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Unread November 10th, 2004, 10:31 AM
James Pretzer James Pretzer is offline
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Join Date: Jun 2004
Posts: 283
Default Dealing with Self-mutilation

I just got back from presenting a day-long workshop on dealing with self-mutilation in adolescents and it reminded me that CTs approach to dealing with self-mutilation hasn't been widely published. Here's the brief version (Note: self-mutilation in retarded, autistic, or psychotic individuals is a different topic):

Self-destructive impulsive behavior may be a significant problem in therapy and it may be necessary to eliminate this behavior quickly. However, this often is easier said than done.

It is easiest to intervene effectively if the therapist maintains a collaborative relationship where therapist and client are working together towards goals the client values. If the therapist takes a stance of “I’m going to stop you from cutting yourself,” or even “You have to stop cutting yourself,” this simply provokes resistance and rebellion. A stance of “Let’s work together to see if we can understand this and find better options” is likely to work much better.

The next step in intervening effectively is to develop an understanding of the motivation for the self-destructive behavior. This can be done by examining the events, thoughts, and feelings leading to the self-destructive impulses or behavior (see Table below). It is important for the therapist not to simply rely on his or her own preconceptions (such as “it’s self-hate” or “it’s a way to manipulate others”) but to collect detailed information about specific incidents before drawing conclusions.

Understanding the Motivation for Self-Mutilation
1. Ask about specific incidents one at a time rather than talking about it in generalterms.

2. Find out both about occasions on which clients have self-mutilated and occasions when they have been tempted but have not injured themselves.

3. Treat your preconceptions, intuitions, and hunches about the motivation for self-mutilation as hypotheses to be tested; don't assume that they are true.

4. Ask for specific information about specific events, then look for general patterns rather than starting off with generalities:

What led up to wanting to hurt yourself?
When did you start feeling like hurting yourself? What was going on before that?
How were you feeling beforehand? What other feelings went along with it?

Thoughts which precede impulses to self-mutilate
What was your immediate reaction when (the precipitating event) happened? What thoughts ran through your head?

What was the point to it? What did you hope to accomplish? How did you expect to feel afterwards?
How did you expect people to react to it? (If a particular individual precipitated the self mutilation, ask specifically about him or her).
Suppose you hadn't done it, what do you think would have happened? How would things have been different? How would you have felt then?
Once the goals of self-mutilation are understood, it is possible to ask "Is there another way to accomplish this which is likely to be more effective or have fewer bad side effects?” If it is possible to identify less destructive, effective responses, these can be substituted for the problem behaviors. Of course, in order to do this effectively, therapist and client may need to address fears and expectations that block promising alternatives and the client may need to master new skills in managing strong feelings, controlling impulses, dealing with dysfunctional thoughts, and resolving relationship problems.

As a temporary, stop-gap measure it is sometimes possible to substitute a minimally self-destructive behavior, such as marking oneself with a marking pen or snapping oneself with a rubber band, for a more damaging act, such as slashing oneself. This less destructive act can later be replaced with more adaptive alternatives.
Since many of the adaptive alternatives to self-destructive behavior involve tolerating strong feelings rather than engaging in desperate attempts to escape painful feelings, additional work to increase affect tolerance (Farrell & Shaw, 1994) may be needed at this point.

Often, working towards more adaptive interpersonal behavior is a crucial part of dealing effectively with suicidality and self-mutilation. Clients who self-mutilate often engage in desperate attempts to avoid abandonment or to have an impact on others. It is frequently useful to help clients recognize their interpersonal strategies (“If I want someone to care, I need to ....”), to examine whether these strategies really are adaptive, and to find more effective alternatives. Often, strong fears (such as, “If I ask for what I want I’ll be rejected!”) block the client from trying promising strategies. It can be important to both address these fears cognitively during the session and to get the client to gradually test these preconceptions through behavioral experiments. Often, a good first step is to encourage the client to try strategies such as assertion in interactions with the therapist during the session, and then discuss the thoughts and fears that emerge as he or she does so.

For further reading:

Farrell, J.M., & Shaw, I.A. (1994). Emotion awareness training: a prerequisite to effective cognitive-behavioral treatment of borderline personality disorder. Cognitive and Behavioral Practice, 1, 71-91.

Freeman, A., Pretzer, J., Fleming, B., & Simon. (2004). Clinical applications of cognitive therapy (Second Edition). Kluwer Academic/Plenum Publications. (especially the chapter on Borderline Personality Disorder)

Layden, M.A., Newman, C.F., Freeman, A., & Morse, S.B. (1993). Cognitive therapy of borderline personality disorder. Needham Heights, Mass: Allyn & Bacon.

Leibenluft, E., Gardner, D.L., & Cowdry, R.W. (1987). The inner experience of the borderline self-mutilator. Journal of Personality Disorders, 1, 317-324.

Linehan, M.M. (1993 ). Cognitive behavioral treatment of borderline personality disorder. New York, Guilford.

Linehan, M.M. (1993 ). Skill training manual for treating borderline personality disorder. New York, Guilford.
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