
                            Therapeutic approaches
                                       
   A group of activists and trainers in the U.K. is working on training
   A&E (emergency room) personnel on ways to make what is often the
   self-injurer's first contact with the medical system a productive
   encounter. [1]This effort is spearheaded by nurses, former
   self-injurers, therapists, and others. Similar efforts in the US,
   Canada, and Australia would be worthwhile.
   
Overall considerations

   In order to help those who self-injure, therapists must understand
   what role this powerful coping mechanism plays in their clients'
   lives. Is it primarily a means of releasing tension? Grounding?
   Communicating? Reliving painful experiences? Understanding why a
   particular person self-injures is key to helping that person stop
   using self-harm as a primary coping mechanism. "[H]aving [immediate
   cessation of self-injurious behavior] as a primary goal may well be
   counter-productive," warn Solomon and Farrand (1996); "techniques
   based on the premise that self-injury should not be reinforced by
   attention, or on the use of sanctions such as withdrawal of treatment,
   will almost certainly cause greater distress."
   
   Therapists need to examine their own motives for wanting a client to
   cease or stabilize his/her self-injurious behavior. Too often, care
   providers focus on stopping the SI as quickly as possible because they
   themselves are not comfortable with it -- it repulses them, makes them
   feel ineffective, frightens them, etc. Situations like this can easily
   deteriorate into a power struggle in which the therapist insists that
   the behavior stop and the client chooses to self-injure covertly and
   becomes reticent and distrustful, thus reducing the chance that a
   useful therapeutic alliance will be formed.
   
   On the other hand, it is legitimate for therapists to help clients
   devise some sort of plan for dealing with self-injurious impulses and
   getting their lives (including SIV) stabilized. When a client is
   engaging in uncontrolled self-injury, the SI and its concomitant
   crises take center stage in therapy, leaving no room for dealing with
   core issues. In order to have a minimum of stability in treatment,
   therapists must walk a fine line between attempting to repress/control
   all self-injurious behavior and allowing the SIV to dominate the
   therapy.
   
   An ideal approach would be one in which SIV is tolerated but has
   specific consequences. For example, a client might be invited to
   contact the therapist when an urge to self-harm occurs, but restricted
   from contact for 24 hours after an actual self-injurious act. In a
   system like this, the self-injurer has a chance to articulate what she
   is trying to communicate through her body without having to resort to
   self-injury, and she knows that carrying through an act of SIV will
   have tangible and immediate (but not permanent) negative effects. This
   kind of agreement between therapist and client can help stabilize the
   SIV and clear the road for dealing with the issues underlying the need
   to injure, allowing the therapist to follow Kehrberg's advice to treat
   self-harm within the context of underlying pathology.
   
   Therapists should ensure that self-injuring clients have access to
   non-judgmental, compassionate medical care for wounds they inflict on
   themselves (Dallam, 1997), care that does not rob them of their
   dignity or autonomy. Together, client and therapist can devise a plan
   for getting physical wounds treated without adding additional stress
   to the situation. This may involve educating physicians at local
   emergency rooms about the nature of SIV.
   
   Since successful treatment of SIV depends heavily on teaching the
   client new ways of coping with stressors so that underlying painful
   material can be dealt with, hospitalization should be used only as a
   last resort when the client is at risk for suicide or severe
   self-injury (Dallam, 1997). Hospitals are artificially safe
   environments, and the necessary tasks of learning to identify the
   feelings behind the act and of choosing a less-destructive method of
   coping need to be practiced and reinforced in the real world.
   
   Favazza (1998) advocates the use of high-dose SSRIs and mood
   stabilizers to get self-injury under control quickly, then suggests
   that care be managed under a team concept, with an overseeing
   psychiatrist who manages meds and coordinates care, a psychotherapist,
   and a group therapist. He also recommends that hospitalizations be
   kept brief.
   
   Several SI units have been started in U.K. hospitals, however, where
   self-injury is tolerated and clients are encouraged to examine their
   behavior after an incident. The staff accept some SI as inevitable and
   try to use these occasions as ways to teach about coping without SI.
   In cases like these, longer hospitalization may have more value.
   
  Approaches taken by those who see self-injury as associated with BPD
  
     * [2]Dialectical Behavioral Therapy
     * [3]Interpersonal Group Therapy
       
  Approaches taken by those who see self-injury as non-BPD-related
  
     * [4]The CPTSD approach
     * [5]Healing from TRS
     * [6]Rational-Emotive Therapy
       
   [7]
   
  Psychopharmacological approaches
  [8]Individual psychotherapy and how to choose a good therapist
  [9]Where to go for professional help
  
  Hypnosis and relaxation
  
   Hypnotic relaxation techniques have apparently been used, with some
   success, as an adjunct to therapy. Malon and Berardi (1987) state that
   treating those who self-injure requires that the therapist realize the
   conflicting needs of the therapist to be in charge of the relationship
   and of the patient to be treated like an equal; if the patient's need
   for being seen as an equal isn't met, no progress can be made with or
   without hypnosis.
   
