Articles: Self-injurious behavior in children and adolescents - Part II: Now what? The treatment of SIB
By Annita B. Jones, Psy.D.
In Part I of "[L=./readarticle.php?id=49]Self-Injurious Behavior in Children and Adolescents: What Is SIB[EL]?" – which appeared in the Spring/Summer '98 issue of "Healing Magazine" – the concept of SIB was identified. This article will describe some treatment issues and approaches.
Each of the case examples in "What Is SIB?" presented different SIB behaviors and antecedents. The first example given was that of Celia, who, at 14, was attracted to the music of Nirvana and Marilyn Manson. By listening to this music, she was identifying with others who seemed to feel the way she did: depressed and unacceptable.
SIB through purging and cutting
Celia began to purge her food to lose weight, thinking that if she were thin, she would be more acceptable. She started to cut herself as a technique to stop the flood of negative feelings about herself. Her parents inadvertently added to her distress by being critical of the way she dressed and wore her hair, and her choices of friends and music. They did not realize that these were all Celia's self-injurious ways of expressing how she was feeling about herself and her world.
The first treatment approach to an adolescent like Celia is to identify that the client is in pain, and that she is communicating that pain through her choice of music, dress and friends. When Celia's choices were not only NOT acknowledged, but also were rejected – symbolic of her feelings being unacceptable to others – Celia moved to the next level of communication: hurting herself and attempting to change her physical identity in order to mask her inner self.
When interviewed, Celia disclosed that she had felt sincere self-loathing as long as she could remember. She had presented to her family and community the facade of happiness because she perceived that to be the expectation. Her parents were chronically tense with each other, often arguing loudly about everything – including the children. Celia felt responsible, as many children do, ignored and unimportant. Her individual identity had not been reinforced by those most important in her life because of their own personal unhappiness.
Treatment for Celia consisted of encouraging her to talk about her family and its interactions. Her interest in music, friends and dress needed to be accepted as expressions of her internal reality. During this process, Celia needed to begin identifying the patterns of her self-expression: What feelings are most uncomfortable? What feelings most quickly result in the urge to purge or cut? What time of day and place is most unsafe? What is the immediate result of the SIB? For how long? Identifying the patterns would allow Celia to begin to have a sense of mastery over her own situation and begin to substitute healthy behaviors for the self-destructive ones.
Techniques to help Celia build in time between the urge to hurt herself and the acting on that urge were vital to the treatment. Celia identified that she needed to feel pain in order to feel some release of the "bad" feelings. Techniques that might address a small amount of her pain could include acts that are uncomfortable but cause no tissue damage, such as squeezing an ice cube or putting a hand in a bucket of ice water. The important aspect of this treatment is developing tolerance to the undesirable affect and learning to delay gratification. Any movement toward this goal should be acknowledged.
Celia's body dysmorphia needed to be addressed, extricated from the symbolism of the expression of pain, and realigned with body acceptance at a more basic level. Group therapy is often helpful in addressing this issue since peer feedback is often more trusted than an authority figure's. Group support can provide a buffer against the harmful messages of our media expressing society's vision: If we are only thin enough or have the perfect nose, life is beautiful!
Adolescence is, in part, a process of individuation. Celia needed to consider who she was and who she wanted to be, apart from her family. Family therapy focused on the family dynamics, in general, and interacting with Celia, in particular. Marriage counseling was in order. At the psychoeducational level, the family had to learn and understand the dynamics of SIB, as well as appropriate responses – rather than reactions – to the behavior. The family needed to learn to respond medically to the injuries, and openly to Celia's poorly expressed needs so they could help her interpret her real needs. For instance, on noting an act of SIB, they could respond empathetically to the results and suggest how Celia might otherwise have expressed the situation – e.g., "Celia, I see you've cut again. I'm sorry you chose to do that. I've noticed that you cut when you feel angry or ignored. Have you been feeling that way? How else could you have let me know that? I did notice, however, that this time you tried several additional techniques before you acted self-destructively – and that is progress!" The focus had to be on the expressed distress rather than on the act. And some measure of progress ALWAYS had to be found.
