Therapeutic Intervention

Self-harming Behavior and Young People
PART A
Young people engaging in self-harming behaviors is referred to as non-suicidal self-injury: this is deliberate, concerted harm to the physical body, without the desire to commit suicide (Klonsky, 2010). Young people often engage in these behaviors through the cutting of the top layer of the skin, hitting, or cutting. Many professionals within the field of mental health find this behaviour very distressing, as there’s such a clear connection to suicide. “Some argue that self-injury should constitute its own diagnostic syndrome in light of the behavior’s clinical significance and presence across multiple disorders” (Klonsky, 2010). Though it is worth noting that self-harming behaviors does manifest with a range of conditions, from eating disorders, to personality disorders, to drug addiction and anxiety issues (Klonsky, 2010). Self-harm is also referred to as “non-suicidal self-injurious behaviour” (NSSI) and the Center for Disease Control cites that suicide is the third main leading cause of death (Klonsky, 2010). According to the CDC’s research, “…19% engage in NSSI, 13% seriously consider suicide, and 6% attempt suicide” (Klonsky, 2010). Determining the exact rates of self-harm can be tricky as they can widely vary, due to the way in which researchers frame their questions. Based on general estimations, those between 2% and 6% of people will engage in self-harming behavior at some junction during their lifetime (ptsd.va.gov).
However, among young people the rates definitely exceed this, hitting the 13% to 35% range (ptsd.va.gov). People who have long-standing mental and emotional health problems and suffer from PTSD are more likely to engage in self-harming behaviors (ptsd.va.gov). It is unclear to the mental health community if these actions are more common in females or males. Some researchers have suggested that the behavior more commonly manifests in adolescent girls; for example in a study with 1802 participants “…with 149 (8%) reporting self-harm, More girls (95/947 [10%]) than boys (54/855 [6%]) reported self-harm (risk ratio 1·6, 95% CI 1·2–2·2)” (Moran et al., 2012). This same study reported a reduction in self-harming behaviors in later adolescence, but that there remained a stronger continuity in girls than in boys (Moran et al., 2012). While this research should be taken into consideration, further studies are needed before one can conclude that this behavior is more prevalent in girls. Self-harming behaviors of young people are deeply concerning, and are an aggravated enough problem that there needs to be a better understanding of the problem and more strategic interventions to address it when it does begin to manifest.
There is an element to this behavior that is puzzling to mental health professionals. Such as why certain depressed, anxious people engage in this behavior when others do not. Still most professionals consider this behavior a disturbing gateway to suicide (Whitlock et al., 2013). However, the research has demonstrated that those who engage in self-harming actions have negative feelings and thoughts more often and at a higher number than the average depressed person (ptsd.va.gov) (Portzky et al., 2008).
One of the risk factors in this behavior is childhood abuse, namely childhood sexual abuse. Another research study found that when women reported incidents of childhood sexual abuse it usually occurred in conjunction with other forms of abuse such as long periods of time left alone, emotional abuse and physical abuse (Gladstone et al., 2004). However, women who experienced childhood sexual abuse were ones who either had tried to kill themselves or occupied themselves with intentional self-harm (Gladstone et al., 2004). Hence, mental health professionals need to be very diligent about identifying childhood sexual abuse in their patients. “Depressed women with a childhood sexual abuse history constitute a subgroup of patients who may require tailored interventions to combat both depression recurrence and harmful and self-defeating coping strategies” (Gladstone et al., 2004). Furthermore, it is important that a therapist properly understand that aside from the abuse, this behavior is caused by a desire to cope. Self-harm is a coping mechanism, one that allows the victim to feel a sense of release, such as a release of tension, and for the victim to feel as is abuse is happening but they are controlling it. It allows them to reframe the abuse they suffered in a way that they are in charge of the abuse suffered.
For mental health professionals, early intervention is crucial, particularly when working with clients who exhibit particular signs such as: “sexually permissive attitudes, sexual preoccupation, persisting pathological dissociation, and PTSD” (Noll et al., 2003). Therapists and mental health experts can conclude that childhood sexual abuse is something that can create devastating, lasting damage. The correlation between sexual abuse and self-harm is high enough that if a client engages in self-harming behaviors, a therapist must definitely find out what types of abuse occurred in childhood, as there were likely to have been some.
When a person engages in self-harm, they are likely to describe a range of feelings, thoughts, moods, and overall intentions. This wide spectrum of change means that it can be more challenging for mental health professionals to address or intervene in the reasons that people seek out self-harming actions. For some patients, self-harm is a distraction. For other patients, it’s a form of punishment. For others, it offers them a sense of release and a minimization of tension and anxiety. And still others it gives them a sense of safety and of feeling protected. A person who engages in self-harm might feel more relaxed, whereas a different person might feel a greater sense of shame. Some patients might feel more at peace and contemplative after engaging in this behavior. Yet other people might feel more agitated and talkative. The onus is on the mental health care community to seek out deeper understanding on the changes in behavior, cognition, mood and physical functioning and communication that occurs before and after people engage in this behavior.
