely to talk about their true thoughts and feelings.

To accomplish this goal, parents can use active listening skills, such as open-ended questions, reflections of feeling, paraphrasing and encouragement. Also, we recommend that parents watch the series and risk being human — risk being impacted by the series and empathizing with their child. The construct of empathy is powerful, particularly if it is sincere. For a three-minute visual summary, consider watching Brene Brown on empathy. In our counseling skills courses, we often talk about “getting in the well of despair” and genuinely connecting with others. We know that talking about suicide paradoxically provides a significant buffer to suicidal action.

2) We need more than prevention programming in schools.

We know from a well-regarded U.S. Air Force study that we need suicide programing at all three levels: prevention, intervention and post-intervention. Many suicide prevention programs have been implemented in the school context, but there is mixed evidence of their effectiveness. From our clinical experience in crisis response, our scholarship and our history with training a specific model of suicide intervention, we need to acknowledge that we are biased about what types of programming should be implemented and when is the right time to implement. We feel that an appropriate first step for a school system is to implement basic screeners and gatekeeper trainings such as Signs of Suicide or Sources of Strength.

However, suicide prevention should not end with identification for referral. Optimally, the process continues by assessing level of risk, identifying reasons for dying and reasons for living, discussing alternatives to dying, enlisting the support of trusted loved ones and limiting access to lethal means or securing the person’s environment. Because youth who struggle with thoughts of suicide often seek out the support of those they trust rather than professional mental health providers, those teachers, coaches and others with open hearts and doors are the most effective gatekeepers for a system. Their nondirection and empathy are useful pedagogical qualities and vital to effective suicide intervention.

We endorse models that empower those “natural helpers” to provide a potentially life-saving intervention for students who are in suicidal distress. Although this may be augmented with the support and follow-up of a trained mental health provider, gatekeepers can implement the steps listed above.

3) Be intentional about identifying caregivers and shifting school culture.

My (Shannonhouse) research involves partnering with school districts and superintendents (in Maine and Georgia) to identify “natural helpers” and equip them with the skills to perform a life-assisting intervention in the moment (i.e., Applied Suicide Intervention Skills Training, or ASIST). These natural helpers are often teachers, resource officers, coaches, administrative staff, bus drivers and other people who are likely to be confidants to students who experience distress. Measuring suicide intervention skills and responder attitudes is easy for an academic. Identifying those school personnel in the trenches who would be first responders is more difficult — it requires the total involvement of administrators. Furthermore, such an approach requires schools to commit to a student-centered response model.

ASIST is relationship-driven and aligned with the values of the helping professions. It meets the needs of students who are at risk by focusing on responding to those immediate needs rather than referring the student (which can lead to further isolation and an increased sense of burdensomeness). Although the student is often referred for more long-term counseling, ASIST provides the student with a six-step intervention at the moment it is most needed and can be performed by anyone over age 18. Having natural helpers trained in ASIST or a similar protocol can dramatically increase a school’s responsiveness and effectiveness to help students in distress.

4) Use an intervention model backed by research.

ASIST is a 14-hour, two-day, internationally recognized and evidence-based model that has been adopted by multiple states and the U.S. Army. It has also been recognized by the CDC and used in crisis centers nationwide. Caregivers trained in ASIST consistently report feeling more ready, willing and able to intervene with a person at risk of suicide.

The program has been evaluated in a variety of settings (click to download), with pretest to post-test improvement noted in trainees’ comfort level at intervention and in their demonstrated intervention skills in response to simulated scenarios. Although outcome research is rare, research compared ASIST-trained counselors with those trained in other models through a double-blind, randomly controlled study of more than 1,500 calls to the National Suicide Prevention Lifeline. Those trained in ASIST more often demonstrated particular behaviors such as exploring invitations, exploring reasons for living, recognizing ambivalence about dying and identifying informal support contacts. Those trained in ASIST also elicited longer calls.

We found that ASIST can be applied to both university and K-12 settings. Our work measured increased suicide intervention skills and beneficial responder attitudes, which have been maintained over time. We have trained more than 500 people in ASIST and have received multiple reports of teachers disarming fully formed suicide plans with their new skills. More recently, we have conducted behavioral observations of ASIST responder behavior and have begun evaluating outcomes of students who have received ASIST intervention. Initial results have been promising, including better coping and commitment to follow-up and decreased lethality.

 

Summary

Although 13 Reasons Why gives us pause for its poor portrayal of effective suicide intervention, we feel that the series raises awareness and, at its core, advocates a community-level response to suicide prevention. This message to “look out for each other” is aligned with more intervention-oriented gatekeeping. We have explored the impact of one such model, ASIST, in several educational settings and found that it improves responder behavior. Furthermore, this approach comes with a mindset that systems can harness their strengths (i.e., natural helpers) to focus on responding to and intervening with the student rather than simply identifying and referring the student to the system.

 

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Please contact me (Laura Shannonhouse) should you have any questions about our research.

 

 

Laura Shannonhouse is an assistant professor in the Counseling and Psychological Services Department at Georgia State University. Her research interests focus on crisis intervention and disaster response, particularly involving social justice issues in this context. Currently, she is conducting community-based research in K-12 schools (suicide first aid) to prevent youth suicide and with disaster-impacted populations in fostering meaning-making through one’s faith tradition (spiritual first aid).

 

Julia L. Whisenhunt is an associate professor of counselor education and college student affairs at the University of West Georgia. She specializes in the areas of self-injury, suicide prevention and creative counseling. She is particularly interested in the relationship between self-injury and suicide and ways that mental health professionals can apply this knowledge to clinical intervention.

 

Dennis Lin is an assistant professor at New Jersey City University, with areas of expertise in play therapy, child/adolescent counseling and assessment, suicide prevention/intervention, quantitative research and meta-analysis. He is also a certified master trainer of Applied Suicide Intervention Skills Training (ASIST).

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Addressing ethical issues in treating client self-injury

By Julia L. Whisenhunt, Nicole Stargell and Caroline Perjessy July 24, 2016

AuthorsAs professional counselors, we enter this field with a desire to understand and help others. There comes a time in every counselor’s career, however, when intellectual understanding is overpowered by the need for empathic understanding. This is particularly true when counselors work with clients who intentionally cut, burn, scratch, hit or otherwise injure themselves.

Jennifer Muehlenkamp and colleagues found that this coping skill, known as nonsuicidal self-injury (SI), may be used by as much as 18 percent of the general population. Furthermore, Laurie Craigen and colleagues found that as many as 39 percent of adolescents may self-injure. It is important to note that SI is separate from socially sanctioned body modification practices (e.g., piercings, tattoos), substance use or physical fighting, which can also seem intentionally harmful but have different underlying purposes.

Purpose of SI

For those who do not purposefully inflict physical harm on themselves, the concept of SI can be both foreign and confusing. As counselors, we need to know that SI works for some people, most often to help them manage intense and often painful emotions. In fact, David Klonsky, a pioneer in SI research, found that emotion regulation is the single most common function of SI. Emotional pain is linked with physiological arousal (e.g., pounding heart, headache), and SI can ease this tension, channel the pain and bring arousal to a bearable level.

Researchers such as Klonsky, Muehlenkamp, Janis Whitlock, Brianna Turner, Alexander Chapman and Brianne Layden have also examined other functions of SI. For example, SI can serve as a method for transforming emotional pain into physical pain, which can be easier to cope with for many people. SI can serve as a way to validate feelings and create a visual representation of the pain within them. Some people who self-injure may do so to cope with feelings of dissociation or depersonalization — to help themselves feel “real” or “alive” again. This is especially relevant for people who feel numb because of depression or trauma. SI can be used to vent anger privately or to channel anger toward the self as a form of punishment.

Finally, although less common, SI can serve as a means of communicating with or influencing others. Despite popular stereotypes, SI is rarely meant to be intentionally manipulative. Most often, clients who self-injure for this reason do so because they do not know more effective ways of communicating their needs and distress. In fact, the majority of clients who self-injure do so in private and are very secretive about it. Admittedly, some people self-injure to either intentionally or unintentionally influence others, but this is not the primary motivation for most clients. Consequently, assuming malicious intent behind SI can be grossly invalidating to clients’ experiences and can severely damage the therapeutic relationship.