SIB through drug and alcohol abuse, unsafe sex
Allison, age 15, began her self-injuring with drugs and alcohol. She did not disclose her sexual abuse by her step-brother until she had escalated to other self-destructive behaviors, including unprotected and indiscriminate sex.
Allison's care included a brief stay in a residential treatment facility (RTF) that could provide appropriate around-the-clock safety until she could begin to resolve the trauma and stabilize her acting-out behaviors. During the RTF stay, Allison learned to identify and verbalize her feelings and thoughts.
She found that she could disclose her abuse to others who had experienced similar incidents and who could understand and empathize. She learned that her mother had been unaware of the abuse, but would be open to hearing about it and taking appropriate action. Allison began to identify the developmental stages that were stunted by the years of trauma, and learn how to compensate for the delays – similar to the compensation someone with a learning disability would develop.
Allison noted, for example, that she could relate to males only in a sexual manner, having failed to learn other ways at appropriate ages. She began to accept that she had not caused the abuse by her step-brother – 10 years older than she. She also discovered that she could relate to males intellectually, as equals with no hidden agendas. She learned that she had rights and boundaries that others should not only be made aware of, but also forced to respect. She learned the difference between healthy guilt and shame, and the pathological levels she felt following the abuse. She started to develop the skills to differentiate the levels, and ask appropriate questions that could help her decide what would be in her best interest to do. She began to desensitize to feelings of anger that she associated with violence, force and helplessness.
SIB through recklessness
Jacob was a 14-year-old male whose parents had abandoned him as a result of their substance abuse. He was adopted at age three, following termination of his parents' rights. He was distrustful of his new family, and had difficulty adjusting to the new environment. When he started school, he manifested academic difficulties and aggressive behaviors toward other students. He destroyed his belongings, and seemed to frequently and deliberately put himself in dangerous situations. Reckless play, running into the street, threatening older children and taking dares from other students were activities in which he engaged. These behaviors escalated into his teen years when he added unprotected sex, drugs and alcohol, skipping school and refusing to complete his schoolwork.
Jacob was using self-injurious behaviors to communicate his feelings of abandonment, failure, loss and frustration.
The treatment for Jacob included residential placement since his locus of control was external, and he was unwilling to contract for behaviors. The structure was necessary to provide the security he could not provide for himself until he could develop some additional coping skills and expressions for his feelings. In placement, Jacob added the behavior of eliciting restraints from the staff in order to express his rage and frustration. Charting these incidents to discover the patterns and antecedents was beneficial in providing insight for Jacob in intervening in the process. Group therapy focused on issues of loss and abandonment.
Jacob began to learn to delay gratification and manage frustration with the improvement of his self-esteem. He learned that his parents' abandonment of him was not because he was worthless, but because they were unable to problem-solve in responsible ways. His relationship with his adoptive family was strengthened as he discussed his SIB and its impact on them. His grades began to improve with some individual assistance and reinforcement for success.
Pattern identification and eclectic use of therapies
The therapy for SIB is a combination of cognitive behavioral (Beck, J.S., 1995), used to help combat the cognitive distortions and incorrect ideas (such as SIB as an acceptable way to manage feelings); behavior modification, used to extinguish some behaviors while installing others; psychodynamic, used to identify the interpersonal, internal and external dynamics, such as lack of attachment (Hughes, D., 1998), that have impacted the complex situation; and an addictions model (Alderman, T., 1997), useful in more chronic cases.
Tracking the behaviors and patterns is vital for the process. This can be accomplished by the clinician, family, staff or patient through keeping a calendar, a diary or a journal about all the components important to the patient. One of the most commonly noted patterns is that people who self-injure typically act when they are alone, and there is no structure in place. Isolating someone who is at risk is the least effective intervention and, in fact, is usually counterproductive. A supervised time-out may be effective if it involves therapeutic intervention.
