Tag Archives: self-harm

Self-injury: An overview for counselors

By Lauren Appel September 16, 2020

The challenges that students face today can be complicated and overwhelming, causing some youth to resort to self-injury to cope with the stress. According to a study by Martin Monto, Nick McRee and Frank Deryck (published as “Nonsuicidal self-injury among a representative sample of US adolescents, 2015” in the American Journal of Public Health), 1 in 4 girls and 1 in 10 boys will self-harm.

From my experience as a school counselor, I have found that the presence of self-injury often indicates significant underlying emotional issues. Given these realities, I believe it is more important than ever for counselors to familiarize themselves with this dilemma. This overview is intended to walk through what self-injury is and isn’t, who tends to be affected and how to intervene.

What is self-injury?

Self-injury, also known as nonsuicidal self-injury (NSSI), can be defined as deliberate, self-inflicted harm to body tissue without suicidal intent. This does not include behaviors that are socially accepted, such as piercings or tattoos. This definition is based on E. David Klonsky’s research presented in “The functions of deliberate self-injury: A review of the evidence,” published in Clinical Psychology Review in 2007.

NSSI includes, but is not limited to, cutting, burning, biting or scratching the skin, head banging, punching and pinching. Common injury sites include the hands, wrists, stomach and thighs, although injuries can occur anywhere on the body.

Who self-injures?

According to data taken from Jennifer Muehlenkamp and colleagues’ 2012 study, “International prevalence of adolescent non-suicidal self-injury and deliberate self-harm,” published in the journal Child and Adolescent Psychiatry and Mental Health:

  • 1.3% of children ages 5-10 self-injure
  • 17% of adolescents self-injure (this figure is high because it includes those who have self-injured only once)
  • 5% of adults self-injure

Overall, females have been reported to self-injure more than males. They tend to prefer cutting more than any other means of self-injury, according to Janis Whitlock and colleagues’ 2011 study, “Nonsuicidal self-injury in a college population: General trends and sex differences,” published in the Journal of American College Health.

Although males are reported to self-injure less often, it is possible that this is being underreported or that the self-injury is hidden behind behaviors deemed as “more masculine.” For instance, males are more likely to deliberately bruise or cause abrasions to themselves by punching walls or instigating fights to have others hurt them.

This aligns with the incorrect perception that males have to demonstrate a certain caliber of “manliness” and that the only acceptable emotion for them to feel is anger. I have had male students who said they would be ridiculed as sissies if they expressed feeling sadness or pain or demonstrated other aspects of vulnerability. Males tend to get more “cool points” for behaviors such as picking fights or punching walls than for engaging in other types of self-harm such as cutting.

Whitlock et al. also discussed how LGBTQIA individuals are affected by self-injury. Those who identify as LGBTQIA self-injure more frequently than do their heterosexual counterparts. In particular, bisexual females were 6.2 times more likely to have engaged in self-injury at some point during their lifetime. These data showed that this subgroup is at the highest risk for NSSI out of the other populations studied in terms of gender and different types of sexual orientation. This is clearly a population at high risk that needs to be monitored.

I have found that individuals in this subgroup often self-injure because they feel split between what is expected of them and who they really are. They tend to carry a significant amount of self-blame for not meeting those expectations or feel frustrated for having what they believe to be disturbing thoughts. When their secret lives become consuming, they often turn to self-injury for “escape.”

Trauma and bullying victims are also at high risk for self-injury according to Laurence Claes and colleagues’ 2015 study, Bullying and victimization, depressive mood, and non-suicidal self-injury in adolescents: The moderating role of parental support,” published in the Journal of Child and Family Studies. Those who have experienced trauma can internalize the event, which causes emotions that are difficult to handle and makes them more susceptible to NSSI. Clients who frequently experience bullying or peer rejection also tend to self-injure more than their counterparts do. My past students who were victims of bullying or abuse often felt that they could not fight back; in other words, they did not externalize their behavior as a coping mechanism. This then led them to an internalizing coping mechanism, which resulted in self-injury.

Myths about self-injury

The following myths are inspired by a fact sheet on top misconceptions about self-injury produced by Saskya Caicedo and Janis Whitlock for the Cornell Research Program on Self-Injury and Recovery.

