Articles: Adolescents who self-injure: implications and strategies for school counselors
By Victoria E. White Kress, Donna M. Gibson, Cynthia A. Reynolds
This article explores strategies for school counselors to use in intervening and managing adolescent students who engage in self-injurious behaviors. The school counselor's roles in intervention, referral, education, advocacy, and prevention are discussed, Implications and recommendations for school counselors are addressed.
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In recent years, the media and popular literature have begun to address the issue of adolescent self-injurious behavior, and many counselors have had an increasing exposure to students who engage in these behaviors. Approximately 13% of adolescents sampled in one recent survey indicated that they engaged in self-injurious behaviors (Ross & Heath, 2002), and research has indicated that self-injury is becoming increasingly prevalent among adolescents (Hawton, Fagg, Simkin, Bale, & Bond, 1997). The incidence of self-injurious behaviors rises to 40% to 61% in adolescent inpatient settings and is ostensibly beginning earlier in the childhood and adolescent years (Conterio, Lader, & Bloom, 1998; Darche, 1990; DiClemente, Ponton, & Hartley, 1991).
Self-injurious behavior is discussed often with regard to the mentally retarded and developmentally disabled populations--people diagnosed with psychotic disorders, personality disorders, and dissociative identity disorder; however it is rarely addressed in discussions of the general adolescent population (Zila & Kiselica, 2001). This article focuses on self-injurious behaviors associated with adolescents in the non-severely mentally disabled population (e.g., mental retardation, schizophrenia, etc.). This article also is delimited to self-injurious behaviors involving self-cutting, interference with wound healing, scratching, and burning, but will not explore issues associated with hair pulling (e.g., trichotillomania), and extreme forms of self-injury (e.g., eye enucleation, amputation of body parts, breaking bones, etc.) as these are less commonly presented in school settings.
It is important to acknowledge that most cultures have forms of culturally acceptable and sanctioned self-injurious behaviors (Favazza, 1996). For example, among adolescents in Western culture, ear piercing, tattooing, and various forms of body piercing are becoming more commonplace. Deviant forms of self-injury are generally considered physically damaging and occur in response to psychological crisis. These acts demonstrate a sense of disconnection and alienation from others; the line between socially sanctioned self-injury and deviant self-injury can be hazy (Dallam, 1997).
Self-cutting is one of the most common forms of self-injury found in the non-hospitalized population, followed by burning, pinching, scratching, biting, self-hitting, and interference with wound healing (Briere & Gil, 1998; Ross & Heath, 2002; Taiminen, Kallio-Soukainen, Nokso-Koivisto, Kaljonen, & Helenius, 1998). The areas that are most typically injured are the arms and wrists, legs, abdomen, head, chest, and genitals, respectively (Conterio et al., 1998; Zila & Kiselica, 2001). In the literature, many varied definitions abound as to what constitutes self-injury. In this article, self-injury will be defined as a volitional act to harm one's body without any intention to die as a result of the behavior (Simeon & Favazza, 2001; Yarura-Tobias, Neziroglu, & Kaplan, 1995).
In many ways, the current awareness of self-injurious behaviors parallels the appreciation of eating disorders that developed in the 1970s and 1980s. At that time, anorexia and bulimia were thought to be rare and interesting conditions, but as public and professional awareness increased, many people began to seek help (Conterio et al., 1998). Despite an increasing awareness of adolescent self-injurious behavior, little is known about what treatments work best with this population (Zila & Kiselica, 2001).
The age at which people first begin to engage in self-cutting behaviors varies; however, these behaviors usually begin in middle adolescence (Herpertz, 1995), with the freshman year of high school being the average age of the first self-injurious behaviors (Ross & Heath, 2002; Favazza & Conterio, 1989). One study found that mental health professionals identified 18 as the average age their clients last engaged in self-cutting behaviors (Suyemoto & MacDonald, 1995). Thus, with regard to self-injury, school counselors are in a unique position to intervene as these behaviors typically begin, and often end, during the adolescent years.
Gender issues may also be present with regard to rates of self-injury. It is commonly stated that females are more likely to engage in self-injury than males. In one study of self-injurious adolescents, 64% were female and 36% were males (Ross & Heath, 2002). Indeed, most studies have indicated the majority of hospitalized self-injuring patients are female (Herpertz, 1995). However, Briere and Gil (1998), using a community sample, found no gender differences with regard to self-injurious behaviors. The belief that females are more likely to engage in self-injury may be related to researchers' use of samples including help-seeking clinical populations, hospitalized patients, and sexual abuse and incest survivor populations; samples that are more likely to be comprised of females. Higher rates of male self-injury in community samples may be due to different definitions of self-injury with some researchers including deliberate recklessness and risk-taking behaviors in which males may be more likely to engage (Ross & Heath).