Medication may also be used in various ways as an adjunct to the therapy. Early trauma usually chronically affects the brain function, leaving the person vulnerable to depression, affect dysregulation, chronic states of hyperarousal, and heightened reactions leading to exacerbated fight, flight or freeze reactions (van der Kolk, B.S., McFarlane, A.C. and Weisarth, L., 1996). Often, the person is unable to manage the physical symptoms of the chemical imbalance while attempting to deal with the trauma, the resulting sequela of beliefs and his or her everyday life. Medication that may be helpful at various points in the treatment could include antidepressants, anxiolytics, mood stabilizers, sleep aids, antipsychotics and occasional, but sparse, pain medications. Antidepressants and anxiolytics are obvious in their purpose. Mood stabilizers may help with the dysregulation of affect as well as self-other aggression. Antipsychotics in low doses may help with the cognitive distortions until the person begins to have clearer reality checks. Sleep aids may be helpful in re-establishing basic needs satisfaction to enhance physical stability – important in combating stress. Klonopin may help with intrusive symptoms and the resulting anxiety. Beta blockers have been helpful in some cases in preventing the desired effects of SIB, therefore potentially decreasing the reliance on the behavior. In my experience, however, this has been successful only with those who are the most motivated to quit the behavior – much the same as nicotine patches would help those who really want to quit smoking. Combining medications such as an SSRI (Serotonin Reuptake Inhibitor) and another antidepressant has been found effective with some intractable chronic depressions.
Using an addictions model in the treatment of SIB
The addictions model (Alderman, T., 1997) is most clearly needed for patients like June. June had been sexually, physically and emotionally abused as a child, removed from her family, and placed in numerous foster situations that failed. As a young child, she began to self-injure to "feel something" by hitting herself with her fists and pulling out her hair. She eventually "graduated" to cutting, burning and excessive piercings as ways of expressing her self-hatred and desire to destroy the parts of herself she could not accept – those she perceived as damaged. In her mind, destroying the outside was a way of externalizing how she felt inside. She expected people to understand her better once they could "see" how she felt. June demonstrated clear complex posttraumatic stress disorder (Chu, J.A., 1998) through both the SIB and other acting-out behaviors. She described intrusive symptoms and felt constantly overstimulated, both internally and externally. She described the benefits of SIB as "numbing" and "relieving the pain."
There are few interventions that are as instantaneous as SIB in stopping emotional pain. The immediate result of self-injuring is a flood of the body's own painkillers – endorphins and other chemicals that help us deal with crisis situations. June felt she could not stop the SIB. Without it, she felt extremely vulnerable and helpless, and experienced extreme urges to self-injure.
The aspects of the addiction to SIB that needed to be addressed included the physical, the emotional and the behavioral. Physically, June could sense a control over her pain. (Control is always an element of need with SIB.) Emotionally, June experienced the numbing she craved. Behaviorally, there was a self-soothing in the ritual she used with the injuring.
June needed to begin to develop a sense of control over her life in other, more realistic ways. For instance, she could have control over eating healthy foods, sleeping as her body needed, dressing appropriately, wearing jewelry, managing her hair, thinking positive thoughts and choosing her friends. Emotionally, June needed to develop a tolerance to the unwanted feelings and express them in more acceptable ways. She also needed to desensitize to the PTSD urgency to DO SOMETHING that usually compels a person to self-injure.
As mentioned earlier, the techniques that help in building time between the urges and the acting on those urges are vital. Clients will find their own best ways. A "safe box" may be helpful. The safe box can contain self-soothing items and items that help the patient become more grounded, especially when intrusive symptoms are present. One client included a picture of her dog, a koosh ball, a card received from her best friend, a ball of modeling clay, a small journal and pens, a smooth rock found on a hike, a button from her school play, and an insert from her favorite CD – Tori Amos. When she began to feel the overwhelming stimulation, the client would go to the safe box. The goal of the safe box was to help June identify the feeling state earlier and earlier in the cycle, and intervene in that cycle.