Although the motivations for SI are complex and unique for every individual, the lay community has often equated SI with suicide. Whitlock and colleagues found that as many as 60 percent of people who self-injure may experience suicidal thoughts or behaviors. Although SI is a strong predictor of suicide, a large portion of people who self-injure do not struggle with suicide.

Several differences exist between SI and suicide regarding intent, means, frequency, severity, and emotional antecedents and consequences. Researchers such as Chapman and Katherine Dixon-Gordon have found that the emotions experienced prior to and following SI and suicide attempts are largely different. Furthermore, Muehlenkamp and Peter Gutierrez found that people who self-injure are often able to identify more reasons for living than are people who are suicidal. In fact, for some people, SI may serve an anti-suicidal function that is life preserving.

Counselors working with clients who self-injure are likely to encounter some ethical dilemmas regarding safety concerns and duty to warn/protect. With that in mind, we want to discuss some ways for counselors to address common ethical concerns that tend to emerge in this type of work. This list is not comprehensive, however, so counselors should use an established ethical decision-making model and consult or seek supervision as necessary.

Counselor values

Although counselors are trained to nonjudgmentally join with their clients, counselors may have intense reactions to SI. Doreen Fleet and Rita Mintz found that shock, sadness, anger, anxiety, frustration and diminished professional self-confidence are common responses to SI.

It is important to remember that the therapeutic relationship can be damaged beyond repair if clients feel judged. Even if counselors temper their initial reactions and support clients who self-injure, other counselor values can be damaging to the client and the therapeutic relationship. For example, it is unhelpful to assume that every client who uses SI needs to be hospitalized. We will discuss safety assessment later in this article, but counselors should remember that SI and suicidality are not equivalent.

Some counselors might feel that a contract specifying no SI would encourage clients to use healthier coping skills, but that can stem from a counselor’s anxiety surrounding the behavior and can lead to clients feeling judged by the one person who is supposed to be nonjudgmental. Moreover, SI works as a coping skill for some clients, and asking them to give up their most effective coping skill in the absence of other ways of coping can leave them feeling scared and helpless. In addition, nonharming alternative behaviors (e.g., snapping a rubber band, using a red water-soluble marker) may reduce risk, but they are not effective ways of addressing the underlying mental health issues.

Out of concern, some counselors may lecture clients on the dangers of SI and the fear that SI evokes for loved ones. Although psychoeducation can be used very effectively with clients who self-injure (e.g., dangers and wound care), there is a fine line between psychoeducation and lecturing. Many people who use SI experience self-imposed shame and guilt or have it imposed on them by others. Consequently, lecturing clients on the consequences of SI or otherwise attempting to convince clients not to self-injure can be harmful.

Similarly, chastising clients for doing permanent damage to their bodies is also unhelpful because SI is commonly a way for some people to connect with their bodies and find physical and emotional relief. It can also be unhelpful to insist on seeing a client’s wounds. If the client would like to show you his or her wounds, that can be therapeutic in itself. However, we are not medical doctors, and we should refer physical assessments to someone who is properly trained.

Overall, counselors should work toward empathic understanding of SI and reduce stereotypes or countertransference in the relationship. Working with clients who self-injure presents unique considerations for clinicians, who must manage their own reactions and beliefs about SI while simultaneously providing sound therapeutic care. Supervision, consultation and treatment teams are key sources of support and monitoring when working with these clients.

Confidentiality

The issue of confidentiality can be complicated when working with clients who self-injure, especially if those clients are minors. Confidentiality and privacy should be explained clearly in informed consent, which is an ongoing process.

At intake, or when SI is disclosed, counselors should explain techniques and interventions that will be used specifically to address SI. Counselors should also be very clear about the duty to protect and how SI might lead to mandated reporting, such as if the client develops suicidal intentions or if SI results in a major health risk (e.g., large, infected wounds).

If the client is a minor and caregivers are aware of the SI, an open discussion should occur to determine what types of information will be shared (e.g., types of interventions, progress toward goals) and how this will be shared with caregivers (e.g., privately over the phone, after session with the client present). If the caregivers of a minor are not aware that the client is using SI, counselors might need to disclose this information to parents because of the possibility of foreseeable harm. Again, however, it is important for the client to feel empowered throughout the treatment process, especially when the counselor must notify parents or loved ones.

Foreseeable harm and safety planning

Although it is important to temper counselor anxiety and methodically work through the counseling process with clients who self-injure, it is also important to actively monitor and continually assess client suicide risk. Clients sometimes minimize their use of SI, and counselors must astutely tune in to the serious nature of this behavior, understand the possibility of increased harm in the future and put adequate interventions in place.

Relatedly, clients might disclose SI before they are ready to work toward goals related to the behavior. Counselors must explore the paradox between autonomy and nonmaleficence, constantly assessing for the point at which risk outweighs the client’s readiness to change. As mentioned previously, it is generally not helpful to ask clients to stop self-injuring in the absence of other effective coping skills. So, part of this process typically involves diminishing risk while simultaneously enhancing the client’s other strengths and coping skills.

Ongoing formal and informal suicide assessment should be part of the therapeutic process. However, it is critical that counselors do this in a way that is neither assumptive nor judgmental. It is also helpful to develop a safety plan with all clients who self-injure. Clients can
use the safety plan during times of distress, regardless of whether suicidal ideation is present. A major component of providing care to clients who self-injure involves the counselor’s efforts to ensure the appropriateness of services through consistent consultation, supervision and referrals.

Assessment of SI and suicide

Assessment of SI begins at intake. We believe it is important to ask all new clients about their history of intentional SI. There are a number of assessment instruments for SI, some of which screen for SI, some that monitor risk of suicide and some that assess the functions of SI. Examples include Kim Gratz’s Deliberate Self-Harm Inventory, Matthew Nock and colleagues’ Self-Injurious Thoughts and Behaviors Interview, Marsha Linehan and colleagues’ Suicide Attempt Self-Injury Interview, and Catherine Glenn and David Klonsky’s Inventory of Statements About Self-Injury. As is the case with any therapeutic issue, counselors should document their use of established assessment instruments, consultation or supervision, and a reputable decision-making model to uphold proper standards of care.

In consideration of the elevated risk of suicide and the sometimes conflicting feelings about life and living that some clients who self-injure may experience, it is important for professional counselors to use recursive suicide risk assessment practices. Without assuming that clients who self-injure are suicidal, counselors should conduct suicide risk assessments at intake, at Branding-Images_injuryperiodic intervals and as indicated throughout the therapeutic relationship. Counselors should remember that suicide risk assessment involves more than asking a quick close-ended question. Rather, it should involve use of a reliable and valid instrument and should include dynamic, ongoing discussions about stress, coping and ideas about living.

When working with clients who self-injure, we ask counselors to remain attuned to the risk factors and warning signs of suicide so that they can respond most appropriately if risk elevates. Safety plans (as opposed to no-harm contracts) are an effective way to build the counseling relationship and minimize client risk. At a minimum, safety plans include identification of warning signs, internal coping strategies, positive distractions, people to ask for help, professionals/agencies to ask for help and ways to make the environment safer.

Competence

As professional counselors, we are charged with practicing only within the boundaries of our competence based on education, training, supervised experience, state and national professional credentials, and appropriate professional experience. However, clients who self-injure usually present with multiple treatment issues that are complicated for both novice and seasoned clinicians to conceptualize.

Clients who self-injure often have trauma and abuse histories. Consequently, they can also struggle with eating disorders, poor body image, personality disorders, anxiety, depression and suicidal ideation. Because clients who self-injure may present with complex symptomatology and even acute distress, counselors may doubt their clinical competence and ability to meet the therapeutic demands of this client population.

Efforts to improve feelings of competence can be addressed in a variety of ways. First, we can encourage counselors to remember that the best way to understand clients’ lived experiences is to create a safe context in which clients feel free to share their stories. Counselors can promote clients’ sense of safety by exhibiting humanistic qualities such as unconditional positive regard, which can both strengthen the therapeutic relationship and convey understanding and acceptance of the client.