Many theories have been proposed concerning the etiology and function of self-injurious behaviors. Generally, theories of the etiology of sell-injury tend to be based on biological, psychological, and sociological explanations. From a biological perspective, the seratonergic system has been implicated in the pathophysiology of self-injury (Dallam, 1997; Simeon et al., 1992) as well as the idea that the endorphin rush associated with self-injury can lead to an addiction to the behavior (Pies & Popli, 1995). Among mental health professionals, one of the more popular psychological theories (Suyemoto & MacDonald, 1995) involves the ability of self-injury to regulate emotions. The psychodynamic-oriented emotional dysregulation theory holds that self-injury is the result of anger turned inward on the self (Feldman, 1988) and that the self-injury results in emotional catharsis (Crowe & Bunclark, 2000). Similarly, Linehan's (1993) biosocial emotional dysregulation theory holds that self-injury in person's diagnosed with borderline personality disorder occurs secondary to a person being highly sensitive and reactive to emotional stimuli, yet having a deficit in emotion regulation skills. In other words, people who self-injure have an inability to distract themselves from their emotional experiences; thus the person self-injures as an attempt to modulate or cope with strong emotions.
Research investigations indicate that people who self-injure have identified the following as reasons for engaging in self-injurious behaviors: (a) feeling concrete pain when psychic pain is too overwhelming; (b) reducing numbness and promoting a sense of being real; (c) keeping traumatic memories from intruding into the consciousness; (d) affect modulation; (e) receiving support and caring from others; (f) discharge of anger, anxiety, despair, and expression of disappointment; (g) gaining a sense of control; (h) self-punishment for perceptions of being bad; and (i) an enhancement of self-esteem (Himber, 1994; Shearer, 1994).
Various life factors and clinical correlates are related to self-injurious behaviors in adolescents. Self-injury is often associated with childhood sexual abuse and subsequent posttraumatic stress disorder reactions (Darche, 1990; Favazza & Rosenthal, 1993; Ghaziuddin, Tsai, Naylor, & Ghaziuddin, 1992; Langbehn & Pfohl, 1993), as well as sexual assault/rape (Greenspan & Samuel, 1989), anxiety and depression (Ross & Heath, 2002) and eating disorders (Cross, 1993).
There are many correlates and predictors that are indicative of self-injurious behavior. Conterio et al. (1998) noted that other life conditions including loss of a parent, childhood illness, physical abuse, marital violence, and familial serf-injury are related to self-injury. However, a history of sexual abuse and family violence are the best predictors of self-injury. Research also identifies adolescents' experiences that trigger self-mutilation, including the following: a recent loss, peer conflict and intimacy problems, body alienation or dissociation related to abuse, and impulse control problems (Conterio et al.; Welch, 2001). Indeed, all of these correlates can be useful in identifying at-risk adolescents for the purposes of intervention and prevention (Walsh & Rosen, 1988).
**********
In recent years, the media and popular literature have begun to address the issue of adolescent self-injurious behavior, and many counselors have had an increasing exposure to students who engage in these behaviors. Approximately 13% of adolescents sampled in one recent survey indicated that they engaged in self-injurious behaviors (Ross & Heath, 2002), and research has indicated that self-injury is becoming increasingly prevalent among adolescents (Hawton, Fagg, Simkin, Bale, & Bond, 1997). The incidence of self-injurious behaviors rises to 40% to 61% in adolescent inpatient settings and is ostensibly beginning earlier in the childhood and adolescent years (Conterio, Lader, & Bloom, 1998; Darche, 1990; DiClemente, Ponton, & Hartley, 1991).
Self-injurious behavior is discussed often with regard to the mentally retarded and developmentally disabled populations--people diagnosed with psychotic disorders, personality disorders, and dissociative identity disorder; however it is rarely addressed in discussions of the general adolescent population (Zila & Kiselica, 2001). This article focuses on self-injurious behaviors associated with adolescents in the non-severely mentally disabled population (e.g., mental retardation, schizophrenia, etc.). This article also is delimited to self-injurious behaviors involving self-cutting, interference with wound healing, scratching, and burning, but will not explore issues associated with hair pulling (e.g., trichotillomania), and extreme forms of self-injury (e.g., eye enucleation, amputation of body parts, breaking bones, etc.) as these are less commonly presented in school settings.
It is important to acknowledge that most cultures have forms of culturally acceptable and sanctioned self-injurious behaviors (Favazza, 1996). For example, among adolescents in Western culture, ear piercing, tattooing, and various forms of body piercing are becoming more commonplace. Deviant forms of self-injury are generally considered physically damaging and occur in response to psychological crisis. These acts demonstrate a sense of disconnection and alienation from others; the line between socially sanctioned self-injury and deviant self-injury can be hazy (Dallam, 1997).
Self-cutting is one of the most common forms of self-injury found in the non-hospitalized population, followed by burning, pinching, scratching, biting, self-hitting, and interference with wound healing (Briere & Gil, 1998; Ross & Heath, 2002; Taiminen, Kallio-Soukainen, Nokso-Koivisto, Kaljonen, & Helenius, 1998). The areas that are most typically injured are the arms and wrists, legs, abdomen, head, chest, and genitals, respectively (Conterio et al., 1998; Zila & Kiselica, 2001). In the literature, many varied definitions abound as to what constitutes self-injury. In this article, self-injury will be defined as a volitional act to harm one's body without any intention to die as a result of the behavior (Simeon & Favazza, 2001; Yarura-Tobias, Neziroglu, & Kaplan, 1995).
