Self-harm treatment approaches and interventions

Self-Harm Treatment

Self-harm: Classification and treatment issues in adolescents

Despite the frequent reportage on adolescent self-harm in the popular media, achieving a consensus on how to treat this difficult problem continues to vex the psychiatric community. One of the first problems is how to define deliberative self-harm (DSH). Some therapists contend that DSH is best classified as an anxiety disorder, and self-harm is a way for the adolescent to self-medicate feelings of panic and a sense of a lack of control about the future. The adolescent retaliates against the world by inflicting harm upon the self rather than dealing with unpleasant thoughts. Others view it as a subset of obsessive-compulsive disorder (OCD), given the repetitive and compulsive nature of the acts. A contrary view of the behavior is that it is less as a condition in and of itself and more of a symptom of a more severe and pervasive condition known as borderline personality disorder (BPD). "Borderline personality disorder (BPD) is a psychiatric disorder with a pervasive pattern of instability in four areas: affect regulation, impulse control, self-image, and interpersonal relationships" (Bland et al. 2007, p.1). These characteristics are often especially manifest and acute in adolescents, especially since even normal adolescents may manifest these symptoms, albeit to a far lesser and self-destructive degree.

The overall self-harm personality profile in both adults and adolescents is characterized by the intense emotions and a heightened sensitivity to rejection characteristic of BPD patients. BPD patients, like self-harm patients are often notoriously difficult to treat, and may be 'passed on' from therapist to therapist after unsuccessful treatments. Personality disorders in adolescents are notoriously unresponsive to conventional talk therapies. It should also be noted as well the dissociative state that self-harmers describe entering into during the 'cutting' and mutilating acts has caused still other therapists to view DSH as symptoms of dissociative personality disorder, a less commonly diagnosed personality disorder than BPD, and one with features not particular to adolescent development. Finally, the addictive quality of DSH is viewed by many therapists to have an addictive quality. They point to its frequent coexistence of other addictions seen in these individuals, such fixations upon alcohol and drug abuse (Mangnall & Yurkovich 2008, p.2). Adolescents may also be especially vulnerable to addictive, thrill-seeking behaviors and a more likely to spiral into the addictive 'high' caused by self-mutilation. However, the use of twelve-step programs for DHS for adolescents, has not been subject to research studies and is not accepted as customary course of treatment at present.

One of the greatest difficulties of treatment shared by BPD and self-harmer is treatment resistance. BPD patients often demand therapists that are emotionally supportive and provide them with understanding and affection, but may not be willing to do the critical, self-searching work demanded of conventional psychotherapy. "In the absence of caring listeners, it may be that self-harmers feel the need to turn to a more dramatic communication method," and therapists may find themselves accused of being unable to give enough 'support' to the patient, because the therapist does not validate all of the patient's impulses (Mangnall & Yurkovich 2008, p.5). The extent to the patient makes such accusations will affect the view of the therapist as to whether DSH is anxiety-related, a compulsive, a personality disorder, or a mixed phenomenon. This is one reason why the classification of the disorder is so contentious, given that subjective therapeutic experiences over time may affect its conceptualization as well as the view of an individual patient.

One therapeutic dynamic amongst self-harmers that has met with some success, as well as with OCD and anxiety conditions is cognitive behavioral therapy. OCD and anxiety disorders often arise, according to CBT therapists, "from inaccurate beliefs about stimuli" such as emotional pressures and developmental issues (Sullivan 2006, p.1). The cognitive therapeutic process is behavior-based. Rather than identify past traumas, the patient focuses on the here and now, identifying and correcting the specific thoughts that produce the anxiety and compulsive behaviors. To identify cognitive errors patients keep a thought record. The document consists of recording the action, the thought that came with it, the accompanying anxiety or fear level, and the resulting ritual and then "writing logical thoughts that could counteract the illogical assumptions" about the self and the need to repeat the behavior (Sullivan 2006, pp.1-2).

For example take the thought: 'I did poorly on a test, so I deserve to be punished.' A cognitive behavioral therapist might ask, what will harming yourself do to improve your grades on the test? Cognitive therapies in general have been shown to be more effective than traditional supportive talk therapies when treating anxiety conditions because they offer concrete steps for self-improvement on a continuing basis (Reeves 2003, p1.). Patients are also asked to identify things they would like to do in which current behavior patterns prevent them from engaging, such as wearing short-sleeved shirts.

Cognitive and cognitive-behavioral therapy shows a higher success rate in anxiety disorders and OCD than traditional psychotherapy, likely because of its behavioral component. The fact that many DSH patients are diagnosed with BPD may complicate treatment, but BPT responds well in some instances to these therapies, too. BPT patients manifest disordered patterns of relationships, thinking, behavior, and coping mechanisms that contribute to unstable life patterns as well as contribute to the kind negative, anxious, depressed, and compulsive thoughts that lead to self-mutilation. It should be noted that BPT patients have often suffered childhood abuse. Abuse "is reported by 40-71% of inpatients with BPD, and the severity of sexual abuse suffered in childhood has been linked to the severity of the borderline pathology found in adulthood" (Bland et al. 2007, p1). An emphasis present rather than past behavior is not to deny the significance trauma may have in the mental dynamics involved in self-harm and BPT, but is merely a comment on cognitive therapy's established greater effectiveness. Cognitive behavioral therapy helps circumvent some of the black and white thinking that makes treating BPT so difficult: "another challenge for nurses working with patients with BPD is the manipulation and splitting of staff. These patients view the world and people in terms of absolutes. This view leads to the nurses being categorized into two groups: weak or strong, good or bad, independent or dependent. Only a few nurses are considered good. The good nurses are idealized, and the bad nurses are ridiculed and berated. The good and bad nurses can even shift categories as the patient with BPD may idealize them at first and later devalue them" (Bland et al. 2007, p.1). Cognitive therapy challenges and questions such black and white thinking, even though it may be tempting for a more conventional therapist to mull over past tragedies with the patient.