Next, counselors engaging in ongoing supervision and consultation can improve their clinical skills related to working with this population. Discussing clients who self-injure, in supervision or consultation contexts, provides counselors with new and different perspectives on their work, which can help them modify their treatment planning and clinical interventions. Consultation and supervision also offer counselors opportunities to reflect on how they feel toward their clients. Considering how strongly our value systems shape our work with clients, this is an invaluable exercise.

It is also imperative that counselors who work with this population review the existing literature on SI, seek continuing education on SI and remain current on emerging SI research. Competent counselors should practice treatment strategies that are evidence based and well-grounded in the literature, and access reputable resources, such as those stemming from the International Society for the Study of Self-Injury.

Finally, in situations in which clients are not progressing or a therapeutic impasse cannot be resolved, competent counselors should understand how and when to refer to another provider. Often, when counselors are unable to promote a strong therapeutic alliance or further treatment goals, it is the result of a lack of training or experience that can be remedied through additional training, supervision and consultation.

Evidence-based practices

SI is a complex treatment issue and, for obvious reasons, counselors may feel ill-equipped to effectively intervene when clients self-injure. However, just like with any treatment issue, effective intervention begins with having a safe and nonjudgmental relationship. This is not to say that knowing the complexities of SI and how to intervene appropriately are unimportant. Rather, we hope readers will remember to start with the relationship and use interventions and treatment strategies that are grounded in the literature.

In the next section, we provide a brief introduction to a few therapeutic strategies that have shown promise with clients who self-injure. It is important to note, however, that no specific treatment interventions have proved largely effective for the treatment of SI. So, counselors often rely on theoretically grounded interventions and those proposed by leaders in the field of SI. For a more detailed yet succinct review of evidence-based practices in the treatment of SI, see the ACA Practice Brief on nonsuicidal self-injury by Julia Whisenhunt and Victoria Kress (see counseling.org/knowledge-center/practice-briefs). The practice brief provides references to a number of researchers who have

examined SI intervention. Additionally, we recommend a recent publication by Catherine Glenn, Joseph Franklin and Matthew Nock, who examined the evidence base of SI treatments for youth and rated their effectiveness using the Journal of Clinical Child and Adolescent Psychology standards level system.

Individual interventions: Dialectical behavior therapy (DBT), created by Marsha Linehan, improves emotion regulation skills and intrapersonal awareness by challenging and modifying one’s cognitions, emotions and behaviors. As mentioned earlier, emotion regulation is the single most common function of SI, so learning to regulate emotions in healthier ways can decrease SI behaviors. DBT interventions are most successful when clients feel supported and accepted by their counselors and when counselors believe in their clients’ ability to change. The evidence base on DBT for SI is still limited, and some results are conflicting, but DBT may be useful for managing some of the emotion dysregulation and alexithymic aspects of SI.

Because of the maladaptive and distorted cognition seen in many people who self-injure, cognitive interventions may be well-indicated. Both David Klonsky and Nadja Slee independently suggest that cognitive therapy has been found to be most effective when focusing on the specific SI behavior and on emotion regulation skills. Problem-solving therapy, a type of cognitive therapy, may be effective when combined with cognitive, behavioral and interpersonal interventions. However, Jennifer Muehlenkamp and others have noted that the long-term results are mixed and inconclusive.

Other empirically based treatment approaches focusing on the behavior of SI include behavioral management strategies, functional assessment analysis of SI and means restriction/delay of SI. Klonsky, Muehlenkamp, Stephen Lewis and Barent Walsh provide a nice overview of these interventions in their book Nonsuicidal Self-Injury, which is part of the Advances in Psychotherapy Evidence-Based Practice series. All of these interventions promote the use of learning new behaviors in an effort to reduce the occurrence of SI.

Pioneered by William Miller and Stephen Rollnick, and applied to the treatment of SI by Victoria Kress and Rachel Hoffman, motivational interviewing (MI) is a humanistic-based therapy that can be used to enhance client motivation to change. At its core, MI is a client-centered approach that demands counselor nonjudgment and acknowledges that every client who comes to counseling is at a different place of readiness for change. Although the application of MI to the treatment of SI has not been researched well, counselors may find MI particularly useful for fostering a strong therapeutic alliance and working with clients who may not be willing or ready to cease self-injuring.

Family interventions: Family support can be a protective factor against SI and suicide. As such, family therapy can promote client change and well-being. Family members who engage in therapy can learn how to communicate with their loved ones in ways that are affirming and nonblaming. Counselors can help educate family members on the reasons that their loved ones engage in SI behaviors.

Family therapy can also help counselors explore family dynamics and how those patterns may have influenced clients’ propensity to self-injure. Trauma, abuse, unhealthy communication patterns, inappropriate alliances and other family dynamics can occur in the family of origin and create toxic relationships that are dysfunctional and in need of repair. Counselors can help clients mend these broken relationships, which in turn can potentially decrease the clients’ desire to self-injure. Klonsky and his co-authors provide a brief overview of the support for applying family therapy to the treatment of SI in their book.

Summary

To help ensure a growth-promoting experience and minimize both risk and liability, counselors should keep a number of things in mind when working with clients who self-injure. These include the following:

  • Monitoring one’s own values when working with clients who self-injure for the purpose of avoiding making the client feel unsafe or creating inappropriate therapeutic conditions
  • Identifying when and how to make disclosures of confidential information regarding SI
  • Identifying foreseeable harm regarding severe SI or suicide
  • Using reliable and valid assessment instruments to identify and monitor SI
  • Monitoring one’s own competence to treat SI
  • Using evidence-based therapeutic interventions

Above all else, we hope readers will remember five key points about SI from this article:

1) SI is often used as a coping skill, but it always has a function (and sometimes multiple functions). For most people, that function is emotion regulation. Therefore, identifying the function or functions can help to guide intervention.

2) Treatment that focuses exclusively on stopping the SI behavior fails to address the underlying reasons for the behavior and is not likely to produce long-term change.

3) Counselors’ reactions — both verbal and nonverbal — communicate clear messages to clients who self-injure. If counselors want their clients to feel safe and not judged, counselors should start by identifying their biases regarding SI.

4) Counselors need to be specially educated and trained in how to intervene with clients who self-injure. There are risks and therapeutic pitfalls that can be minimized with adequate understanding of SI.

5) SI and suicide are not equivalent, but counselors should work to monitor suicide risk without assuming that all clients who self-injure are suicidal.

The information provided in this article is not exhaustive, but we hope readers will be stimulated to continue learning about SI so that when (not if) a client presents with SI, they will feel better able to intervene.

 

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We would like to extend a heartfelt thanks to our friends and colleagues Victoria Kress and Chelsea Zoldan for their contributions to this article.

 

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Julia L. Whisenhunt is an assistant professor of counselor education and college student affairs at the University of West Georgia. She is an editorial board member for the Journal of Counselor Leadership & Advocacy and serves Chi Sigma Iota (CSI) International through committee membership. A licensed professional counselor (LPC), national certified counselor (NCC) and certified professional clinical supervisor (CPCS) in Georgia, she specializes in the areas of self-injury, suicide prevention and creative counseling. Contact her at jwhisenh@westga.edu.

Nicole Stargell is an assistant professor in the Department of Educational Leadership and Counseling at the University of North Carolina at Pembroke. She is a member of the CSI International Counselor Community Engagement Committee, the ACA Practice Briefs advisory group and the editorial board for the Counseling Outcome Research & Evaluation journal. She is an LPC, NCC and licensed school counselor.

Caroline Perjessy is an assistant professor of counselor education and college student affairs at the University of West Georgia.  An editorial board member of the Association for Specialists in Group Work, she has presented and published on dialectical behavior therapy and postmodern approaches to counselor practice and pedagogy. She is an LPC and CPCS in Georgia.

