Definition and Description0 “Self-mutilation refers to intentional, non-lethal, repetitive bodily harm or disfigurement that is socially unacceptable.” (Pearson, 2011, 78)0 Self-mutilation is not a disorder in itself but a symptom of other disorders.0 “Usually begins in late childhood or early adolescence, and may continue for ten or fifteen years or more” (Pearson, 2011, 79)
CategoriesMajorStereotypicModerate or Superficial
Major0 “extreme acts that occur suddenly and cause considerable damage” (Pearson, 2011, 79)0 “associated with a psychotic state or acute intoxication” (Pearson, 2011, 79)
Stereotypic0 “repetitive, often rhythmic self-injurious” (Pearson, 2011, 79)0 “found in autistic, mentally retarded, and in about a third of individuals with Tourette’s syndrome” (Pearson, 2011, 79) Click on the book above to read an excerpt from Kathryn Erskines book Mockingbird about an autistic girl named Caitlin having an episode with self-harm.
Mockingbird by: Kathryn Erskine “I touch it. It’s rough. I rub my finger across the wood back and forth harderand harder until a splinter cuts me. I hit the splinter back. There is a drop of blood in the wood now. It is red and it spreads… seepinginto a crack and bleeding across the unfinished wood. Like Devon’s chest. No! I rub the wood harder and harder to try to erase the blood but it won’t goaway. Caitlin! I press my finger against the raw wood and rub faster and faster and it hurtsbut I don’t care because I want to stop the blood but it’s still there and I can’tmake it stop! Caitlin! I can’t stop it! Caitlin! It’s Mrs. Brook calling from somewhere and I feel pulling on my armbut I yank my hand free. No! I have to erase the blood! I have to. I have to. I haveto! I HAVE TO!” (Erskine, 2010, 17-18)
Moderate or superficial0 “type that mental health professionals are most likely to encounter” (Pearson, 2011, 79)0 “includes hair pulling, skin scratching, picking, cutting, burning, and carving” (Pearson, 2011, 79) 0 Compulsive- 0 “repetitive, ritualistic behavior that occurs many times in a day” (Pearson, 2011, 79) 0 “hair pulling (trichotillomania) and various insults to the skin (scratching, picking, or digging)” (Pearson, 2011, 79) 0 Episodic- occasional and usually a symptom of another disorder 0 Repetitive- addictive and a part of their identity Example of trichotillomania
Prevalence0 Cited as ‘”the next teen disorder’” (Pearson, 2011, 80) 0 Follow the link below: Demi Lovato Talks About Cutting0 Most prevalent environments 0 Prisons 0 Inpatient Facilities0 Borderline personality disorder 0 Individuals with Borderline personality disorder have a tendency to self-mutilate. 0 Follow the link below to hear an explanation of BPD and the reasons they cut: Mental Health Professonal on BPD and Cutting
Developmental Influences0 Loss of parent to divorce or out-of-home placement0 Serious injury or surgery during childhood0 Sexual or physical abuse0 Witness to family violence
Functions0 What does it serve to do? 0Coping mechanism 0Return to awareness from disassociation 0Increase in endorphins 0Allows them to “tell” about the depth of Click on the book internal pain cover above to read an excerpt from Cut 0Punishment by Patricia 0Ritual and symbolism McCormick where her main character Callie describes her reaction to cutting herself for the first time.
Cut By: Patricia McCormick “A tingle arced across my scalp. The floortipped up at me and my body spiraled away. ThenI was on the ceiling looking down, waiting to seewhat would happen next. What happened nextwas that a perfect, straight line of blood bloomedfrom under the edge of the blade. The line grewinto a long, fat bubble, a lush crimson bubble thatgot bigger and bigger. I watched from above,waiting to see how big it would get before it burst.When it did, I felt awesome, Satisfied, finally. Thenexhausted.” (McCormick, 2000, 3)
Theoretical ViewsBiological TheoriesPsychodynamic TheoriesCognitive Behavioral TheoryNarrative Theory
Biological Theories0 Low levels of serotonin which can cause depression0 Addiction to endorphins causing a high feeling
Psychodynamic Theories0 Beliefs 0 Believes that self-mutilation is a return to the early infant state 0 Infants lack the capacity for coping with loss 0 Believes that the skin is the boundary between “me” and “not me” 0 Cuts to reassure themselves that the boundary exists 0 Believed to be post traumatic stress disorder (PTSD)0 Reasons 0 Life and death instinct conflict 0 Symbolic castration 0 An attempt to identify with the menstruating mother0 Order of self-mutilating episode 1) The experience or perception of loss 2) The resultant increase in tension that cannot be expressed verbally 3) A state of dissociation or depersonalization 4) An irresistible urge to mutilate oneself 5) The act of mutilation 6) The tension relief and return to pre-incident state (Pearson, 2011, 86)
Cognitive Behavioral Theory0 Seen as a symptom of faulty beliefs stemming from negative self-image and low self-esteem0 Cutting is negative reinforcement0 Reactions of others is positive reinforcement
Narrative Theory0 Reenactments of childhood trauma 0 Common themes 0 Hatred of ones body 0 Belief that talking about things is not acceptable 0 Inability to self-protect 0 Loneliness due to the inability to form relationships
