Counseling Clients Who Self-Harm
Counselor Toolbox

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Working with Individuals Who Self-Harm

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~ Define self-injury / self-harm
~ Differentiate SSI from NSSI

Self Harm vs. Suicide
~ Self-injury / Self-Harm
~ Any voluntary behavior that intentionally injures or harms the body
~ Some self-injurious behaviors are done for reasons other than suicide.
~ Distress-Tolerance/Emotion Regulation
~ Attention seeking
~ Absolution from demands
~ Suicide attempts involve a conscious intention to die. The objective of NSSI injury seems to be to relieve unbearable pain or sense of powerlessness
Differences Between NSSI &
Suicidal Behaviors
~ Intent of NSSI is to feel better
~ NSSI methods are generally not lethal
~ NSSI is used frequently. Suicidal behaviors are must less common
~ The level of psychological distress is often lower in NSSI
~ People who are suicidal often see things dichotomously. Those with NSSI are less dichotomous
~ Aftermath of NSSI is often short term improvement
BDSM and Body Modification
~ BDSM/Sensation play and body modification, while injurious, are not considered NSSI unless the intent of the action was to harm the body.
~ (DSM-5) still includes Sexual Sadism Disorder and Sexual Masochism Disorder as potential diagnoses. But a diagnosis now requires the interest or activities to cause “clinically significant distress …” (or to be done without consent).
~ In NSSI, people experience overwhelming negative feeling states prior to self-injury, then feel relief and distraction, followed by regret and shame.
~ BDSM practitioners feel excitement and anticipation ahead of time, pleasure during the encounter, and a sense of deep connection and a stronger sense of self-empowerment and authenticity afterward.
~ Only females self injure.
~ 30-40% of people who self-injure are male
~ It is a failed suicide attempt
~ Often NSSI is a means of avoiding suicide (but can accidentally escalate too far)
~ Self-injury is untreatable
~ Everyone who self-injures has BPD
~ Cutting is the only form of self-injury
~ People who self-injure enjoy the pain
~ People who self-injure are a danger to others
Prevalence and Risk Factors
~ NSSI is most common among adolescents and young adults, and the age of onset is reported to occur between 12 and 14 years.
~ DSM-5 includes NSSI as a condition requiring further study.
~ Prevalence rates (7.5–46.5% adolescents, 38.9% university students, 4–23% adults)
~ High correlation with trauma and comorbidity with many other mental or physical health disorders
~ Gratz et al. (2002) emphasized the role of parental relationship in the etiology of self-injurious behaviors:
~ Insecure paternal attachment and both maternal and paternal emotional neglect were significant predictors of NSSI within women
~ NSSI in men was primarily predicted by childhood separation (usually from father)
Risk Factors cont…
~ NSSI is often an unhealthy approach to emotional regulation and distress
~ For approximately 90% of patients, NSSI decreases symptoms and/or aids in dissociation
~ Anxiety
~ Depressed mood
~ Racing thoughts
~ Anger
~ Flash-backs
~ NSSI may generate desired feelings (power, control, euphoria, “something”)
~ During periods of grief, insecurity, loneliness, extreme boredom, self-pity, and alienation, NSSI also may signal distress to elicit a caring response from others
Risk Factors
~ High levels of negative and unpleasant thoughts and feelings
~ Poor communication skills and problem-solving abilities
~ Trauma via abuse, maltreatment, hostility, and marked criticism during childhood
~ Under- or over-arousal responses to stress
~ High valuation of NSSI to achieve a desired response
~ Need for self-punishment
~ Modeling behaviors based on exposure to NSSI among peers, on the Internet—i.e., postings on YouTube—and in the media
Relationship of NSSI to ED
~ Both eating disorders and NSSI affect how people feel and are often used as a way to change, express, or suppress emotions.

NSSI Functions
~ Escape (Positive and negative reinforcement)
~ Positive: Endorphins
~ Negative: Distraction from emotional or other pain
~ Signal of distress to gain attention
~ Sally’s parents are fighting
~ John broke up with Sally
~ Sam crashed his car when he was depressed

NSSI Functions
~ Attempts to remove distressing interpersonal demands or gain a sense of control
~ Annual state testing
~ Football playoffs
~ Moving out
~ Enmeshed family
~ Self Punishment
~ For abandonment/isolation
~ For failure
~ For survival