Behaviorally, June needed to find other self-soothing rituals that were healthy. Some possibilities were telephoning friends, going for a walk, journaling, giving herself a manicure, dying her hair, working on a project, drawing and changing her patterns.
If individuals want to quit smoking, their patterns need to be identified: when the urge is strongest, when they reach for a cigarette, when they feel the most frustrated... It is then helpful to insert different behaviors in those slots identified as difficult. The addiction to SIB is potentially more compelling than the addiction to cigarettes, and it needs similar attention. It takes six weeks to extinguish one behavior and six weeks to replace it if the total focus can be on the behavior. The PTSD-complicated addiction to SIB makes it much more difficult to change.
The treatment for June would be protracted and tedious. Helping a managed care company or other insurer understand that SIB is often a way the client avoids acting on suicidal ideations may be advantageous to the client's treatment. Many clients who self-injure also have suicidal ideations; but most of the time, SIB is NOT an expression of suicidal ideations. That was the case with June. The adolescent would begin to flood with affect, quickly escalate to suicidal ideation, and intervene with self-injurious behavior – which would stop the flood of affect. In effect, she had already begun to intervene in the cycle of suicidal ideations – just not in the manner society would prefer.
To guarantee consistency and structure, June needed to be in a safe environment during the course of her treatment. She, of course, would initially act out more, but would eventually accept the security offered by the limits. The placement could involve therapeutic foster care or residential care, but had to be secure. Its goal would be to help June identify why she self- injures and what alternative methods she could use to communicate the information, rather than to prevent her from self-injuring.
SIB and OCD
At a young age, Lillian began to exhibit compulsiveness about her appearance, her room, her schoolwork, her belongings and her home. She would bathe several times a day, and become irate if anything in her room was moved. She believed that in order for everything to be "perfect," she had to remain completely in control of her environment. This thinking was extended to her emotions, as well. Lillian learned that she could stop any emotions that made her feel undesirable by pinching herself. When she would inevitably fall short of "perfect," her efforts would escalate: She would become more and more obsessive about her environment, her person and her feelings.
As the pinching became less effective at helping her avoid feelings of undesirability, Lillian experimented with different methods of self-injury. She eventually settled on cutting herself with a razor blade as the most satisfactory. To avoid being too obvious, the child would cut herself over and over in the same place. And she learned just how deeply to cut to reach the desired effect without requiring stitches. (In the event stitches are needed, they need to be administered with as little interaction with the client as possible to avoid reinforcing the stitching as SIB. The medical personnel involved need to understand the behavior and avoid shaming or raging at the patient, or mislabeling the behavior as suicidal.)
SIB followed Lillian into adulthood. Though in medical school and on her way to an exciting career, she continued to hurt herself. Her self-injury had become so ritualistic that she developed a "schedule" of acting on it. Increased frustration with the challenges of a medical education and conflicts with her schedule eventually rendered her techniques ineffective (which is what brings some into therapy). She then took on other forms of SIB, including restricting food and sleep, and carefully drawing blood with sterile syringes. It was only when confronted by a colleague who had observed some of her behaviors that Lillian decided to get help.
Lillian's treatment included an immediate medication evaluation for obsessive-compulsive disorder (OCD). The medications most commonly used with OCD are Luvox and Anafranil, with Prozac the backup if side effects are too offensive. The ritualistic nature of her acting out indicated how strong the habit and obsessive portion of her disorder were. They had to be addressed. Because she was high functioning in her daily life and capable of cognitive restructuring, she was expected to respond well to cognitive behavioral therapy with a strong psychoeducational component. Anxiety – a component of both OCD and SIB – also needed to be addressed. Lillian needed to find alternative coping tools for anxiety, as well as ways to avoid taking on situations that would exacerbate anxiety. The bulk of Lillian's therapy was aimed toward the effects the OCD and resulting behaviors had on her life, and its development – especially in regards to interpersonal skills.