Letters to the editor: ct@counseling.org

 

 

Responding to the rise in self-injury among youth

By Brent G. Richardson & Kendra A. Surmitis October 23, 2014

The prevalence of nonsuicidal self-injury (NSSI) among adolescents and young adults has rapidly and significantly increased in recent years, leading mental health professionals and researchers to describe its pervasiveness as epidemic. By definition, a person does not engage in NSSI with intent Photo of authors Brent Richardson and Kendra Surmitisto die. Rather, NSSI is a means of regulating emotions, relieving tensions, managing dissociative symptoms and influencing others. It is critical that counselors working with youth gain an understanding of NSSI and recognize its prevalence within the adolescent population.

There is growing evidence that many teenagers who engage in NSSI have been influenced by their peers. In 1985, Barent Walsh and Paul Rosen defined self-injury contagion in two ways:

1) When acts of self-injury occur among two or more persons within the same group within a 24-hour period

2) When acts of self-injury occur within a group of statistically significant clusters or bursts

The primary focus of this article is to identify environments that present a high risk for self-injury contagion and to suggest opportunities for counselors to minimize and prevent contagion when working with adolescents.

Benefits and pitfalls of group work

Many programs designed to treat adolescents who self-injure include group therapy as an essential ingredient in the treatment milieu. S.A.F.E. (Self Abuse Finally Ends) Alternatives, founded in 1985 by Karen Conterio and Wendy Lader, was the first treatment facility designed specifically for people who self-injure. Since its inception, clinicians at S.A.F.E. Alternatives have used group therapy as a central feature of its treatment programs. Dialectical behavior therapy (DBT), which combines individual therapy, group skills training and family education, has emerged as one of the most effective treatments for adolescents who are suicidal and/or self-injure. Many of the key skills needed to reduce self-injurious behaviors (for example, emotional regulation, distress tolerance and interpersonal communication skills) are learned and practiced in group therapy. Solution-focused therapist Matthew Selekman recently developed a nine-session Stress-Busters’ Leadership Group geared specifically toward adolescents who engage in self-destructive behaviors. The group is applicable in both school and community settings. While these group approaches (S.A.F.E. Alternatives, DBT and Stress-Busters) have several differences, it is important to note that each is largely didactic, highly structured and skill-based.

Group work is appealing both to adolescents and counselors for a number of reasons. For logistical and developmental reasons, group homes, residential facilities and hospitals typically utilize various forms of group work as their primary mode of treatment. Groups are more efficient and cost-effective than individual approaches because they enable counselors to work with more clients. In addition, group work tends to be a better developmental fit for adolescents than individual therapy, and adolescents often prefer it because a significant amount of social learning occurs in the context of formal and informal groups (for example, family group, classroom group, social group and sports teams).

Youth who self-injure tend to feel isolated and disconnected. Although individual counselors can inform youth that they are not alone, the group process allows them to experience a sense of universality with their peers, while learning from others who are at different stages in the recovery process. By assisting and supporting others, members begin to see themselves in a different light. One of the most effective ways to boost a youth’s self-esteem and self-confidence is to structure situations in which he or she can help others and feel altruistic.

Despite the potential benefits of using groups as a component in treating those who self-injure, there are also possible pitfalls that could disrupt the process or even increase self-injurious behaviors. Walsh, author of Treating Self-Injury, says counselors should be mindful that anytime individuals who self-injure are treated in groups, there is an increased risk for a contagion effect. In addition, he warns that groups that are largely cathartic in nature — wherein youth are encouraged to openly express their emotions and share traumatic experiences — are often counterproductive with this population. These types of groups can increase the risk of contagion because open discussion of self-injury antecedents, behaviors and consequences can be exceptionally triggering for some young clients.

Many clinicians and researchers assert that group leaders should structure activities that focus on empowerment and replacement or coping skills training, while prohibiting detailed discussion of self-injury. This can be challenging for counselors because sharing and hearing details about self-injury can be so alluring for both counselors and group members. Adolescent clients may view group therapy as an opportunity to compare wounds and share stories. These disclosures should be severely limited or prohibited from the onset, however. Counselors may want to acknowledge that discussing self-injury in great detail may be important but emphasize that those details should be shared in individual therapy rather than with group members.   

In summary, NSSI groups are most likely to be effective if:

1) Group leaders have significant training and understanding of treating self-injury and managing contagion

2) Membership is closed to enhance cohesion and trust

3) The group is governed by strict rules prohibiting the discussion of details of self-injury and the sharing of wounds or scars in the group

4) As with DBT groups, the sessions are highly structured, didactic and focus on teaching new skills and behaviors (for example, emotional regulation, mindfulness, self-soothing, distress tolerance and exercise) to help reduce further incidents of self-injury

Benefits and pitfalls of residential facilities

Similar to treatment in group therapy, clinicians who work with youth in residential treatment can be effective in counteracting self-injury, provided they follow the proper precautions.

The residential population is likely at higher risk for contagion due to peer influence and the prevalence of severe psychopathology such as eating disorders and issues with affective regulation. In fact, a number of researchers have observed that NSSI occurs in significant clusters in residential settings, including community-based group homes, special education boarding schools, juvenile detention facilities and psychiatric inpatient settings. Recognizing the potential for contagion in a residential population allows for appropriate precautions when determining the benefits of residential treatment on a case-by-case basis, and it can aid in the appropriate response to NSSI.

Several studies have found that self-injurious behaviors often increase for adolescents, regardless of Photo of self-injury wounds on armwhether they have a prior history of self-harm, during residential treatment. Clinical settings that feature multiple youth living together who exhibit emotional dysregulation can aggravate dysfunctional behaviors, including NSSI. Consequently, the increased likelihood of exposure to self-injury in a residential facility leads to the question of whether the benefits of inpatient care are worth the potential risks associated with contagion.

Despite concern for social contagion, several arguments can be made in favor of choosing residential treatment for NSSI. For example, cases that include high-risk behaviors such as clinically significant disordered eating require structured, intensive treatment. In similar circumstances, placement in a residential facility may be warranted, even if nonresidential treatment may pose less risk of self-injury contagion.

The first step in response to the risk of social contagion is making the appropriate referral to residential care on an individual client basis, while avoiding unnecessary hospitalization. Within the residential setting, precautions guide clinicians toward the appropriate response to NSSI. These responses include educating the individual client, confronting triggers of social contagion and using encouragement to motivate youth to build and share healthy coping skills.   

Subsequently, many of the challenges and recommendations for counselors who work in residential facilities are similar to those provided for group counselors. Although communicating with peers in a communal environment is beneficial for those who feel isolated and may benefit from peer support, mental health counselors are advised to educate residents on the negative effects of sharing stories of self-injury. These clients should instead be instructed to share stories of healing and healthy coping behaviors. 

Benefits and pitfalls of websites and message boards

Although the Internet is a potentially valuable source of support and information for self-injurers, various websites can also be breeding grounds for social contagion. Approximately 93 percent of American youth ages 12 to 17 use the Internet, and nearly two-thirds of adolescent Internet users go online daily. These numbers are growing every day. In the past decade, the number of websites intended for or about people who self-injure has increased. Research conducted in 2007 by Janis Whitlock, Wendy Lader and Karen Conterio revealed there were more than 500 message boards focused on self-injury. These researchers also observed the parallel between the increase in self-injury websites and the growth in self-injury awareness in society. Internet message boards provide a potent medium for bringing together adolescents who self-injure.

These self-injury websites and message boards offer a number of potential benefits. The Internet may have particular relevance and appeal for adolescents who are socially avoidant or feel marginalized. These youth may feel extreme relief upon finally being able to make meaningful connections with individuals who share similar concerns and experiences. The anonymity of these sites might also encourage youths to share more frequent and truthful disclosures about their feelings and behaviors. Positive peer pressure is another potential benefit. As is the case in group counseling, these adolescents might more readily accept online feedback from peers that encourages them to practice safer, more productive ways of expressing their emotions.

Thus, it is important that counselors not minimize the perceived value that these sites have for young clients who self-injure. Though social scientists and mental health professionals often focus on the potential harm of these discussion groups, adolescents who use them tend to self-report positive experiences as a result of their participation. For example, in one survey of self-harm discussion group members, Craig Murray and Jezz Fox found that the majority of respondents reported having reduced the frequency and severity of their self-injurious behaviors. The respondents attributed this largely to the support and guidance they found online.