Self-injury is a suicide attempt or a failed suicide attempt. Research has shown that most people who self-injure do not have the intention to die by suicide. The main motivation for self-harm is to deal with emotional stress or pain. The category name of nonsuicidal self-injury in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders provides a sense of separation from suicidal intent. This category is also being used by other organizations and in research, thus creating a distinct line between self-injury and suicidal intent. The majority of my students who self-injure have expressed no interest in ending their lives; they were simply causing superficial injuries.

Self-injury is done to seek attention. Some individuals may use self-injury as a tool to seek attention, but it is important to realize that this action still represents a desperate cry for help. Why are they going to such drastic lengths to get attention? This is a question that we, as counselors, need to ask ourselves so that we can intervene accordingly. However, the majority of those who self-injure go to great effort to hide any evidence of cuts or scars. They tend to be secretive and have a difficult time discussing the underlying issues that plague them. Those who cut in secret demonstrate extreme emotional distress and need substantial help.

Anyone who self-injures is part of the Goth or emo subgroups. Research shows that self-injury is not limited to one specific group. Self-injury does not occur on the basis of gender, socioeconomic status, sexual orientation, social group, race, profession or other categories. It is true that some groups are more affected than others by self-injury (as seen in previous demographics), but no group is completely excluded.

Someone who self-injures can quit if they really want to stop. Many experts in this area indicate that self-injury has the qualities of an addiction. The act of self-injury causes endorphins and other neurochemicals to be released in the brain, which essentially gives the person a type of “high.” The chemicals eventually dissipate, and then a craving develops to experience that feeling again. This creates a cycle of addiction that makes it even harder to stop the behavior. Many individuals may need help and additional support to be able to stop self-injuring.

Although I have students who experiment with cutting and do it out of curiosity, there is a subgroup of students who chronically self-injure. They can’t seem to “kick the habit,” no matter how hard they try. Typically, this means that their underlying issues have yet to be resolved and that an adequate replacement coping mechanism needs to be put in place.

Someone who self-injures is a danger to others. Typically, those who self-injure are people who tend to internalize their emotional issues rather than externalize them. In other words, people who self-injure take their frustrations out on themselves rather than on others. This particular trait makes it highly unlikely that people who self-injure would harm someone other than themselves.

Why do people self-injure?

From my experience, there are a few main reasons that someone may self-injure. These do not, by any means, cover every possibility. In addition, some people may have multiple reasons that motivate their behavior to self-injure.

As a coping mechanism: Based on research findings, self-injury is a way to cope with emotional pain and distress that can stem from mental illness or trauma. These two issues typically involve internalizing behaviors, which is one of the factors in the personalities of those who self-injure. Those who self-injure lack healthy coping skills that allow them to function.

To feel or to numb: Especially in cases of depression, there can be physical symptoms such as numbness and emptiness. This disconnect with the body can cause individuals to self-injure for the sake of being able to feel something again.

On the opposite end of the spectrum, some people feel too much. This tends to occur in people who may have anxiety and are overwhelmed by emotions. Self-injury for these individuals is a form of distraction that places their focus on the injury rather than on the tidal wave of emotions engulfing them.

To self-punish: People who use self-injury for this reason tend to loathe themselves and to have extremely poor self-esteem. They often are perfectionists and will punish themselves for perceived academic, athletic or social failures. This is often where the high achievers are grouped: They expect nothing less than perfection from themselves, and they “pay for it” when they believe that they have fallen short.

Immediate interventions

The following are examples of immediate interventions that counselors can take with clients who engage in self-injury.

Screen for suicide. Although it has been established that the majority of self-injury cases do not involve suicidal intent, it is important in new cases to establish which category the action falls under: NSSI or preemptive attempt of suicide.

It is always a good idea to ask some screener questions such as “Have you thought about suicide?” and “Do you have a plan?” But avoid asking, “Do you think about hurting yourself?” It is obvious that the person is already hurting themselves, and if they answer that question affirmatively, then it is likely because they are engaging in NSSI versus trying to kill themselves. However, a misunderstanding about their answer could lead to a false positive of the person being suicidal. If the person does present as suicidal, then follow additional threat assessment guidelines.

Be aware of the need for medical attention. If the individual presents with fresh injuries, counselors should be alert to possible infections, the need for stitches or other medical issues that may arise. Often, people who self-injure cover up their cuts or injuries, and the trapped moisture can cause a bacterial yeast infection. With those who have created bruising, it is important to check for possible broken bones. This evaluation also creates an opportunity for counselors to explain the risk factors that accompany self-injury and how students or clients can protect themselves from medical crises.