The long road to recovery
To summarize, "self-injurious behavior" is a broad term that includes any self-destructive or self-defeating behavior used to express or communicate something that is otherwise perceived as unacceptable. The treatment involves helping the patient:
It is an incremental process of slowly letting go of the SIB while adding the more acceptable behaviors and communication skills. Structure, safety and consistency are vital. Understanding the dynamics of SIB is also vital. Reinforcing positive action is the primary response of those involved in treatment as they help the patient develop intervention techniques to break the cycle.
The treatment of SIB requires the patience to allow the client to move through the process as slowly as necessary to reach mastery at each new level of behavioral change. Please give yourself permission to feel frustrated, scared, angry, manipulated, useless, nervous, irritated, sad or upset without expressing these emotions to the patient. Take care of yourself; this is tedious and painful therapy for the therapist, and requires developing your own healthy coping tools!
For those reading this who are self-injuring, please seek help. This article is an overview of dynamics and ideas – NOT therapy. There is help in many different settings. I urge you to find it.
Each of the case examples in "What Is SIB?" presented different SIB behaviors and antecedents. The first example given was that of Celia, who, at 14, was attracted to the music of Nirvana and Marilyn Manson. By listening to this music, she was identifying with others who seemed to feel the way she did: depressed and unacceptable.
SIB through purging and cutting
Celia began to purge her food to lose weight, thinking that if she were thin, she would be more acceptable. She started to cut herself as a technique to stop the flood of negative feelings about herself. Her parents inadvertently added to her distress by being critical of the way she dressed and wore her hair, and her choices of friends and music. They did not realize that these were all Celia's self-injurious ways of expressing how she was feeling about herself and her world.
The first treatment approach to an adolescent like Celia is to identify that the client is in pain, and that she is communicating that pain through her choice of music, dress and friends. When Celia's choices were not only NOT acknowledged, but also were rejected – symbolic of her feelings being unacceptable to others – Celia moved to the next level of communication: hurting herself and attempting to change her physical identity in order to mask her inner self.
When interviewed, Celia disclosed that she had felt sincere self-loathing as long as she could remember. She had presented to her family and community the facade of happiness because she perceived that to be the expectation. Her parents were chronically tense with each other, often arguing loudly about everything – including the children. Celia felt responsible, as many children do, ignored and unimportant. Her individual identity had not been reinforced by those most important in her life because of their own personal unhappiness.
Treatment for Celia consisted of encouraging her to talk about her family and its interactions. Her interest in music, friends and dress needed to be accepted as expressions of her internal reality. During this process, Celia needed to begin identifying the patterns of her self-expression: What feelings are most uncomfortable? What feelings most quickly result in the urge to purge or cut? What time of day and place is most unsafe? What is the immediate result of the SIB? For how long? Identifying the patterns would allow Celia to begin to have a sense of mastery over her own situation and begin to substitute healthy behaviors for the self-destructive ones.
Techniques to help Celia build in time between the urge to hurt herself and the acting on that urge were vital to the treatment. Celia identified that she needed to feel pain in order to feel some release of the "bad" feelings. Techniques that might address a small amount of her pain could include acts that are uncomfortable but cause no tissue damage, such as squeezing an ice cube or putting a hand in a bucket of ice water. The important aspect of this treatment is developing tolerance to the undesirable affect and learning to delay gratification. Any movement toward this goal should be acknowledged.
Celia's body dysmorphia needed to be addressed, extricated from the symbolism of the expression of pain, and realigned with body acceptance at a more basic level. Group therapy is often helpful in addressing this issue since peer feedback is often more trusted than an authority figure's. Group support can provide a buffer against the harmful messages of our media expressing society's vision: If we are only thin enough or have the perfect nose, life is beautiful!
