Group Therapy for Self-Cutting: Aims, Risks, and Treatment

Introduction to Group Therapy

The aim of this research is to investigate and identify the key elements for successful group therapy and to propose those elements as guiding principles for future group counselling guidelines, as well as for theoretical and program development. Therapists must recognize the essential factors of group therapy that contribute to positive therapeutic outcomes. The important elements of group therapy established by a board of professionals are proposed here as guiding principles for future group therapy theory and program development (Edwards, 2001).

Group therapy is a type of psychotherapy in which one or more therapists work with a small group of patients together. It typically involves one or more psychologists leading a group of approximately five to fifteen clients. Group counselling is frequently viewed as one of the most helpful alternatives for many client concerns. Group therapy is a procedure distinguished by different stages and corresponding therapeutic tasks. Therapists who understand these stages and their core dynamics are better positioned to guide their groups through the difficult — and at times confusing — nature of group work.

Group counselling normally involves one or two skilled group therapists and four to ten patients. Almost all therapy groups meet every week at the same time for around two hours. Although the phrase could technically apply to any type of psychotherapy administered to a group, it is most commonly associated with a particular form of therapy that utilizes the group dynamic. Therapy in a group environment can have numerous advantages: it provides a support network and the chance to meet others going through the same issues. In cooperation with the therapist and other group members, participants are encouraged to share their experiences and work toward understanding themselves more deeply. Groups normally meet for a specified period of time and are often designed to target a particular concern, such as obesity, social anxiety, depression, or substance abuse. Other groups focus more broadly on enhancing social skills and helping individuals handle issues like loneliness, anger, low self-esteem, and shyness. Groups also frequently assist those who have experienced a loss of any kind — such as the death of a child or a spouse (Group Therapy, 2015).

Understanding Self-Cutting

"Non-suicidal self-directed violence" (SDV) is also known as "non-suicidal self-injury" (NSSI) or "deliberate self-harm" (DSH) (Crosby et al., 2011). Cutting is a common form of self-harm and typically occurs repeatedly — it is never a one-time incident. It usually involves the use of sharp objects such as razors, sharp stones, knives, and broken glass. When such items are unavailable, individuals may use other objects or methods to break the skin, including:

• Pencil erasers (through hard rubbing)
• Deep scratching (to draw blood)
• Pinching
• Punching oneself
• Burning the skin
• Biting

Common cut sites include the wrists, arms, lower legs, and ankles. Hidden sites can include the inner thighs, abdomen, genitals, feet, and areas under the breasts or arms. The marks left after cutting are typically well concealed to allow the behaviour to continue without detection. Self-cutting is associated with various psychiatric difficulties (Muehlenkamp et al., 2012) and occurs primarily as a means of coping with painful emotions (Ferrales & Koukel, n.d.).

Individuals who engage in NSSI typically do so in an effort to escape feelings of being trapped by intolerable psychological and emotional situations that make them feel powerless. For such individuals, cutting offers temporary relief from agitation and anxiety, or provides respite from negative feelings such as low self-esteem, depression, emotional numbness, apathy, and hopelessness. Self-cutting can also generate feelings of self-efficacy or control. This self-harming behaviour has been recognized as potentially addictive, as it involves an overwhelming preoccupation with the relief experienced after the cutting incident. Some researchers believe that individuals who self-injure may also develop a craving for the body's natural feel-good chemicals — endorphins — that are released when the skin is cut. Endorphins generate natural feelings of happiness (Ferrales & Koukel, n.d.).

Risk Factors for Self-Cutting

The Mayo Clinic has identified several factors that can raise the risk of self-cutting and self-injury:

• Gender: Females appear to be at greater risk of self-cutting than males.
• Age: Self-injury typically begins during adolescence.
• Peer influence: Having close friends or associates who engage in self-cutting increases risk.
• Life circumstances: Unstable relationships or traumatic experiences are associated with higher risk.
• Mental health issues: Individuals who self-cut often have reduced coping skills and co-occurring mental health disorders such as depression, anxiety, or post-traumatic stress disorder.
• Substance use: Self-cutters frequently harm themselves while under the influence of drugs or alcohol (Ferrales & Koukel, n.d.).

Aims and Dynamics of Group Therapy

Descriptions of group therapy first appeared in the literature under the terms "group counselling" and "group therapy." Therapists who apply a solution-oriented therapeutic approach understand how a group can almost exponentially expand the pool of possible solutions to existing concerns. A group that focuses on strengths and resources tends to generate a more positive atmosphere for both patient and clinician. Solution-focused group therapy creates an environment in which clients become enthusiastic about discovering hidden strengths and previously unrecognized internal solutions.

The increased application of the group therapy format is producing meaningful changes in how group therapy is delivered. Although solution-focused therapy has gained recognition for its use with individuals, comparatively little attention has been given to its application in group therapy formats. Initially, solution-focused therapy was met with considerable opposition due to its notions, assumptions, and techniques, which challenged traditional therapy values.

Self-harm can itself be a way of coping with distress in the absence of other strategies. It may help individuals express emotions that cannot be conveyed verbally, distract from painful circumstances, or release emotional hurt. While an individual may feel better briefly after self-harming, the painful emotions typically return, along with the urge to hurt oneself again. Self-harm is essentially a means of conveying and managing deep stress and emotional pain. Once individuals learn to interact freely with other group members, they tend to recreate the same interaction patterns that have been difficult for them outside the group. The group therapy environment provides a secure space in which to experiment with new ways of relating to oneself and others.