Whitlock and her colleagues were some of the first researchers to study the content of self-injury message boards to better understand their role in sharing information about self-injurious practices and influencing help-seeking behaviors. These researchers found that the most common type of exchange on the message boards involved providing informal support to other posters through comments such as “We’re glad you’ve come here” and “Just relax and try to breathe deeply and slowly.”

However, in addition to the supportive communication found on NSSI-related sites, researchers also found dangerous messages. While 44 percent of all help-seeking posts presented favorable attitudes toward seeking mental health treatment, approximately 20 percent of the posts discouraged individuals from seeking treatment and/or voiced negative views about therapy. There was also considerable discussion about better ways to conceal scars and maintain secrecy.

These researchers warned that self-injury message boards expose vulnerable youth to a normalizing environment of encouragement for self-injury and hold the potential for fueling social contagion. On several sites, members shared new and often more dangerous techniques and instruments for cutting and even offered links to sites where self-injury paraphernalia could be purchased. Sites that feature graphic depictions of self-injury, including many videos on YouTube, can be highly suggestive or triggering to other self-injurious participants. Unfortunately, those who self-injure can become better at self-injury by learning from others they meet online. Some posters use chat rooms to coerce others, model self-destructive behaviors, compete with others and discourage others from stopping their self-injurious behaviors or seeking help.

As is evident, self-injury websites and message boards are helpful for some and counterproductive for others. Regardless, this needs to be an area of therapeutic inquiry. In fact, the popularity of the Internet among adolescents presents a crucial argument for assessment of Internet use in general, as well as specific assessment of Internet exposure to self-injury. Mental health professionals should therefore educate themselves about various websites for self-injurers (some recommended sites are included in the next section).

Whitlock and her fellow researchers suggested that clinicians maintain a curious, neutral, nonjudgmental tone when asking questions such as the following:

  • How comfortable do you feel hearing stories from others who self-injure?
  • Have you shared your own story? How did you feel?
  • What do you like most about having friends whom you really know only through the Internet?
  • How honest are you when you share information on the Internet? (Do you minimize or tend to embellish?)
  • Do you ever take advice from Internet friends? If so, can you provide examples of advice that you used?

Some NSSI sites have minimal or no monitoring for potentially dangerous content. If there are moderators, they typically have minimal or no training in mental health. With certain clients, counselors might assess that it is best to be direct in encouraging or discouraging particular sites or interactive behaviors. Counselors can clarify concerns about why some sites might be traumatic or triggering and therefore countertherapeutic. These direct suggestions will likely be more fruitful with adolescents who have entered counseling voluntarily, begun to develop a therapeutic relationship with the counselor and voiced a desire to stop or reduce self-injury.

Summary recommendations

In this article, several mediums have been identified as environments at high risk for social contagion of NSSI — namely group treatment, residential facilities and social media. Key considerations for the prevention of social contagion were identified. These include:

  • Developing a clinical understanding of social contagion and its significant impact on the adolescent population through training and further research
  • Working with clients who engage in NSSI to develop awareness of appropriate environments to discuss their self-injury stories, such as individual therapy sessions
  • Asking clients who self-injure to cover up scars, wounds and bandages that can be triggering
  • Prohibiting graphic detail of NSSI at the onset of group therapy
  • Incorporating strength-based strategies that encourage healthy coping behaviors in treatment
  • Assessing client Internet use, with specific attention paid to exposure to self-injury imagery
  • Determining the appropriate level of treatment and avoiding unnecessary hospitalizations that may invoke NSSI in vulnerable clients
  • Instructing clients to share stories of healing and healthy coping behaviors to decrease the opportunity for contagion, while inspiring altruistic motives in a group environment

Furthermore, the role of mental health counselors working with youth engaging in NSSI extends past the therapeutic relationship encountered in treatment to the family system and school setting to which the child is connected. Providing appropriate referrals to information for concerned individuals in the child’s life, such as parents and other caretakers, is an important action in attending to NSSI and contagion among peers. The following websites provide helpful information grounded in clinical research and professional standards.

Empowering family members and other members of the client’s care system to understand self-injury will help them to comprehend the messages sent by the child who is engaging in the behavior, while promoting an atmosphere of awareness to counteract opportunities for contagion. As a provider of information, it is crucial that the counselor is clear when it comes to appropriate Internet material, such as empirically validated information for families, and the potential misinformation provided by sites containing blogs and graphic imagery. The prevention of contagion begins with understanding NSSI in youth and empowering the people in their lives who also share in the opportunity to preclude self-injury among adolescents.

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This article was adapted from a previous article published in the American Mental Health Counselors Association’s Journal of Mental Health Counseling.

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Brent G. Richardson is chair of the Department of Counseling at Xavier University in Cincinnati. Contact him at richardb@xavier.edu.

Kendra A. Surmitis is an assistant professor of counseling in the Department of Educational Psychology at Northern Arizona University. Contact her at kendra.surmitis@nau.edu.

Letters to the editor: ct@counseling.org

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When the hurt is aimed inward

Lynne Shallcross May 1, 2013

faceCutting. Burning. Headbanging. Embedding. Self-hitting. Pinpricking. Thinking about people intentionally hurting themselves in these ways can be difficult but, sometimes, counselors don’t have a choice.

When a client struggling with nonsuicidal self-injury (NSSI) appears in a counselor’s office, the counselor’s task is to help — and the perhaps natural reaction to cringe or admonish the client is not an effective way of achieving that goal, says Trevor Buser, an assistant professor of counseling at Rider University in New Jersey who has been researching and presenting on NSSI for about six years.

“A few of the NSSI methods, such as needle insertion, are a bit graphic to describe,” says Buser, who presented on assessing and diagnosing NSSI at the American Counseling Association 2013 Conference & Expo in Cincinnati in March. “I sometimes notice students grimacing when I deliver a lecture on the topic. This kind of reaction is understandable. I’ve felt unsettled too upon hearing some descriptions of NSSI. At the same time, we need to be sensitive to the verbal and nonverbal communications that we are sending to clients about these behaviors. Several authors have recommended that we counselors maintain a calm, accepting posture while clients share details about the use of NSSI.”

Offering that sense of calm and acceptance was integral to Kim Johancen-Walt’s work with “Jennifer,” a client Johancen-Walt calls one of her most memorable. When Johancen-Walt first met Jennifer, then 15, the teenage client was already cutting several times daily, but that soon ballooned to upward of 50 times a day. During the course of their work together, Jennifer was placed in residential treatment and was hospitalized once due to life-threatening circumstances from her self-injury.

Jennifer experienced trauma as a child, having grown up in a chaotic environment with an absent father and an alcoholic mother. “Although Jennifer’s family had overcome many challenges and now offered support, she was still struggling with old patterns of thinking that continued to fuel self-injury,” says Johancen-Walt, an ACA member who has 20 years of experience working with clients on issues of self-injury and suicide in a variety of settings. A third of her caseload in her private practice in Durango, Colo., involves clients either currently or formerly engaged in self-injury. “When I asked Jennifer why she self-injured, she talked about how it helped her to ‘feel something.’ Due to her childhood experiences, she had a deeply infected belief system that she was both invisible and undeserving.”

Equipped with that information and knowing that Jennifer felt very disconnected from herself and others, Johancen-Walt focused on building her relationship with Jennifer. “I wanted to give her a corrective experience in our therapy that communicated that she was both seen and valued. I accepted her unconditionally and told her she deserved love and kindness throughout treatment,” Johancen-Walt says. “Although the old messages of self-hatred were still there, she now had a different way of defining herself. With my help, along with [that of] many others, she was eventually able to do what I now refer to as ‘putting a wedge in the choke hold of self-injury.’”

Johancen-Walt still has a list that Jennifer found online of 72 strategies to avoid self-mutilating. The strategies include putting a rubber band on your wrist and snapping it when experiencing an urge to self-harm and holding ice cubes until they melt. But Jennifer’s favorite strategy was one that she created herself — going someplace where self-injury was not invited and committing to stay there until the urge passed.

