When clients self harm
Self-harm in clients presents one of the most challenging situations a therapist will face. While adults report a six percent lifetime prevalence of self-harming behavior, adolescents say that they have self-harmed at almost three times that rate. Whatever the exact number, it is a highly concerning behavior that demands our utmost attention. Here is what you need to know about working with clients who self-harm.
Summary
- Self-harm, also known as non-suicidal self-injury (NSSI), involves intentionally harming oneself without the intent to die and is often linked to emotional distress, borderline personality disorder, and other mental health conditions.
- Common methods of self-harm include cutting, burning, picking, inserting objects under the skin, and hitting oneself, with individuals often using these behaviors to manage overwhelming emotions or a sense of numbness.
- While self-harm is distinct from suicidal ideation, it can increase the risk of suicide, making early intervention and comprehensive treatment crucial for those who engage in this behavior.
- Effective treatment approaches include Cognitive-Behavioral Therapy (CBT), Dialectical Behavioral Therapy (DBT), mindfulness techniques, family involvement, and, in some cases, medication, though research on pharmacological interventions remains limited.
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What is self-harm?
Self-harm is often referred to in the scientific literature as non-suicidal self-injury or NSSI. When we speak of self-harm, we mean any non-socially sanctioned (e.g., piercing, tattoos) intentional injury to our bodies without the intent to die. It is a behavior most closely associated with borderline personality disorder. However, non-suicidal self-injury is listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a “condition in need of further study”, which means it may be recognized as a distinct disorder in the future.
Types of self-harm
- Cutting is by far the most common form of self-harm. People frequently use a razor, knife, scissors, or other sharp object to make cuts to the arms or legs. These cuts may be light or draw blood, depending on the individual.
- Burning is another popular type of self-harm. Using a match, lighter, or end of a cigarette to burn the skin.
- A rarer method of NSSI is inserting items under the skin, like a paperclip or small object.
- Picking is an under-the-radar form of self-harm. Some pick the skin to form a fresh wound. Others continuously pick an existing wound so it never heals. Picking is more socially acceptable than cutting or burning so it may go unnoticed as NSSI.
- Other types of self-harm may include: punching yourself, banging your head against a wall, or hair pulling.
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Why do people self-harm?
The reasons for self-harm are complicated and multifaceted. The following are some potential reasons and high-risk variables:
Reasons to resort to self-harm
- Individuals who self-harm often have difficulty tolerating emotional distress. The physical pain from NSSI is preferred over the emotional pain.
- In contrast, individuals who feel emotionally numb may self-harm so they feel something. Pain is more desirable than not feeling at all.
- Looking at self-harm from a more physiological perspective, NSSI releases endorphins, which are feel-good hormones. Therefore, self-harm acts as a positive reinforcement.
Why do people self harm?
- Childhood physical and sexual abuse, along with neglect, are often associated with a higher rate of self-harm.
- People suffering from depression and low self-worth are linked with self-harming behavior.
- Individuals with eating disorders also share a high association with NSSI. Self-harm may give people a sense of control they otherwise feel they are missing.
- Youth who are bullied or rejected by peers are more likely to self-harm. Social isolation appears to be a prime risk factor.
- Conversely, it should also be noted that strong family relationships and social support serve a protective function against self-harm.
Is self-harm the same as suicidal thinking?
Self-harm and suicidality are not the same. In fact, most individuals who self-harm do not have suicidal ideation. Self-harm, however, may be a precursor for those who commit suicide. Over half of the children who die by suicide have a history of self-harming. It is possible that NSSI may normalize self-injury and make it easier for those with suicidal ideation to follow through if they do have suicidal thoughts.
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Treatment of self-harming behavior
Self-harm is very difficult to treat and has not yet been well-studied. The research on effective interventions is not yet fully formed but the following therapies and techniques have shown the most promise.
Therapies
Cognitive-Behavioral Therapy (CBT)
CBT is the most studied therapy in treating NSSI. Variations of CBT have shown some effectiveness in reducing self-harming behavior. Particularly, problem-solving therapy and Acceptance and Commitment Therapy (ACT) have exhibited promise.
Dialectical Behavioral Therapy (DBT)
Although technically an offshoot of CBT, DBT deserves its own mention in treating NSSI. It was initially developed to treat borderline personality disorder and its focus on emotion regulation, problem solving, and distress tolerance make it a primary intervention for self-harm. The DBT ACCEPTS skill is a particularly beneficial intervention.
- The Dialectical Behavior Therapy Skills Workbook is a valuable resource for DBT activities and worksheets that can be utilized with clients who self-harm.
Medication
The research on treating NSSI with medication is in its infancy. However, Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs) have shown some potential in reducing self-harming behavior.
Treatment techniques and tips for therapists
Be direct
Individuals who self-harm want to hide it. They possess considerable shame regarding their behavior. Therapists must talk candidly about NSSI without judgment. They need to validate and show compassion for their client’s pain to decrease their shame and increase their openness to further discussion.