   The study in question reports success with three types of hypnosis:
     * Breath counting: the patient is led into a trance and instructed
       to notice her breathing, counting each deep slow breath.
     * Positive imagery: the patient is put into a trance state and
       instructed to visualize herself in a calm, pleasant, relaxing
       place doing something she enjoys. This image is held for a while.
     * Affect bridge: after trance is achieved, the patient is asked to
       use the current unpleasant feelings to remember other times in his
       life when he's felt this way. Memories that are too distressing to
       talk about in a normal state are sometimes speakable in a trance
       state.
       
   It's important to note that in all of these techniques, the therapist
   must remain seated close to the patient, offering encouraging words
   and/or touches when appropriate. Malon and Berardi go so far as to say
   that "simple hypnotic techniques...offered the most immediate relief
   when delivered with a strong communicative focus and close
   here-and-now contact."
   
  Hospital-based treatment
  
   SAFE Alternatives (1-800-DONTCUT) is an inpatient program specifically
   for self-injurers located at MacNeal Hospital in a Chicago suburb
   (this program was formerly located at Rock Creek Hospital and at
   Hartgrove Hospital). The program combines milieu therapy,
   cognitive-behavioral therapies, and group and individual exercises to
   help patients gain an awareness of why they hurt themselves and how to
   stop. They claim to be the only inpatient unit for self-injurers in
   the U.S., though Rock Creek continues to have a program specifically
   for SI, as do a few other hospitals. Although their zero-tolerance
   policy toward SI is controversial, they claim to have lost very few
   clients because of it. There is no empirical evidence of the success
   of their approach, and I personally am uncomfortable with their overly
   aggressive marketing style. The hospital is quite expensive, and if
   you haven't insurance, you probably can't afford it.
   
   [10]The Sanctuary at Friends' Hospital in Philadelphia is an inpatient
   unit for trauma survivors that is aware of the special needs of
   self-injurers and takes them into account in its treatment program.
   
   Butler Hospital in Rhode Island offers a partial hospitalization
   program that uses dialectical behavioral therapy to treat a diverse
   patient population of self-injurers. In a recent assessment of their
   program, they conclude, "Two years of operation of the women's partial
   program provides promising anecdotal evidence that DBT, which is an
   outpatient approach, can be effectively modified for hospital
   settings. . . . Our experience with more than 500 women certainly
   suggests that such treatment may be a feasible alternative to
   inpatient hospitalization" (Simpson, et al. 1998). Butler can be
   contacted at (401) 455-6200.
   
   The Rock Creek center still offers an inpatient self-injury management
   program and can be reached at 1-800-669-2426.
   
Treatment efficacy

   In a 1998 review, Hawton et al. evaluated the effectiveness of ten
   different approaches to treating self-harm: problem-solving therapy, a
   special emergency room card getting the patient faster treatment in
   the ER, intensive education and outreach, and dialectical behavior
   therapy were compared to standard aftercare; inpatient behavior
   therapy was compared to inpatient insight-oriented therapy; admission
   to the hospital was compared to discharge after the ER visit;
   flupenthixol (fluanxol, an anti-psychotic drug not available in the US
   with severe potential side-effects) and antidepressants were each
   compared to placebo; followup by the initial treating therapist was
   contrasted to followup by a different therapist; and long-term therapy
   was compared with short-term therapy.
   
   They found no significant difference in % of repeaters who were in the
   long-term vs short-term therapy trials, the antidepressant vs placebo
   trials (which used mianserin, a drug that increases serotonin in the
   brain, and nomifensine, a dopaminergic drug that has serious side
   effects and is no longer available), the intensive
   intervention/outreach vs standard aftercare trials, the emergency card
   trials, and the hospital admission vs discharge trials and the
   (possibly too small to yield a significant effect) inpatient behavior
   vs insight-oriented therapy studies.
   
   The problem solving studies showed a distinct reduction in SI among
   those who got problem-solving therapy, but the results of combined
   studies did not reach statistical significance. The flupenthixol study
   showed significant reduction in repeat self-harm, but it was a very
   small study and there is some concern that the possible side effects
   of fluanxol outweighed any benefit.
   
   The two trials showing a significant decrease in repeat self-harm
   among the experimental group were the DBT studies (the DBT group has
   fewer repeaters) and the same vs different therapist doing followup
   (the % of repeaters was higher in the group that saw the same
   therapist).
   
   [INLINE]
   
  next section: [11]Self-Help
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References

   1. file://localhost/usr/home/llama/Web/psych/firstline.html
   2. http://www.palace.net/~llama/psych/dbt.html
   3. http://www.palace.net/~llama/psych/ipg.html
   4. http://www.palace.net/~llama/psych/herman.html
   5. http://www.palace.net/~llama/psych/miller.html
   6. http://www.palace.net/~llama/psych/ret.html
   7. http://www.palace.net/~llama/psych/pharm.html
   8. http://www.palace.net/~llama/psych/therapy.html
   9. file://localhost/usr/home/llama/Web/psych/restherp.html
  10. http://www.sanctuarysage.com/
  11. file://localhost/usr/home/llama/Web/psych/fself.html
  12. file://localhost/usr/home/llama/Web/psych/injury.html