In many ways, the current awareness of self-injurious behaviors parallels the appreciation of eating disorders that developed in the 1970s and 1980s. At that time, anorexia and bulimia were thought to be rare and interesting conditions, but as public and professional awareness increased, many people began to seek help (Conterio et al., 1998). Despite an increasing awareness of adolescent self-injurious behavior, little is known about what treatments work best with this population (Zila & Kiselica, 2001).
The age at which people first begin to engage in self-cutting behaviors varies; however, these behaviors usually begin in middle adolescence (Herpertz, 1995), with the freshman year of high school being the average age of the first self-injurious behaviors (Ross & Heath, 2002; Favazza & Conterio, 1989). One study found that mental health professionals identified 18 as the average age their clients last engaged in self-cutting behaviors (Suyemoto & MacDonald, 1995). Thus, with regard to self-injury, school counselors are in a unique position to intervene as these behaviors typically begin, and often end, during the adolescent years.
Gender issues may also be present with regard to rates of self-injury. It is commonly stated that females are more likely to engage in self-injury than males. In one study of self-injurious adolescents, 64% were female and 36% were males (Ross & Heath, 2002). Indeed, most studies have indicated the majority of hospitalized self-injuring patients are female (Herpertz, 1995). However, Briere and Gil (1998), using a community sample, found no gender differences with regard to self-injurious behaviors. The belief that females are more likely to engage in self-injury may be related to researchers' use of samples including help-seeking clinical populations, hospitalized patients, and sexual abuse and incest survivor populations; samples that are more likely to be comprised of females. Higher rates of male self-injury in community samples may be due to different definitions of self-injury with some researchers including deliberate recklessness and risk-taking behaviors in which males may be more likely to engage (Ross & Heath).
Many theories have been proposed concerning the etiology and function of self-injurious behaviors. Generally, theories of the etiology of sell-injury tend to be based on biological, psychological, and sociological explanations. From a biological perspective, the seratonergic system has been implicated in the pathophysiology of self-injury (Dallam, 1997; Simeon et al., 1992) as well as the idea that the endorphin rush associated with self-injury can lead to an addiction to the behavior (Pies & Popli, 1995). Among mental health professionals, one of the more popular psychological theories (Suyemoto & MacDonald, 1995) involves the ability of self-injury to regulate emotions. The psychodynamic-oriented emotional dysregulation theory holds that self-injury is the result of anger turned inward on the self (Feldman, 1988) and that the self-injury results in emotional catharsis (Crowe & Bunclark, 2000). Similarly, Linehan's (1993) biosocial emotional dysregulation theory holds that self-injury in person's diagnosed with borderline personality disorder occurs secondary to a person being highly sensitive and reactive to emotional stimuli, yet having a deficit in emotion regulation skills. In other words, people who self-injure have an inability to distract themselves from their emotional experiences; thus the person self-injures as an attempt to modulate or cope with strong emotions.
Research investigations indicate that people who self-injure have identified the following as reasons for engaging in self-injurious behaviors: (a) feeling concrete pain when psychic pain is too overwhelming; (b) reducing numbness and promoting a sense of being real; (c) keeping traumatic memories from intruding into the consciousness; (d) affect modulation; (e) receiving support and caring from others; (f) discharge of anger, anxiety, despair, and expression of disappointment; (g) gaining a sense of control; (h) self-punishment for perceptions of being bad; and (i) an enhancement of self-esteem (Himber, 1994; Shearer, 1994).
Various life factors and clinical correlates are related to self-injurious behaviors in adolescents. Self-injury is often associated with childhood sexual abuse and subsequent posttraumatic stress disorder reactions (Darche, 1990; Favazza & Rosenthal, 1993; Ghaziuddin, Tsai, Naylor, & Ghaziuddin, 1992; Langbehn & Pfohl, 1993), as well as sexual assault/rape (Greenspan & Samuel, 1989), anxiety and depression (Ross & Heath, 2002) and eating disorders (Cross, 1993).
There are many correlates and predictors that are indicative of self-injurious behavior. Conterio et al. (1998) noted that other life conditions including loss of a parent, childhood illness, physical abuse, marital violence, and familial serf-injury are related to self-injury. However, a history of sexual abuse and family violence are the best predictors of self-injury. Research also identifies adolescents' experiences that trigger self-mutilation, including the following: a recent loss, peer conflict and intimacy problems, body alienation or dissociation related to abuse, and impulse control problems (Conterio et al.; Welch, 2001). Indeed, all of these correlates can be useful in identifying at-risk adolescents for the purposes of intervention and prevention (Walsh & Rosen, 1988).
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