Notify a family member or person of support. In these situations, it is necessary to inform the individual’s parent, spouse or person of support. Self-harm is a sign of serious emotional distress, and the family needs to be made aware of what is happening so that they can be on the alert. It is also wise to talk with the person about removing any objects they could use to harm themselves, such as knives, scissors, push pins, lighters and so on. When first speaking with the student or client, try to collect information about which instruments they favor in inflicting self-harm so that there is a better idea of what objects need to be removed. Working with significant people in the client’s life is key to ensuring the client’s safety.

Supportive interventions

The following are examples of supportive interventions that counselors can use with clients who engage in self-injury.

Identify triggers. One of the best strategies for helping students or clients who engage in NSSI is to identify their triggers. Does it involve perceived failure? Does it involve feeling awkward? Does it involve rejection by peers? Once the triggers are named, the next step is to work with the student or client to outline a plan for when these triggers arise. What alternative strategy can they use? What kind of self-talk will they employ? Do they need a break from the stressful activity? All of this needs to be planned and practiced.

Identify a network of trusted individuals. What I have learned on the basis of my students’ experiences is that part of the method of operation for those who self-injure is to isolate. When students or clients do try to stop engaging in self-injury, they will need some sort of outlet for dealing with all of their complex emotions. Working with these students or clients to come up with a group of people they can trust is crucial to their recovery.

Find appropriate replacement behaviors. Odds are, the person has been using self-injury as a coping mechanism for a long time, and in order to recover, they will need to learn healthy coping strategies. Many people who struggle with self-injury are often high-sensory seeking, particularly with tactile sensory input. Replacing self-injury with fidget items that provide tactile feedback (cotton balls, string, erasers, textured stress balls, etc.) may offer more successful replacement behaviors.

Other methods of expression, such as drawing or writing, can also be beneficial because they provide an outlet for the person’s anxieties. This makes it less likely that the person will bottle up their emotions as much.

Use cognitive behavioral techniques. Cognitive behavioral techniques include identifying cognitive distortions (“thinking errors” or “thinking traps”) and learning how to engage in positive self-talk. They involve the realization that when we are thinking negatively or getting stuck on an inaccurate idea, that may skew our perspective. Some examples include:

  • Mind reading: Thinking that we know what others are thinking about us
  • Ignoring the good: Paying more attention to things that are bad
  • Setting the bar too high: Expecting ourselves to be perfect
  • Blowing things up: Making a small thing into a big deal

Once the student or client gains awareness of their faulty thinking, they can replace it with positive self-talk. For example, for ignoring the good, a student might say, “In my paper, I had trouble with this section, but I did a good job with explaining my argument overall.” For further information, refer to the “Thinking Errors” worksheet at therapistaid.com.

Encourage self-compassion. Strategies that involve identifying clients’ strengths and talents can help them to better understand and embrace their positive aspects. Helping students find activities in which they can really shine and develop their strengths is especially beneficial.

Safe websites that offer support

It is important to be wary of online supports for individuals who engage in NSSI. I have often encountered so-called support groups online whose members showed graphic pictures of self-injury in a sense of one-upmanship. These sites are triggering and tend to encourage further self-injury.

Over the years, I have found the following sites to be both helpful and safe:

By using these strategies and resources, we can support our clients in developing new and positive coping skills. Together with their families and outside providers, we can make a difference in addressing NSSI.

 

 

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Lauren Appel is a behavior specialist in a North Carolina school system with a background as a school counselor. Contact her at lauren.appel@caswell.k12.nc.us.

 

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

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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.

The ‘storm and stress’ of adolescence and young adulthood

By Laurie Meyers October 25, 2018

For much of human history, the idea of adolescence being a distinct life stage was nonexistent. True, in the Middle Ages, children were recognized not merely as “mini” adults but as distinct beings with different needs. However, the years from ages 13 to 19 were not considered part of childhood until the turn of the 19th century. Instead, the “teen years” were the time when one began to assume adult responsibilities such as making a living and starting a family.

During the late 1800s, changes in child labor laws and the push for universal education for those under the age of 16 began to influence society’s perspective on when adulthood began. G. Stanley Hall, the first president of the American Psychological Association (APA), is credited with the modern “discovery” of adolescence, defining it in a 1904 book as a new developmental stage — created by societal changes — in which children grow into adults. Hall described adolescence as a time of “storm and stress” and, unlike later researchers, ascribed this life stage as lasting from ages 14-24 (rather than today’s generally accepted range of 13-19).