Treatment0 Insufficient evidence to prove efficiency of any treatment0 Making the self-harm the focus is argued0 Brief therapies are needed, but also lack in intensity0 Reluctant participants make therapy difficult
Medication0 Selective serotonin reuptake inhibitors or SSRI’s (Prozac, Paxil, Luvox, etc.) can reduce self- mutilation in some clients by controlling the depression induced by low serotonin levels0 Must also include psychological treatment
DBT (Dialectical Behavioral Therapy)0 Goal is behavior modification0 No data collected only with women, but data provides some support for effectiveness 0 Structure 0 One hour weekly of individual therapy 0 Two and a half hours of weekly group therapy 0 Continued for a year 0 Team approach 0 Phone consultation between sessions 0 Manual available 0 Training 0 Instruction in mindfulness 0 Interpersonal effectiveness 0 Emotion regulation 0 Distress tolerance 0 Pitfalls 0 Finances 0 Time commitment 0 Best for highly motivated clients
MACT (Manual AssistedCognitive-Behavior Therapy) 0 Response to the need for brief therapy 0 Delivered in maximum of 6 sessions 0 Can be entirely bibliotherapy with 6 booklets 0 Evidence showed depressive symptoms reduced
CAT (Cognitive Analytic Therapy)0 For repeat self-mutilators0 Very Brief- possible in one session 0 Structure 0 Problem-solving focus 0 Shared role relationship 0 Intervention 0 Self-harm Self Help file for the client (completed before session) 0 Assessor’s Response File for counselor (completed before session) 0 Assessments give focus to the sessions
Narrative Therapy0 Circle Strategies- Outside to Inside Approach 0 Outer circle- learn about the context of the client’s life minus the trauma and symptoms 0 Middle circle- focus directly on the trauma and symptoms; build a support system 0 Inner circle- Create a protective presence in place of the non- protective presence.
Group Therapy0 In conjunction with individual therapy 0 Challenges 0 Loss within the group can trigger self-mutilation 0 Mutilation can be used as a communication technique 0 Mutilation may be used to manipulate the group 0 Members can gain status by self-mutilating 0 Strategies to Deter 0 Labeling SMB 0 Reframe “helpful” behaviors as “harmful” in helping 0 Benefits 0 Communicating about distress 0 Practice skills 0 Receive feedback
Inpatient Treatment0 For extreme situations0 S.A.F.E. Alternatives program Click on the webpage above to go to the S.A.F.E Alternatives webpage for more on their inpatient treatment options,
Considerations0 Do’s (according to client perception) 0 Care about the person beyond the injury 0 Offer compassion for the injuries 0 Be willing to talk about it 0 Help shed light on the origins of the behavior 0 Point out the ambivalence 0 Find different ways to express feelings 0 Create support systems 0 Recognize the behavior can not be dropped immediately 0 Celebrate small gains0 Don’ts (according to Conterio and Lader) 0 Displaying wounds or scars 0 Prescribe substitute behaviors 0 Anger release techniques 0 Physical activity 0 Hypnosis 0 Heroic Rescue (Pearson, 2011, 93-94)
Diversity Issues0 Prominent with Caucasian (77%)0 Prominent with females, bisexual, or questioning0 Persons with Disabilities 0 Stereotypic type 0 Intellectual disability 0 Expressive communication skills are poor 0 Compulsive behaviors 0 Same treatments as other populations (medication and/or behavior modification)
Assessment0 No specific assessment0 MMPI-2 does identify self-mutilating behaviors 0 Click on MMPI-2 above to link to the Pearson summary of this assessment0 Observation and direct questioning are the best methods for identifying self-mutilation0 Should be apart of initial intake
Counselor Issues0 Hard for the counselor to keep their reactions neutral0 Requires serious commitment0 Specifying with the client how self-mutilation will be handled beforehand0 Recognizing their limits as a counselor for this issue
Ethical Concerns0 Knowing when it is appropriate to hospitalize0 Refusing therapy without a referral0 Physically intervene or not if a client self-mutilates during the session0 Informed consent needs to address how self- mutilation will be handled
ReferencesConterio, K. (2011). S.a.f.e. alternatives. Retrieved from http://www.selfinjury.com/Demi Lovato Talks About Cutting Herself. Available from: http://youtu.be/RVq-sLFu6M4. (last accessed 7/1/2012).Erskine, K. (2010). Mockingbird. Philomel.Froeschle, J. (2004). Just cut it out: Legal and ethical challenges in counseling students who self-mutilate. Professional School Counseling, 7(4), 231-235.McCormick, P. (2000). Cut. Push.Pearson Custom Education, Counseling COUN 6731. Copyright 2011 by Pearson Learning Solutions. Boston, MA.Pearson Education. (2012). Minnesota multiphasic personality inventory®-2 (mmpi®-2). Retrieved from http://psychcorp.pearsonassessments.com/HAIWEB/Cultures/en-us/Productdetail.htm?Pid=MMPI-2&Mode=summaryPersonality Disorders: What Is Borderline Personality Disorder?. Available from: http://youtu.be/1lxdhKhTP1w. (last accessed 7/1/2012).Zila, L. S. (2001). Understanding and counseling self-mutilation in female adolescents and young adults. Journal Of Counseling & Development, 79(1), 46.