Most individuals feel in some way strange or different because of their problems or the way they feel; it is deeply encouraging to discover that others share similar challenges — and that it is possible to move past them (Metcalf, 1998). With the assistance of group leaders, members come to understand how their actions affect others. The group becomes a safe place to try out new ways of treating oneself and others, and the focus shifts from seeing oneself as defective to learning how to live as richly and fully as possible.

Self-harm is strongly associated with borderline personality disorder, where it is among the nine diagnostic criteria for the condition. Individuals who are bipolar, have other personality disorders, or experience anxiety, depression, psychosis, or manic episodes may be more prone to self-injury than others. Childhood trauma — such as severe neglect or abuse — is also a risk factor, and research indicates that self-harm is common among people with eating disorders. The reasons underlying self-injurious urges are not universally agreed upon. People who harm themselves frequently report feelings of loneliness, difficulty expressing their emotions, and problems in relationships of many kinds. Others may harm themselves in an effort to manage stress or emotional distress.

Self-harm may follow a cycle similar to that of a drug or alcohol addiction: an individual might feel anxiety, followed by impulse, resistance, tension, and finally release — which may then be followed by shame and renewed anxiety. The individual may feel that burning, cutting, or other acts involving physical pain are the only means of alleviating these feelings. Behavioral signs of self-harm include frequent unexplained accidents, wearing concealing clothing in warm weather, apparent agitation, keeping sharp objects without clear explanation, withdrawing for long periods, difficulty functioning at school or work, and low self-esteem. While some individuals who self-harm take careful precautions to avoid serious injury — using sterile blades, cleaning wounds, and avoiding major blood vessels — others may not take such measures and may seriously harm themselves. Either way, habitual self-harm poses significant risks to health and functioning in both the short and long term (Smith & Segal, 2016).

The aims of group therapy and individual therapy are often similar; however, in group therapy the therapist may use the group dynamic to pursue those aims differently (Fehr, 2012). The general aims of the group include:

Helping individuals identify maladaptive behaviour. Being in a group therapy setting can help individuals identify their own traits and behavioral patterns more clearly. With the space that compassion provides, participants may discover that their ways of coping are less adaptive than they would like. Group therapy helps people view themselves and their behaviours more objectively (Fehr, 2012).

Assisting with emotional difficulties through feedback. Discussing emotional challenges with group members and the therapist generates a wide range of responses. This may include professional guidance from the therapist as well as practical insight from fellow group members who have encountered similar issues. The goal is to help participants become more familiar with their own coping techniques so they can manage difficulties when they arise (Fehr, 2012).

Providing a supportive environment. Group therapy is not only an opportunity to receive feedback and advice — it is also a chance to reach out and support others. What is discussed in therapy sessions remains confidential. Talking with people who are experiencing similar difficulties helps participants feel encouraged and less isolated (Fehr, 2012).

Conclusion

Group therapy helps individuals recognize that they are not alone in their struggles. Effective group counselling depends on the preparation of group leaders and their ability to plan and facilitate groups successfully. This preparation involves screening members, choosing a manageable group size, selecting a consistent location and meeting time, and establishing clear ground rules. Many patients enter therapy believing they are uniquely miserable — that only they possess particular frightening or unacceptable problems, fantasies, thoughts, or desires. Group therapy addresses this isolation by facilitating the giving and receiving of encouragement among members.

In addition, group therapy helps participants relate more effectively to others and to themselves. It provides a safety net where members can observe how they interact with others in real time and gain insight into how they relate to themselves. Beyond strengthening relationship skills, reducing isolation, and helping individuals find their voice, group therapy is also beneficial for those dealing with social anxiety, significant life changes, depression, and a range of other concerns (Sobell & Sobell, 2011).

References

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Crosby, A. E., Ortega, L., & Melanson, C. (2011). Self-directed violence surveillance: Uniform definitions and recommended data elements. Centers for Disease Control and Prevention.

Edwards, S. A. (2001). The essential elements of multi-family group therapy: A Delphi study.

Fehr, S. S. (Ed.). (2012). 101 interventions in group therapy. Routledge.

Ferrales, D., & Koukel, S. (n.d.). Teens and self-cutting (self-harm): Information for parents. New Mexico State University.

Glass, S. D. (2010). The practical handbook of group counselling. Trafford Publishing.

Group Therapy. (2015). Retrieved February 19, 2016, from http://www.counselling-directory.org.uk/group-therapy.html

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Lyness, D. (2015, July). Cutting. KidsHealth. http://kidshealth.org/en/teens/cutting.html

Mayo Clinic. (2012). Self-injury/cutting: Risk factors. http://www.mayoclinic.org/diseases-conditions/self-injury/basics/risk-factors/con-20025897

Metcalf, L. (1998). Solution focused group therapy: Ideas for groups in private practice, schools, agencies, and treatment programs. Simon and Schuster.

Muehlenkamp, J. J., Claes, L., Havertape, L., & Plener, P. L. (2012). International prevalence of adolescent non-suicidal self-injury and deliberate self-harm. Child and Adolescent Psychiatry and Mental Health, 6. https://doi.org/10.1186/1753-2000-6-10

Samuel, G. (n.d.). Effective group counselling. ERIC/CASS Digest. http://www.ericdigests.org/1994/group.htm

Shulman, L. (2010). Dynamics and skills of group counselling. Cengage Learning.

Smith, M., & Segal, E. (2016). Cutting and self-harm. HelpGuide. http://www.helpguide.org/articles/anxiety/cutting-and-self-harm.htm

Sobell, L. C., & Sobell, M. B. (2011). Group therapy for substance use disorders: A motivational cognitive-behavioural approach. Guilford Press.