NSSI Categories
~ NSSI may fall within 4 descriptive categories:
~ Major
~ Infrequent acts that destroy significant body tissue, such as eye enucleation and amputation of body parts.
~ 75% occur during a psychotic state, mainly schizophrenia
~ Most times patients cannot articulate logical reasons for their actions. (I cut off my hand because it was making me evil.)
~ Treatment: Prevention esp. for patients with a history or bipolar or psychotic disorders
~ Look out for sudden shifts in behavior or appearance which might indicate the beginnings of a psychotic (including MDD w/psychotic features or manic episode

NSSI Categories
~ NSSI may fall within 4 descriptive categories:
~ Stereotypic
~ Repetitive head banging; eye gouging; biting lips, the tongue, cheeks, or fingers and face or head slapping. (May include stimming when injurious)
~ The behaviors may be monotonously repetitive, have a rhythmic pattern, and be performed without shame or guilt
~ Patients with this form of NSSI often cannot articulate what is bothering them.
~ Effective biopsychosocial differential diagnosis
~ Behavior therapy is the primary intervention

NSSI Categories
~ NSSI may fall within 4 descriptive categories:
~ Compulsive (OCD related behaviors)
~ Severe skin scratching, hair pulling (trichotillomania)
~ Treatment
~ Develop a relapse prevention plan
~ Rule out intoxication or withdrawal
~ Psychotherapy
~ Medicate underlying mental illness if present

NSSI Categories
~ NSSI may fall within 4 descriptive categories:
~ Impulsive (Triggered Goal Directed)
~ Hair pulling, skin cutting, burning, and carving; sticking pins or other objects under the skin; interfering with wound healing; and smashing hand or foot bones
~ Treatment
~ Develop a safety plan
~ Consider medication for underlying mental illness

~ Impulsive NSSI
~ Psychotherapy (esp. DBT and ACT)
~ Backward chaining
~ Emotion regulation/Vulnerability Prevention to be aware of emotions, able to cope with them
~ Positive self-care
~ Mindfulness (to STOP: Stop, Take a breath, Observe, Plan)
~ Coping Skills
~ Distress Tolerance
~ Interpersonal Effectiveness

NSSI Does NOT Mean Safe
~ NSSI is a predictive factor for suicidal behavior for some patients but not for others
~ NSSI triples the risk of subsequent but also concomitant suicidal behavior
~ A third variable may either mitigate or exacerbate NSSI to Suicide
~ Suicidal ideation
~ Personality disorder
~ Low self esteem
~ Substance abuse (esp. opiates and alcohol)
~ Age (adolescence)
~ Culture
NSSI Does NOT Mean Safe
~ NSSI may be a strategy of emotional adaptation and regulation. If this strategy fails, the adolescent must undertake more severe forms of self-injury, which become progressively closer to suicidal behavior
Tips for Treatment
~ Take a curious approach to the person’s behaviors
~ Remember that these behaviors communicate some underlying distress. Recovery will involve addressing the underlying issues
~ Assess your own reaction to these behaviors before at-tempting to engage the person in a conversation about them
~ NSSI & EDs
~ Help the person start to identify other coping skills that they may use when they get the urge to engage in NSSI or ED.
~ Reducing the NSSI or the ED does NOT mean the other will also be reduced. Dual treatment is essential
For Families
~ Feedback
~ Responsibility on the person
~ Advice
~ Menu of Options w/ no-harm contracts
~ Only if clients is willing
~ Provides structure and motivation (an emergency list of responses)
~ Ensure the focus on the contract is development of new behaviors vs. elimination of old behaviors. (i.e. When you got upset this week, how many times did you [use the new tool])
~ Avoid setting 100% goals to prevent setting the person up for failure.
~ Empathy
~ Self-Efficacy

For Families
~ Create win-win situations (List of NSSI behaviors and alternatives)
~ You need something to help you get control when you feel that way. I want you to reduce your self injury.
~ Hold ice cubes
~ Draw on self with red pen
~ Snap a rubber band on your wrist
~ Listen to loud music
~ Go on a run/pushups/squats/wall sits
~ Talk to ___________________
~ Reward positive progress (vs. punishing NSSI)
~ Refuse to engage a fight. Let the person choose and experience natural consequences.
~ Communicate assertively and openly
~ Practice self care

~ NSSI is a common issue to see in all age groups, but is more common in adolescents
~ NSSI usually represents a way of dealing with distress the best the person knows how
~ Treatment involves identifying the
~ Triggers of the NSSI and developing skills and resources to help the person mitigate or eliminate the distress caused by the situation
~ Functions of the NSSI and developing alternate behaviors that meet the same need
~ Balance energy (anger)
~ Get support
~ Feel in control/empowered
~ Feel “something”
~ Get relief from demands
~ …

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