Although adolescence is still considered to be synonymous with the teen years, Hall’s instinct to single out the early 20s as different from later “adult” years was prescient. In the past decade, neurological research has discovered that the brain does not fully mature until one’s mid-to-late 20s. This revelation has spurred many researchers, particularly in mental health fields, to call for a separate developmental stage that is generally referred to as “young” or “emerging” adulthood.

Adding more than a soupçon of complication to both the recognition of emerging adulthood and the established research on adolescence is the reality that being a teen or 20-something in the information age is, in many ways, significantly different — and arguably more difficult — than it was for previous generations.

Stressed and depressed

An abundance of research indicates that teens and young adults are experiencing increased levels of stress and depression. In recent years, APA’s annual “Stress in America” survey has gathered data only on adults. However, in the survey released in 2014, “Stress in America: Are Teens Adopting Adults’ Stress Habits?” young people ages 13-17 were also included.

Survey respondents reported that during the school year, they had a stress level of 5.8 on a 10-point scale. During the summer break, teens reported a slight decrease in stress levels — 4.6 on a 10-point scale. Furthermore, 31 percent of survey respondents said that their stress levels had increased over the past year. In response to their high levels of stress, 40 percent of respondents reported feeling irritable or angry, 36 percent reported feeling nervous or anxious, 36 percent reported feeling fatigued or tired, and 31 percent reported feeling overwhelmed.

Depression is another significant concern among adolescents. According to the National Institute of Mental Health, in 2016 (the most recent year for which statistics are available), an estimated 3.1 million adolescents ages 12-17 experienced at least one major depressive episode. That number represented 12.8 percent of the U.S. population in that age bracket.

Although most mental health surveys do not specifically target “young” or developing adults, data are available relating to college students. Among the more than 31,000 college students who completed the 2017 American College Health Association National College Health Assessment, 39.3 percent reported being so depressed that they found it hard to function at some point during the previous 12 months. Anxiety levels among respondents were even higher: 60.9 percent reported feeling overwhelming anxiety at some point during the prior year.

The high levels of anxiety and depression indicated in these studies are part of a national pattern of significantly increasing distress. A national poll published in May by the American Psychiatric Association noted a sharp increase in American anxiety levels over the past year. On a scale of 0-100, this year’s “national anxiety score” was a 51 — a five-point jump since 2017. A study published in the June 2018 issue of the journal Psychological Medicine found that rates of depression rose across all age brackets of Americans for those 12 and over from 2005 to 2015. Most significantly, among those ages 12-17, depression rates increased from 8.7 percent in 2005 to 12.7 percent in 2015.

Under pressure

Some researchers are eager to blame technology — particularly social media — for the increase of depression and anxiety among teenagers and young adults. The reality is more complex and involves myriad factors.

It is undeniable that some people do find their lives lacking when compared with what they see on social media. Carefully curated Facebook feeds can suggest to them that their friends are happier and more successful than they are. Celebrity photos on Instagram — most of which are professionally produced and heavily filtered — can encourage unrealistic expectations about body image and personal appearance. However, when one considers the role that social media plays in the quest for perfection, it may be something of a chicken-and-egg scenario.

A 2017 study on perfectionism that appeared in the journal Psychological Bulletin found that beginning in the 1980s, a culture of “competitive individualism” in the United States, Canada and the United Kingdom steadily increased the quest for personal perfection. So, is what we see on social media pushing us toward unattainable standards of perfection, or is it a reflection of the pressure we put on ourselves? At this point in time, we may be caught in a reinforcing loop. The study found that current generations not only feel intense societal pressure to be perfect but also expect perfection from themselves and others. The study’s authors also believe that this rise in perfectionism may be linked to an increase in myriad psychological problems.

Today’s teenagers and young adults are unquestionably subject to high expectations and demands. Licensed mental health counselor David Flack, who has worked with adolescents and young adults for 20 years, says he has seen a significant increase in anxiety related to academic performance among his clients.

“It is not uncommon for teens I meet with to have three, four or even more hours of homework most days,” he says. This reality creates significant pressure and is particularly stressful for students who are predisposed to anxiety. Flack, a member of the American Counseling Association, also believes that such heavy academic workloads are interfering with important social and developmental processes because many teenagers may be spending more time doing homework than socializing and engaging in extracurricular or other age-appropriate activities.