Adolescence is, in part, a process of individuation. Celia needed to consider who she was and who she wanted to be, apart from her family. Family therapy focused on the family dynamics, in general, and interacting with Celia, in particular. Marriage counseling was in order. At the psychoeducational level, the family had to learn and understand the dynamics of SIB, as well as appropriate responses – rather than reactions – to the behavior. The family needed to learn to respond medically to the injuries, and openly to Celia's poorly expressed needs so they could help her interpret her real needs. For instance, on noting an act of SIB, they could respond empathetically to the results and suggest how Celia might otherwise have expressed the situation – e.g., "Celia, I see you've cut again. I'm sorry you chose to do that. I've noticed that you cut when you feel angry or ignored. Have you been feeling that way? How else could you have let me know that? I did notice, however, that this time you tried several additional techniques before you acted self-destructively – and that is progress!" The focus had to be on the expressed distress rather than on the act. And some measure of progress ALWAYS had to be found.
SIB through drug and alcohol abuse, unsafe sex
Allison, age 15, began her self-injuring with drugs and alcohol. She did not disclose her sexual abuse by her step-brother until she had escalated to other self-destructive behaviors, including unprotected and indiscriminate sex.
Allison's care included a brief stay in a residential treatment facility (RTF) that could provide appropriate around-the-clock safety until she could begin to resolve the trauma and stabilize her acting-out behaviors. During the RTF stay, Allison learned to identify and verbalize her feelings and thoughts.
She found that she could disclose her abuse to others who had experienced similar incidents and who could understand and empathize. She learned that her mother had been unaware of the abuse, but would be open to hearing about it and taking appropriate action. Allison began to identify the developmental stages that were stunted by the years of trauma, and learn how to compensate for the delays – similar to the compensation someone with a learning disability would develop.
Allison noted, for example, that she could relate to males only in a sexual manner, having failed to learn other ways at appropriate ages. She began to accept that she had not caused the abuse by her step-brother – 10 years older than she. She also discovered that she could relate to males intellectually, as equals with no hidden agendas. She learned that she had rights and boundaries that others should not only be made aware of, but also forced to respect. She learned the difference between healthy guilt and shame, and the pathological levels she felt following the abuse. She started to develop the skills to differentiate the levels, and ask appropriate questions that could help her decide what would be in her best interest to do. She began to desensitize to feelings of anger that she associated with violence, force and helplessness.
SIB through recklessness
Jacob was a 14-year-old male whose parents had abandoned him as a result of their substance abuse. He was adopted at age three, following termination of his parents' rights. He was distrustful of his new family, and had difficulty adjusting to the new environment. When he started school, he manifested academic difficulties and aggressive behaviors toward other students. He destroyed his belongings, and seemed to frequently and deliberately put himself in dangerous situations. Reckless play, running into the street, threatening older children and taking dares from other students were activities in which he engaged. These behaviors escalated into his teen years when he added unprotected sex, drugs and alcohol, skipping school and refusing to complete his schoolwork.
Jacob was using self-injurious behaviors to communicate his feelings of abandonment, failure, loss and frustration.
The treatment for Jacob included residential placement since his locus of control was external, and he was unwilling to contract for behaviors. The structure was necessary to provide the security he could not provide for himself until he could develop some additional coping skills and expressions for his feelings. In placement, Jacob added the behavior of eliciting restraints from the staff in order to express his rage and frustration. Charting these incidents to discover the patterns and antecedents was beneficial in providing insight for Jacob in intervening in the process. Group therapy focused on issues of loss and abandonment.
Jacob began to learn to delay gratification and manage frustration with the improvement of his self-esteem. He learned that his parents' abandonment of him was not because he was worthless, but because they were unable to problem-solve in responsible ways. His relationship with his adoptive family was strengthened as he discussed his SIB and its impact on them. His grades began to improve with some individual assistance and reinforcement for success.
Pattern identification and eclectic use of therapies
The therapy for SIB is a combination of cognitive behavioral (Beck, J.S., 1995), used to help combat the cognitive distortions and incorrect ideas (such as SIB as an acceptable way to manage feelings); behavior modification, used to extinguish some behaviors while installing others; psychodynamic, used to identify the interpersonal, internal and external dynamics, such as lack of attachment (Hughes, D., 1998), that have impacted the complex situation; and an addictions model (Alderman, T., 1997), useful in more chronic cases.