Identifying triggers
Recognizing what precedes self-harming behavior is a main goal of therapy. Once emotional and behavioral triggers are identified, therapists can work on replacing self-injurious behavior with more adaptive responses.
Family involvement
Involving a client’s family (especially when they are an adolescent) is key to the reduction of self-harming behavior. Families must be educated about NSSI and be encouraged to exhibit empathy for their loved ones. Parents may feel inclined to punish their children for self-harming behavior and need to learn that support, rather than criticism, is the means to improvement.
Mindfulness
Mindfulness meditation has several components that are valuable in treating self-harm. Often, feeling numb is the reason why individuals self-injure. Mindfulness helps people connect to their feelings and alleviate that numbness. Alternatively, mindfulness meditation can aid clients in focusing on their bodily sensations and environment rather than their emotional pain. Through mindfulness, people also learn to face their feelings without judgment, causing less torment.
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Relapse prevention
Treating someone who exhibits NSSI may require a higher level of monitoring than the usual outpatient client. Therapists need to be prepared to have more contact with these clients to help prevent relapse. This can take the form of more frequent sessions or check-ins as needed. An attractive aspect of a full DBT program is the phone coaching that occurs when necessary outside of regularly scheduled sessions.
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Self-harming behavior is an alarming development for any therapist. Working with clients who self-harm requires comprehensive treatment and close monitoring.
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References
Gottlieb, A. (2020, March 25). Sheppard Pratt. How Dialectical Behavior Therapy Treats Self Harm. https://www.sheppardpratt.org/news-views/story/how-dialectical-behavior-therapy-treats-self-harm/
Haw, C., Hawton, K., Houston, K., & Townsend, E. (2001). Psychiatric and personality disorders in deliberate self-harm patients. The British journal of psychiatry : the journal of mental science, 178(1), 48–54. https://doi.org/10.1192/bjp.178.1.48
Klonsky, E. D., Victor, S. E., & Saffer, B. Y. (2014). Nonsuicidal self-injury: what we know, and what we need to know. Canadian journal of psychiatry, 59(11), 565–568. https://doi.org/10.1177/070674371405901101
McEvoy, D., Brannigan, R., Cooke, L., et al. (2023) Risk and protective factors for self-harm in adolescents and young adults: An umbrella review of systematic reviews, Journal of Psychiatric Research,168, 353-380. https://doi.org/10.1016/j.jpsychires.2023.10.017
Muehlenkamp, J.J., Claes, L., Havertape, L. et al. International prevalence of adolescent non-suicidal self-injury and deliberate self-harm. Child and Adolescent Psychiatry and Mental Health 6, 10 (2012). https://doi.org/10.1186/1753-2000-6-10
National Institute of Mental Health. Borderline Personality Disorder.https://www.nimh.nih.gov/health/topics/borderline-personality-disorder
Rodway, C., Tham, S. G., Ibrahim, S., Turnbull, P., Windfuhr, K., Shaw, J., Kapur, N., & Appleby, L. (2016). Suicide in children and young people in England: a consecutive case series. Lancet Psychiatry, 3(8), 751–759. https://doi.org/10.1016/S2215-0366(16)30094-3
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Störkel, L.M., Karabatsiakis, A., Hepp, J. et al. Salivary beta-endorphin in nonsuicidal self-injury: an ambulatory assessment study. Neuropsychopharmacol. 46, 1357–1363 (2021). https://doi.org/10.1038/s41386-020-00914-2
Townsend, E., Ness, J., Waters, K., Rehman, M., Kapur, N., Clements, C., Geulayov, G., Bale, E., Casey, D. and Hawton, K. (2022), Life problems in children and adolescents who self-harm: findings from the multicentre study of self-harm in England. Child and Adolescent Mental Health, 27: 352-360. https://doi.org/10.1111/camh.12544
Turner, B. J., Austin, S. B., & Chapman, A. L. (2014). Treating nonsuicidal self-injury: a systematic review of psychological and pharmacological interventions. Canadian Journal of Psychiatry, 59(11), 576–585. https://doi.org/10.1177/070674371405901103
Warne, N., Heron, J., Mars, B., Moran, P., Stewart, A., Munafò, M., Biddle, L., Skinner, A., Gunnell, D., & Bould, H. (2021). Comorbidity of self-harm and disordered eating in young people: Evidence from a UK population-based cohort. Journal of affective disorders, 282, 386–390. https://doi.org/10.1016/j.jad.2020.12.053
Washburn, J. J., Richardt, S. L., Styer, D. M., Gebhardt, M., Juzwin, K. R., Yourek, A., & Aldridge, D. (2012). Psychotherapeutic approaches to non-suicidal self-injury in adolescents. Child and adolescent psychiatry and mental health, 6(1), 14. https://doi.org/10.1186/1753-2000-6-14
Zetterqvist M. (2015). The DSM-5 diagnosis of nonsuicidal self-injury disorder: a review of the empirical literature. Child and adolescent psychiatry and mental health, 9, 31. https://doi.org/10.1186/s13034-015-0062-7