Licensed professional counselor (LPC) Sean Roberts, an ACA member who specializes in working with young adults, says he has witnessed a precipitous increase in anxiety among clients. He thinks this is strongly, though not solely, linked to teenagers and young adults feeling increased pressure to succeed.

Not coincidentally, the anxiety they experience makes it only more difficult for them to achieve. “Anxiety has a neurological effect,” explains ACA member Amy Gaesser, an assistant professor of counselor education at the State University of New York at Brockport whose research focuses on the social and emotional well-being of students in school. “The survival part of the brain activates and shuts off or interferes with the parts of the brain that help us think clearly.”

This can have a significant effect on academic performance, says Gaesser, a certified school counselor in New York who gives presentations and offers private consultations with parents. For example, some students can study extensively and be fully prepared for a test, but because of their anxiety, can have trouble accessing that information while taking the test. Anxiety can also interfere with the ability to take in and synthesize information, Gaesser says. Students become frustrated with their seeming inability to “get it,” which affects their feelings of self-efficacy and can even make them question their level of intelligence. Once a pattern of academic difficulty tied to anxiety is established, the problem can become self-perpetuating.

Disrupting the cycle is vital, says Gaesser, who recommends the emotional freedom technique (EFT) as an effective method of interrupting the stress response and downregulating the brain. In EFT, participants respond to stressful thoughts or situations by visualizing an alternative outcome while taking their hands and tapping acupuncture points on the body that have been linked to stress reduction. Students can go through the whole sequence of body points or just use the areas they find work best for them, she says.

Gaesser also recommends the “4-7-8” breathing method as a quick way to interrupt the stress response. This involves breathing in for four seconds, holding the breath for seven seconds and then breathing out for eight seconds. Students can practice this method themselves, but Gaesser thinks that teachers should also use it in their classrooms as a way to begin class.

Peter Allen, an LPC based in Oregon who specializes in counseling young adults and adolescents, used to work with teenagers in a wilderness therapy setting. Most of his clients were struggling with a variety of issues, including substance abuse, conduct problems (although not usually at the conduct disorder level) and mood disorders, principally depression and anxiety. In most cases, Allen says, the core elements of the wilderness setting were effective in helping these clients address their various presenting issues.

In part, he believes that’s because the pressures of school, family and social life were stripped away, leaving these teenage clients to focus on the basics, such as securing food and shelter. Surviving in the wilderness also required working together and building a community, which helped teach clients new communication skills. Participants also got daily exercise, ate healthy meals and were required to follow a regular sleep schedule, all of which had a calming and stabilizing effect. “Once diet, sleep and exercise have been regulated, about half of the problems disappear right away,” Allen says.

Many wilderness therapy clients also benefit from what Allen calls “expanding the size of their world. … If you are a 15-year-old kid and doing bad at school, arguing with your parents, your world is tiny.” The wilderness program not only provided literal wide-open spaces, but also introduced clients to people from different places and adults who didn’t have the same expectations as the teenagers’ parents or teachers did.

The wilderness can also serve as a mirror for clients, says Roberts, who has also worked in wilderness therapy, or, as he says it is becoming more commonly known, outdoor behavioral health care. For instance, when clients who struggle with executive function and organization encounter bad weather for which they are not prepared, the experience can be a vivid demonstration of the importance of working on those problem areas. Another example: Someone who is struggling with distress tolerance will need to get used to having to build a fire after hiking all day.

Information overload?

Although none of the counselors interviewed for this article view social media or technology as inherently negative, they agree that living in the information age is complicated. The current generation of teens and young adults is awash in an unprecedented flood of information, asserts Roberts, clinical director at Cascade Crest Transitions, a program that provides support to young adults struggling to launch their independence by attending college or obtaining a job. He maintains that this technological bombardment not only is difficult to assimilate but also can encourage the tendency to “get stuck” in one’s own head.

Allen adds that in the age of the internet, children and adolescents are exposed to a lot of information and knowledge at an earlier age than previous generations were. In certain cases, it is information that they may not have the maturity to handle. For example, most children and adolescents who grew up in the latter half of the 20th century had to somehow get their hands on a copy of Playboy or another adult magazine to satisfy their sexual curiosity. Today’s children and teens are exposed online to myriad genres of easy-to-access pornography, which not only present unrealistic ideals of sexuality but also can include disturbing practices such as bestiality and pedophilia. Children and young adolescents today are also more likely to be exposed to media coverage of frightening or horrific events before they have the ability to contextualize all that they are taking in, Allen says. He believes this early exposure is contributing to a kind of “nonspecific existential dread” that he says he commonly sees in his clients.