“She reminded me that just as with other types of addictive behavior, we have to help people replace faulty coping skills with more effective ones,” Johancen-Walt says. “This takes time, but eventually the scale can tip and the costs of self-injury can begin to outweigh the benefits [for clients]. She also taught me how quickly habituation can happen and why we have to talk about self-injury from the beginning of treatment.”

At the point when Johancen-Walt and Jennifer stopped working together, Jennifer was still having occasional “slips,” Johancen-Walt says, but she was also righting herself more quickly and maintaining the progress they had made together. “We both defined her treatment as a success and acknowledged that she was a long way away from where she was at the beginning of treatment,” Johancen-Walt says.

Johancen-Walt emphasizes that she represented only one component of the support Jennifer received. Her support system also included her family, the caregivers in residential treatment and the school-based outpatient program where Johancen-Walt was then working as a therapist. “I believe that our work — and relentless support — helped her explore other possible ways of viewing herself in the world and an awareness that reality is subjective,” Johancen-Walt says. “Although it took several months, and a break from therapy while in residential treatment, she was finally able to accept care and validation from others, and [she] improved quickly. Her lens had effectively changed,” says Johancen-Walt, who contributed a chapter to The Adolescent & Young Adult Self-Harming Treatment Manual by Matthew D. Selekman.

Jennifer stands as one of the most difficult self-injury cases Johancen-Walt has ever treated, and yet she also remains a lasting inspiration to Johancen-Walt. “Jennifer is probably one of my most memorable cases not only because I saw her early in my career as a therapist, but for a variety of other reasons as well. She taught me more about self-injury than any book or course could have ever offered, and she also taught me about the resiliency of the human spirit. Jennifer eventually stood up to self-injury and suicide and offered me countless tips and strategies that I still use to this day. When I am feeling discouraged about a particularly difficult case of self-injury, I think of her and remember that there is always hope. I carry that with me on the journey.”

An equal-opportunity issue

Reported rates of self-injury vary, depending in part on the definition researchers use for self-injury and the population being studied, says Victoria Kress, a professor of counseling at Youngstown State University in Youngstown, Ohio. The highest rates are typically reported among adolescents. An article published last year in the journal Pediatrics notes that in samples of early adolescents and older adolescents, the rates of NSSI range between approximately 7 and 24 percent.

Together with researchers from Stanford, Harvard, Cornell and Princeton, Kress studied self-injury among college students from eight universities in 2006 and 2007 and found that the lifetime self-injury rates among that population averaged a little more than 15 percent.

Although there is a higher prevalence for self-injury among adolescents and college-age young adults, Kelly Wester, an associate professor in the Department of Counseling and Educational Development at the University of North Carolina at Greensboro, points out that NSSI has been reported in children as young as 7 and in adults older than 70. It is not uncommon for self-injury to begin during adolescence and continue into adulthood, according to Wester.

“The longer someone engages, the harder it is to extinguish it,” says Wester, an ACA member who presented on self-injury at the ACA Conference in Cincinnati. The longer self-injury continues, she explains, the more likely it will become an automatic response in how the person copes with stressful events, emotions or thoughts. Over time, clients might come to view self-injury as something that has “always worked for them,” Wester says.

NSSI refers to the deliberate, direct, self-inflicted damaging of a superficial or moderate amount of bodily tissue without the intent to die and without social sanction, says Buser, past president of the International Association of Addictions and Offender Counselors, a division of ACA. “The issue of social sanction is emphasized … to differentiate this behavior from culturally accepted forms of self-injury, such as body piercings or rites of passage,” he adds.

Several recent studies have found no variation in rates of NSSI according to racial or ethnic background, biological sex or socioeconomic status, Buser says. However, higher prevalence rates have been identified for individuals who identify as lesbian, gay or bisexual, he says.

Historically, self-injury has been conceptualized primarily as a problem among females, but research shows that it is just as common among men, says Kress, president of Chi Sigma Iota, the international counseling honor society, and a presenter at the ACA Conference on spirituality as an insulating factor against NSSI. There are gender differences, however, in how people self-injure, Kress says. For instance, men are more likely to engage in self-hitting and head-banging, whereas women are more likely to engage in cutting.

Buser says one of the best known models, developed by Matthew Nock and Mitchell Prinstein, organizes the functions of NSSI into four basic categories, two involving interpersonal functions and two involving intrapersonal functions. “From the interpersonal perspective, clients may use NSSI as a way to avoid negative exchanges with others — for example, punishment — or obtain positive exchanges with others — for example, concern or care,” Buser says. “From the intrapersonal perspective, clients may engage in NSSI to stimulate positive affect or to reduce negative affect. In reviews of research on this topic, it appears that affect regulation — for example, tension reduction — is the most commonly reported function by clients who self-injure. In this sense, NSSI can be conceptualized as a coping mechanism for many clients.”

Indeed, Wester says a common thread among clients who self-injure is difficulty with emotional regulation. Oftentimes, these clients either don’t understand the emotions they are feeling or are unable to communicate them, so when something stressful happens, they can’t regulate their emotional state and can’t tolerate the feelings. Self-injury temporarily allows these individuals to relieve the emotional pain or connect with it, Wester says.

The goal for counselors, Wester says, is to help these clients recognize they are gaining control only temporarily through self-injury. With a counselor’s help, she says, clients can learn to slow down, identify the emotion, label it correctly and deal with it, thus gaining more permanent control without resorting to self-injury. Once clients possess the ability to regulate those heightened emotions, they are less likely to move forward into self-injury, Wester says.

On another end of the spectrum, Wester says, people who feel emotionally numb may self-injure in an effort to feel something. Additionally, Johancen-Walt says, although anyone can be at risk for self-injury, unresolved grief and loss appear to be common risk factors.

An invitation to share

Whether a client will present in a counselor’s office and openly acknowledge engaging in self-injury depends on the individual, Buser says. “Certainly, some clients are ashamed about their use of NSSI and may not disclose it to a counselor,” he says. “In fact, there is evidence that most individuals who perform NSSI do not seek psychotherapeutic services at all.”

Johancen-Walt says that many of her clients who self-injure are referred by others who care about them, including family members, friends, other counselors, teachers or doctors. “Out of those self-referred, many have reached a state of desperation where they feel completely out of control because either the self-injury is no longer working for them or because they know they are becoming more at risk,” she says.

In Wester’s experience, many clients who self-injure present with other issues such as depression, anxiety or grief. Because clients might feel uncomfortable mentioning that they self-injure, Wester says counselors should include questions about self-injury in their intake paperwork, in addition to asking the question directly in session. “Verbally ask if the client has hurt themselves in any way intentionally,” she says. “Ask for examples, and tell the client you know it’s different from suicide. It tells them that the counselor is OK with talking about it.”

Johancen-Walt agrees. “Clients are checking out our comfort level with this topic from the moment they enter our offices,” she says. “If I fail to address it, then I risk communicating to my client that I am not safe. If I can’t tolerate holding self-injury, then I can’t tolerate the reasons they are doing it.”

Additionally, if a client relays information about a significant loss, Johancen-Walt typically asks how the client has been coping with the impact of that loss. “This question is an invitation to talk about self-injury if it is in the room,” she says. “[With clients who] have not disclosed self-injury but I suspect it has been one of their strategies, I may offer stories of others who have experienced similar losses to those of the client and who resorted to various forms of self-injury. I will then ask the client if this is something they have thought about. This invitation communicates to the client that they are not alone and also communicates that I have experience talking to clients about it.”

Kress has worked for nearly two decades with clients who self-injure and has been researching and writing about the topic for 15 years. She offers a number of questions that can be helpful in assessing a client’s self-injury behavior and identifying potential risks:

  • Have you ever deliberately cut your body, burned your body, stuck sharp objects into your arm, broken your own bones, banged your head against a wall or picked at scabs or injuries without intending to kill yourself?
  • If yes, describe when you first did this, when you most recently did this and how often you do this.
  • Was there a time in your life when you engaged in self-injury more frequently? If yes, when?
  • Was there ever a time that you felt like you didn’t need to self-injure? If yes, what was different at that time?
  • What does self-injury mean to you?
  • What are some of the reasons you self-injure?
  • Do you wish to stop self-injuring?