PART B
While pharmacological approaches are popular and prevalent (Ougrin et al., 2015), the non-pharmacological approach that I would suggest to help people in the relevant population would be twofold. The first would be to address the compulsive urge to feel pain. Having the patient wear a rubber band around the wrist can assist with this, and when the patient has an urge to cut, burn or hit him or herself, they can snap the bracelet against their wrist (Young, 2010). Alternatives to the rubber band that can sometimes be effective are rubbing an ice cube on the skin, or taking a cold shower. The first prong of this therapeutic approach is designed to distract the mind and the nervous system for that insatiable need to feel pain. Feeling a small amount of physical discomfort can often be adequate to satiate the body from more intense outlets of self-harm. Psychotherapy should be used to deal with the issues that are motivating this behaviour and the feelings attached to them. This type of therapy should be tailored to meet the specific needs of the individual. However, when the patient is in the throes of a bad day or a bad moment where feelings have become unmanageable and the urge to engage in self-injury is strong, a rubber band isn’t going to cut it, nor is waiting for the next therapy session. Hence, the second part of this therapy will include a means of emotional release through art, music, exercise or writing therapy. These outlets will give the patient a form of release, but will do so in a way that is safe, and which teaches the young person a proper coping mechanism that they can use for the rest of their lives (Miner et al., 2016). For instance, non-competitive exercise has been proven to minimize the urge to self-harm (Nock, 2006). The patient needs to make sure the circumstances and environment where the exercise is occurring is safe. The patient needs to be able to understand that this is exercise that is there not with a specific result in mind or to compete with others. It functions to exhaust the body and mind, and alleviate the urge to self-injure, which it does with a great deal of consistent success.
Similarly, writing/journaling can also be a powerful tool to interrupt the urge to self-harm: “Can be shared with therapist in the moment via text or during therapy session; it should not focus primarily on details of self-injury as this may triggering and a rehearsal. Rather the emphasis should be on identifying emotions, changing thoughts, using coping behaviors” (Walsh, 2018). Writing in this manner can be useful not just in disrupting the toxic urge to self-injure but it can offer valuable insight to the feelings that are floating beneath the surface. Bringing these entries to a therapist can offer invaluable insight into the buried emotions that are motivating the urge to self-harm. Numerous research has discussed the effectiveness of therapies within the arts or within physical exercises as a means of interrupting the desire to self-harm (Greydanus, & Shek, 2009) (Simpson, 2001) (Lowenstein, 2005) (DeSilva et al., 2013). Writing and other techniques in the arts or exercise, are cost-effective and readily available and give the client a sense of empowerment as one who takes an active role in their own healing (Hilton, 2015). When it comes to art therapy, for clients who are more visual, the canvas or clay can be swapped out as a physical object: hence, rather than mutilate the human body, the patient has something outside of themselves to inflict expression upon. If properly coached, the client can view art making as a symbolic medication of the self-mutilating clients own body (Milia, 2012). “The creative process itself provides an arena for the discharge and mastery of aggressive impulses, and develops self-control, self-esteem, and symbolic capacities, all of which are crucial in the treatment of self-mutilating behaviors” (Milia, 2012). In this manner, experts have shown how various forms of art therapy act as a meaningful substitution to interrupt self-injurious tendencies.
Art therapy has already been proven to be effective with children who act out: “It suggests that art made in the safe confines of the art therapy room may enable a child to
explore and express feelings that cannot easily be put into words. Instead of acting out
‘difficult’ feelings the child puts these into the object. This can then be shared with the
therapist. The art can act as a ‘container’ for powerful emotions, and can be a means of
communication between child and art therapist” (Waller, 2006). In many ways, adults who engage in self-harm are emotionally stunted, and have coping skills that are akin to that of a child. Furthermore, some clients who engage in self-harm aren’t going to want to journal, as they will have certain feelings they can’t put into words. This is exactly why art therapy or exercise can be so beneficial. It offers a release that allows the human body to get rid of pent up emotions that demand to be addressed. Another study found that art therapy when combined with cognitive behavioral therapy could reduce many of the symptoms that led to self-harming behavior in individuals who had been sexually abused (Pifalo, 2006). For example, things like under-response, hyper-response, depression, post-traumatic stress, dissociation, anger, anxiety, sexual preoccupation, sexual concern, and sexual distress were all reduced when given art and cognitive therapy (Pifalo, 2006). Thus, this therapeutic approach has high rates of effectiveness and is worth attempting with patients on a case-by-case basis. However, it might be difficult to convince patients to even try it, particularly the ones who are very attached to self-harming behaviors or who have been doing such behaviors for a very long time. In terms of an intervention for nursing, these methods offer tremendous promise, and nurses everywhere have to a duty to familiar with their efficacy.










References
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Gladstone, G. L., Parker, G. B., Mitchell, P. B., Malhi, G. S., Wilhelm, K., & Austin, M. P. (2004). Implications of childhood trauma for depressed women: an analysis of pathways from childhood sexual abuse to deliberate self-harm and revictimization. American Journal of Psychiatry, 161(8), 1417-1425.
Greydanus, D. E., & Shek, D. (2009). Deliberate self-harm and suicide in adolescents. The Keio journal of medicine, 58(3), 144-151.
Hilton, B. (2015, June). Scraping By-Self Care Writing for non-suicidal self-injury. Retrieved from https://www120.secure.griffith.edu.au/rch/file/1740ead5-a3d5-4a31-8b24-92c5e861d36c/1/Hilton_2016_01Thesis.pdf
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Walsh, B. (2018). Interventions for Self-Harm: What Works and What Does Not. Retrieved from https://www.inholland.nl/media/10858/presentatie-dr-b-walsh.pdf
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