Roberts says that technology offers many positive benefits, but it also sometimes provides adolescents and young adults with a means to avoid their problems. He stresses the need for counselors to learn more about the draw of technology so that they can help clients evaluate whether they are using it in positive or negative ways. Roberts gives gaming as an example. For those who know little about it, gaming may seem like an excuse to “do nothing.” In reality, he says, it is a legitimate hobby that can provide enjoyment, stress release and even a sense of community while boosting problem-solving skills. However, like any other activity, when gaming gets in the way of schoolwork, chores or getting out of the house, it becomes a problem to be addressed, he says.

Another complicated aspect of online life is social media. For all the potential benefits, social media feeds have made it so that virtually no part of life is private anymore, Allen says. Many adolescents may not fully understand that by making everything public, the internet is, in essence, “forever” or grasp the potential ramifications of that reality, he says. In addition, he notes, social media feeds can encourage social contagion.

ACA member Amanda LaGuardia, a former private practitioner whose research focuses on self-harm, agrees. Much of the social media content targeted to young girls is focused on body image, says LaGuardia, a licensed professional counselor supervisor in Texas and a licensed professional clinical counselor supervisor in Ohio. Many of her former clients talked about the images they saw on Instagram, such as already-thin celebrities discussing “thigh gap” (as part of a supposedly “perfect” body, women and girls must have thighs that don’t touch each other) and other unrealistic physical standards. Such posts are usually popular, garnering a large number of likes and admiring comments, which gives girls the impression that this is what their bodies should look like, she says.

However, such standards are unrealistic for most females and are simply unachievable for girls with developing bodies, continues LaGuardia, an assistant professor at the University of Cincinnati. Regardless, these images are presented as the feminine ideal, presuming to highlight all of the elements that will make women attractive to men. At the same time, girls are often subject to sexual harassment at school and too often told by those in authority “that’s just how boys are” (boys will be boys) and that girls just need to find a way to deal with it, she says.

All of these messages about how girls should look and act and what they should accept come at a time when they are already struggling to figure out who they are. It is overwhelming, and self-injury is becoming a more common way to cope with the distress. Self-harm used to be most common in the eating disorder population, but according to LaGuardia, social media has introduced it to a wider audience. It isn’t necessarily that self-injury is presented as a positive behavior online. Most people who talk about it on social media are seeking support, she says. However, the widespread nature of the discussion has created social contagion.

The best thing counselors can do to help is listen and affirm, LaGuardia emphasizes. When adolescents talk about their experiences, some counselors focus on helping them feel better about themselves, but that is not what they need most, she asserts. Instead, adolescents need to express what they are going through and to process their confusion verbally. Counselors should respond, she suggests, by saying things such as, “That sounds really difficult” and “I’m here and I’m listening.”

“So many of the messages they [adolescents] are receiving are controlling,” LaGuardia explains. “They need to feel in control.”

As these clients become more comfortable, they will begin to talk about how they are coping with their turmoil. LaGuardia explains that these clients view self-injury as a means of surviving what they are currently experiencing, not a solution. “I ask clients, ‘Is this something you see working for you for the rest of your life?’ I’ve never had anyone say yes.”

Usually, LaGuardia notes, clients will say that they hope not to engage in self-harm forever, but at the current time, they don’t know what else to do. At that point, counselors can ask whether this coping method is something the client is ready to change. LaGuardia says the first step is finding out what the client needs help coping with and then exploring ways that will allow the client to cope without self-harm.

The most common underlying problem for clients who self-harm is conflict with a parent or sibling, LaGuardia says. In such cases, she works with the whole family on communication skills. She starts with the adolescent clients, teaching them how to express their needs without self-injury. She asks the adolescents to think about their most stressful conflicts and what they would like their parents to know. Then, through role-play, LaGuardia helps these clients practice asking for what they need.

Often, LaGuardia will also bring in the parents and have the adolescent express the source of conflict. As the parents and adolescent talk, things can get heated, so LaGuardia is there to help redirect the conversation. She also tries to educate parents about what adolescents need, which includes being treated as independent young adults and given space to grow, while at the same time knowing that their parents are always there to listen to them regardless of
the circumstances.