Johancen-Walt and Wester point out that clients who engage in self-injury often use more than one method. Over time, Wester says, the severity of the chosen method of self-injury can increase.

Buser and his wife, Juleen Buser, who is also an assistant professor at Rider University, developed the HIRE model last year to assess a client’s self-injury behaviors. HIRE stands for history, interest in change, reasons for engaging and exposure to risk. The model helps counselors facilitate an informal assessment of NSSI in those four primary domains.

In the HIRE model, “history” refers to clients’ methods and frequency of engaging in NSSI. “Interest in change” refers to their motivation for reducing NSSI behaviors. “Reasons for engaging” provides counselors with insights into what clients are trying to alleviate. “Exposure to risk” addresses safety concerns, such as sense of control while self-injuring, use of alcohol or drugs while self-injuring and level of tolerance to self-injury.

More information on the HIRE model will be included in an article the Busers wrote that is in press for an upcoming issue of the Journal of Mental Health Counseling.

Finding a way in 

After identifying that a client is engaged in self-injury, Buser recommends conducting a functional analysis of the behavior as a good first step. Determine how, when and where the client is engaging in self-injury. From the client’s perspective, what purposes does it serve? How does the client feel during and after the self-injury?

“In the midst of these questions, I’ve found it useful to remember the value of empathy and other Rogerian conditions such as positive regard,” Buser says. “Many clients have gone to great lengths to hide their use of NSSI from others. Ideally, then, we’re attempting to provide a place where clients can share openly about NSSI and reflect on the functions being served.”

Another important preliminary step is bringing attention to safety concerns, Buser says. “If, for example, the client regularly uses alcohol or drugs or dissociates while self-injuring, then more intensive levels of intervention might be advisable,” he says. “Although we can point to indicators of increased risk for harm, as described in the NSSI research, I believe it’s particularly important for counseling staff members to come together and establish protocols for handling extreme cases of NSSI within their setting.”

Although most people don’t see any appeal to self-injury, it is important to understand that those who engage in it do so because they are getting something out of it, says Kress, who directs a community counseling clinic at Youngstown State. “You can’t say, ‘OK, you can’t do this anymore,’ and [expect that] will just happen,” she says. “If it was that easy, we [counselors] wouldn’t have jobs.”

Kress works with clients to highlight the natural consequences of self-injury and determine what problems the behavior might be causing in their lives. She says enhancing these clients’ motivation to change is paramount because, otherwise, they may choose not to follow through on what the counselor suggests.

In fact, after first assessing clients’ self-injurious behavior, Kress says the second step counselors should take is to assess clients’ motivation to stop. Kress finds motivational interviewing questions helpful for that purpose. Among the questions she uses:

  • How is self-injury getting in the way of you reaching your life goals?
  • How is the self-injury getting in the way of your day-to-day life?
  • What negative consequences has the self-injury invited into your life?
  • What is important to you? How does the self-injury get in the way of these important things?
  • What would your life look like if self-injury were not in it?

“Many people assume that clients who self-injure want to stop the behavior,” Kress says. “In my experience, almost all of my clients have ambivalence about ceasing the self-injury. A part of them finds that this behavior is working for them. The interventions typically used with this population, such as cognitive behavior therapy (CBT) or behavior therapy (BT), require [that] the client is motivated to change. If the client isn’t motivated to change, attempts to use CBT and BT approaches will likely be unsuccessful since in these approaches, clients are required to be active participants. In assessing and then enhancing a client’s motivation to change, counselors can develop a better understanding of the client’s motivations and goals, build trust via this collaborative process and deepen a client’s motivation to follow through on making behavioral changes. Even with clients who have no interest in ceasing the self-injury, I find that over time and with increased trust, I am able to assess the negative impacts and consequences of the self-injury and use that as a building block upon which behavioral changes can then be invited.”

One of the most important ingredients in a counselor’s ability to effectively help NSSI clients is building a strong therapeutic alliance, Kress says, and that includes not forcing the counselor’s values or goals on the client. In the opinion of Kress, if clients aren’t self-injuring with suicidal intentions, it is not appropriate for counselors to tell them they must stop.

Wester agrees, saying it is up to the client, not the counselor, to determine that extinguishing the self-injurious behavior should be the goal. Wester sets boundaries and communicates those boundaries to clients, telling them she will report their self-injurious behavior if there is mortal danger or if the individual is suicidal. But outside of that, she doesn’t force clients to set a goal of eliminating the behavior.

“You’re not going to make a client do something they don’t want to do,” she says. “If they’re open and honest with you, you need to accept them for what they’re doing and who they are. Be genuine and offer unconditional positive regard. What I’ve found in the past is if you force [the behavior to stop], clients will continue to do it; they just won’t talk to you about it, so it can actually become more dangerous.”

Probing the question of why these clients self-injure is also crucial, Johancen-Walt says. “People self-mutilate for a variety of reasons, and we have to be careful about making assumptions about a behavior. Over the years, I have received countless answers to that question. However, one of the most common responses I have received is that it serves as a form of ‘relief’ from emotional suffering. In these instances, it can be both a distraction and expression of emotional pain.”

Another common explanation is that clients want to “feel something,” Johancen-Walt says, which is usually indicative of those who feel incredibly disconnected from themselves and from those around them. Although less common, Johancen-Walt says some clients use self-injury as a form of self-punishment. “They have come to believe that they have to be punished, not only for their mistakes, but also for the mistakes of those around them,” she says.

Counselors must be careful not to make assumptions about these clients, especially concerning whether they are “attention seeking” or “manipulative,” Johancen-Walt says. “If a therapist communicates a kind of blasé attitude toward a client’s self-injury, then they are at risk of communicating to the client that their wounds are not significant enough to warrant care or even attention. Through this type of interaction, we are telling the client that they need to do something more drastic or life-threatening to get our help and support.”

Treatment and the therapeutic relationship

In reading the research being done in this area, Buser says it is too early to determine which counseling treatment is most effective for NSSI. He agrees with Kress’ suggestion of motivational interviewing, pointing out that it originated in treating addictions but has been used more recently with self-injury as well. Several researchers who have written on the topic have discussed the use of CBT in treating these clients, Buser adds. This would include finding and rehearsing replacement behaviors that may satisfy the same functions clients are seeking with self-injury but in a more adaptive way.

Kress notes that research has also supported the use of dialectical behavior therapy (DBT). “An example of a behavioral therapy technique, which is also used in DBT and often in CBT approaches, is a chain analysis,” Kress says. “In a chain analysis, you break down the sequence of behaviors and events — one at a time, like a chain — that lead to an incident of self-injury. A chain analysis is kind of like a road map in which the clients identify how they arrived at the place of self-injury. They identify where the road began and possible alternative adaptive pathways that lead away from the self-injury. In developing a chain analysis, clients can develop insight into their self-injury triggers, as well as the thoughts and their actions that have supported self-injury, and they can learn how to respond in more adaptive, self-nurturing ways.”

Working from a strengths-based perspective allows these clients to find and lean on their own existing strengths for support, Kress says. “For example, one of my clients is a voracious reader and found that reading helped distract her from stressful situations. We developed a behavioral plan that involved her always carrying a book in her purse, and she would read when she had urges to self-injure. Pulling on clients’ identified resources is so much more powerful than a counselor suggesting behavioral distractions. Clients know best what works for them. As a counselor, I see my role as being the person who supports them in identifying and applying their strengths.”

In a study Wester conducted, therapy from any perspective was shown to be helpful to clients dealing with self-injury. “I think it goes back to the therapeutic relationship,” Wester says. “It’s the nonjudgmental aspect.” Wester says she consistently hears from these clients that they feel judged, whether by medical professionals, teachers or others, for their self-injurious behavior. As a result, the individuals feel shamed and hide their behavior further. Regardless of the counseling theory or technique followed, Wester says, the most helpful thing a counselor can bring to session with a self-injuring client is unconditional support and nonjudgmental acceptance.