Adult transitions

Allen is the program director at College Excel, a residential, coaching-based college support program. The program’s clients are typically young adults who are coming out of high school and looking for extra support to succeed in college or those who previously attended college but dropped out because of a mental health issue or learning disability.

Many of the students have some level of anxiety and depression and often struggle with executive function deficits. College Excel provides the students with mental health support and coaching on life and study habits. Allen says he tries to run the program through the lens of good mental health practices. Calling on his background in wilderness therapy, he also encourages students to eat well, follow a consistent sleep schedule and get regular exercise. College Excel staff do not live on-site, but the program does provide students with housing, which helps them establish a sense of community and support — elements that are common among those who successfully adjust to college life, Allen points out.

Allen says that many of the program’s clients struggle with attention-deficit disorder and organization. College Excel staff teach students basic organizational skills such as using their attention strategically. For example, with students who struggle with memory and retaining information, Google Calendar can be a particularly useful tool. It can tell students where they need to be at any given moment, freeing up their attention and memory for other tasks.

Allen also talks with students about the importance of a clean workspace and provides them with practical tips on organization. For example, he says, students who constantly misplace things can save time and frustration by designating a space for pens, papers and other basics so that they will always know where to find them.

Students also work on developing good study habits. For example, rather than growing frustrated with their struggles to focus on what they’re reading for long periods of time, clients learn to study in 15- to 20-minute chunks, with five-minute breaks in between.

Roberts’ program is geared toward young adults who are coming from inpatient treatment and are ready to enter college or find a job. In addition to receiving ongoing mental health treatment, these clients take classes that focus on interpersonal skills, stress regulation, goal setting, time management and money management. They are also encouraged to exercise, and all students are matched with a case manager who helps them focus on sleep hygiene, peer interaction, health and nutrition, and, in some cases, dating.

Clients are required to attend one individual and one group counseling session per week. Counselors are also on-site five days a week, which allows them to give feedback outside of sessions. For example, a counselor might say to a student, “You say that you want to socialize, but you’re constantly retreating to your room or on the phone.” This opens up a discussion about why the student isn’t following through on counseling goals and allows the counselor and client to work on solutions together, Roberts says.

The students are usually enrolled in college or working when they start Roberts’ program. The coaching and classes take place around the students’ schedules, and staff members are available to help clients through whatever challenges they are facing in school or at work. Clients typically remain in the program about nine to 12 months. During the last six months, they move out of program housing and into their own apartments or college dorms.

Allen closes by noting that today’s adolescents and young adults — the oft-discussed millennials — are very much aware that older generations generally view them in a negative light. He believes this widespread maligning carries a psychic weight for this generation and can contribute to limiting their self-efficacy and sense of options.

Because this negative image of adolescents and young adults is so prevalent, Allen believes that even counselors may fall prey to it. “You can’t hold them in contempt and do good work,” he emphasizes. “The best thing we could be doing for them is stoking the fire of creativity.”

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

Counseling Today (ct.counseling.org)

Books and DVDs (counseling.org/publications/bookstore)

  • Youth at Risk, sixth edition, edited by David Capuzzi and Douglas R. Gross
  • A Contemporary Approach to Substance Use Disorders, second edition, by Ford Brooks and Bill McHenry
  • Active Interventions for Kids and Teens, by Jeffrey S. Ashby, Terry Kottman and Don DeGraaf
  • Suicide Assessment and Prevention, DVD, presented by John S. Westefeld

ACA Mental Health Resources (counseling.org/knowledge-center/mental-health-resources)

  • Suicide Prevention
  • Substance Use Disorders and Addiction
  • LGBTQ Resources

Webinars (aca.digitellinc.com/aca/pages/events)

  • “Depression/Bipolar” with Carmen S. Gill (CPA22120)
  • “Trauma/OCD/Anxiety” with Victoria E. Kress (CPA22118)
  • “Substance Abuse/Disruptive Impulse Control/Conduct Disorder” with Shannon Karl (CPA22116)
  • “Counseling Students Who Have Experienced Trauma: Practical Recommendations at the Elementary, Secondary and College Levels” with Richard Joseph Behun, Julie A. Cerrito and Eric W. Owens (CPA24339)

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org

 

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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.

’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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