Johancen-Walt says she also tries to help clients externalize the self-injury. “I will teach clients who are ashamed and not wanting to talk about their behavior or what is fueling it that self-injury wants them to stay silent,” she says. “Self-injury keeps its power by being the only ‘person’ the client can confide in. It doesn’t want the client talking about it because it would feel threatened. Many clients feel isolated and separated from caring others, and I remind them that self-injury wants them alone so that it can remain a central figure in their lives.”

“In order to stay vigilant early in recovery,” she continues, “I remind clients that self-injury is a tricky beast, and if we extinguish one form of self-injury, then it may try to find another way in. It will have a new face but will still be trying to exert its power over the client. For example, a client who no longer experiences relief from cutting may begin flirting with other forms of self-injury, such as eating-disordered behavior, unaware that self-injury found a side door.”

Externalizing the behavior can also reduce resistance on the part of the client, Johancen-Walt says, helping the counselor and client to form a united front against self-injury.

With clients whose self-injury stems from an inability to identify emotions, Wester says creative approaches such as the expressive arts or music can sometimes help more than talk therapy alone. Wester has used masks with clients who self-injure, inviting them to draw or write on the outside of the mask what they show to the outside world. On the inside of the mask, they write or draw what they are experiencing internally. Wester often uses music with adolescent clients, asking them to bring in songs that represent what is going on in their lives.

Self-injury and suicide

Research suggests that counselors view working with self-injuring clients as one of the most stressful aspects of being a counselor, Kress says, in part because they worry about these clients attempting suicide. Kress points out that, by definition, self-injury is different from suicide. “It’s causing damage without suicidal intention,” she says.

Wester concurs, explaining that self-injury and suicide serve very different purposes for clients. “Suicide is to end life,” she says. “Self-injury is to control something in order to keep living and move forward.” In fact, Wester says, self-injury can even be a suicide preventer for some clients, providing them with what they view as temporary relief from suffering.

However, Kress says, she and some of her counseling colleagues conducted research in the fall and found that self-injury can sometimes be a gateway to suicide attempts. The research was published in the Journal of Adolescent Health in April and involved 1,466 students at five U.S. colleges. “If someone self-injures, you do want to take that seriously because they do have a higher risk for suicide attempts,” Kress says.

Buser says researchers have found that individuals who engage in NSSI are more likely to experience suicidal thoughts, and Johancen-Walt adds that suicide risk increases the longer someone engages in self-injury.

As difficult as it is to absorb that information without feeling anxious, Kress implores counselors not to overreact, such as by attempting to hospitalize clients to make them stop injuring themselves. “We have an ethical obligation to intervene if they’re suicidal, but with self-injury, if they don’t have suicidal ideation, you can’t [force them to stop],” she says.

If a counselor tries to force a self-injuring client to stop when the client hasn’t set that as a goal, it can harm the therapeutic alliance, Kress says. However, she says, counselors can and should regularly assess self-injuring clients for suicide risk.

Buser points out that suicide assessment questions should directly inquire whether a client is having thoughts about killing himself or herself because vague questions about “hurting” oneself could lead to confusion.

Johancen-Walt emphasizes that counselors should not assume that clients engaged in self-injury are suicidal because many are not. “However,” she says, “if self-injury is not addressed in treatment, a client’s risk of suicide may increase over time. This happens as tolerance to the behavior increases. These individuals may need ‘more of the drug’ in order to achieve the same amount of relief from their earlier behavior. For someone who is cutting in order to cope with emotional pain, this is a dangerous addiction. If these behaviors are left unchecked, a few shallow cuts to the wrist could change into deeper injuries resulting in permanent injury or death.”

A little understanding

In terms of fully understanding self-injury, Wester says, there is still a long way to go. For example, she says, the biological roots of self-injury and the reason people choose self-injury are still unknown. “There are a lot of theories and models that explain self-injury once clients are engaging in it, but there is little known about why people choose it. Why not eating disorders or substance abuse [instead]? No one truly understands why someone chooses self-injury over something else.”

The biological components of self-injury are just beginning to show up in research studies, she adds, but the question of why people choose self-injury over a different maladaptive coping mechanism has yet to be tackled.

Research will likely inform where treatment for NSSI goes in the future, but these counselors offer a few pieces of current guidance to those working with clients who self-injure.

Remember that the end goal may not be to eliminate the self-injurious behavior completely, Johancen-Walt says. Instead, it may be to change the client’s relationship with the behavior. “For example,” she says, “when the client is triggered and experiences an urge to ‘use,’ they can view that event as an opportunity to practice more effective coping skills, to figure out what they need and to validate themselves. This is a process I refer to as ‘shaking hands’ with self-injury.”

Johancen-Walt says counselors must also understand that these clients are engaging in self-injury in an attempt to survive; otherwise, they wouldn’t be doing it. She encourages counselors to share that sense of understanding with their clients. “I have had several clients over the years tell me that if they had not been self-mutilating they would have completed suicide,” she says. “By sharing this [understanding] with clients, I am not only communicating unconditional acceptance, I am also saying something to them that they have not heard from others in their lives, who have typically reacted out of fear and panic.”

Kress echoes that need for understanding. “Understand that the self-injury is their attempt to regulate their emotions. In a way, it is a life-sustaining behavior, whereas suicide is a life-taking behavior,” she says. “Consider what the client is trying to convey to themselves or to others by injuring. [This] is where you will find their ‘soft spot’ and be able to help them heal and change. People who self-injure have many capacities. Help them connect with these strengths and help them use these strengths to fight the self-injury influence.”

Finding the “soft spot” within each client means recognizing that each individual is unique — something Johancen-Walt says is vital in this work. One of her mentors taught her that counselors get into trouble as soon as they think they have clients figured out. Johancen-Walt carries that lesson with her, especially in her work with self-injuring clients.

“This is an important reminder for therapists who may think they have ‘seen it all,’” she says. “I remember that clients coming to my office are all unique individuals with their own unique set of challenges, strengths and resources. It is my job to listen.”

To contact the individuals interviewed for this article, email:

Prevention efforts

Not much is known about how to prevent self-injury among clients who have not yet begun to engage in it, says Victoria Kress, a professor of counseling at Youngstown State University in Ohio. But considering that self-injury often relates to an inability to regulate emotions, she believes any techniques that involve enhancing emotional regulation, identifying emotions and expressing feelings would be helpful in averting future self-injurious behavior among clients.

“Since interpersonal interactions and frustrations are the incidents that most frequently spur an episode of self-injury, people may benefit too from social-skills training, which places an emphasis on enhancing one’s ability to effectively communicate with others, especially as related to conflict situations,” Kress says. Additionally, research Kress recently completed suggests that helping to enhance a client’s sense of spirituality, meaning in life and life purpose may help to prevent self-injurious behaviors.

Prevention efforts would do well to focus on the development of basic coping and social skills, says Trevor Buser, an assistant professor of counseling at Rider University in New Jersey. “For example, training in stress management techniques, such as mindfulness, diaphragmatic breathing or progressive muscle relaxation, may provide healthy alternatives for individuals who would otherwise perform NSSI [nonsuicidal self-injury] for emotional regulation,” he says. “Incidentally, the same approach is often taken in prevention programs for substance and alcohol abuse, so these types of programs may be protective in multiple ways.”

— Lynne Shallcross

Learn more

For additional reading on the topic of self-injury, consider checking out these journal articles published by ACA or its divisions:

  • “Exploring Self-Injury Through a Relational Cultural Lens” by Heather Trepal, Journal of Counseling & Development, Fall 2010 issue
  • “Coping Behaviors, Abuse History and Counseling: Differentiating College Students Who Self-Injure” by Kelly Wester & Heather Trepal, Journal of College Counseling, Fall 2010 issue
  • “Assessment and Self-Injury: Implications for Counselors” by Laurie Craigen, Amanda Healey, Cynthia Walley, Rebekah Byrd & Jennifer Schuster, 
  • Measurement and Evaluation in Counseling and Development, April 2010
  • “Self-Injurious Behaviors: Assessment and Diagnosis” by Victoria Kress, Journal of Counseling & Development, Fall 2003 issue

Lynne Shallcross is the associate editor and senior writer for Counseling Today. Contact her at lshallcross@counseling.org.

Letters to the editor: ct@counseling.org