Tracking the behaviors and patterns is vital for the process. This can be accomplished by the clinician, family, staff or patient through keeping a calendar, a diary or a journal about all the components important to the patient. One of the most commonly noted patterns is that people who self-injure typically act when they are alone, and there is no structure in place. Isolating someone who is at risk is the least effective intervention and, in fact, is usually counterproductive. A supervised time-out may be effective if it involves therapeutic intervention.
Medication may also be used in various ways as an adjunct to the therapy. Early trauma usually chronically affects the brain function, leaving the person vulnerable to depression, affect dysregulation, chronic states of hyperarousal, and heightened reactions leading to exacerbated fight, flight or freeze reactions (van der Kolk, B.S., McFarlane, A.C. and Weisarth, L., 1996). Often, the person is unable to manage the physical symptoms of the chemical imbalance while attempting to deal with the trauma, the resulting sequela of beliefs and his or her everyday life. Medication that may be helpful at various points in the treatment could include antidepressants, anxiolytics, mood stabilizers, sleep aids, antipsychotics and occasional, but sparse, pain medications. Antidepressants and anxiolytics are obvious in their purpose. Mood stabilizers may help with the dysregulation of affect as well as self-other aggression. Antipsychotics in low doses may help with the cognitive distortions until the person begins to have clearer reality checks. Sleep aids may be helpful in re-establishing basic needs satisfaction to enhance physical stability – important in combating stress. Klonopin may help with intrusive symptoms and the resulting anxiety. Beta blockers have been helpful in some cases in preventing the desired effects of SIB, therefore potentially decreasing the reliance on the behavior. In my experience, however, this has been successful only with those who are the most motivated to quit the behavior – much the same as nicotine patches would help those who really want to quit smoking. Combining medications such as an SSRI (Serotonin Reuptake Inhibitor) and another antidepressant has been found effective with some intractable chronic depressions.
Using an addictions model in the treatment of SIB
The addictions model (Alderman, T., 1997) is most clearly needed for patients like June. June had been sexually, physically and emotionally abused as a child, removed from her family, and placed in numerous foster situations that failed. As a young child, she began to self-injure to "feel something" by hitting herself with her fists and pulling out her hair. She eventually "graduated" to cutting, burning and excessive piercings as ways of expressing her self-hatred and desire to destroy the parts of herself she could not accept – those she perceived as damaged. In her mind, destroying the outside was a way of externalizing how she felt inside. She expected people to understand her better once they could "see" how she felt. June demonstrated clear complex posttraumatic stress disorder (Chu, J.A., 1998) through both the SIB and other acting-out behaviors. She described intrusive symptoms and felt constantly overstimulated, both internally and externally. She described the benefits of SIB as "numbing" and "relieving the pain."
There are few interventions that are as instantaneous as SIB in stopping emotional pain. The immediate result of self-injuring is a flood of the body's own painkillers – endorphins and other chemicals that help us deal with crisis situations. June felt she could not stop the SIB. Without it, she felt extremely vulnerable and helpless, and experienced extreme urges to self-injure.
The aspects of the addiction to SIB that needed to be addressed included the physical, the emotional and the behavioral. Physically, June could sense a control over her pain. (Control is always an element of need with SIB.) Emotionally, June experienced the numbing she craved. Behaviorally, there was a self-soothing in the ritual she used with the injuring.
June needed to begin to develop a sense of control over her life in other, more realistic ways. For instance, she could have control over eating healthy foods, sleeping as her body needed, dressing appropriately, wearing jewelry, managing her hair, thinking positive thoughts and choosing her friends. Emotionally, June needed to develop a tolerance to the unwanted feelings and express them in more acceptable ways. She also needed to desensitize to the PTSD urgency to DO SOMETHING that usually compels a person to self-injure.
As mentioned earlier, the techniques that help in building time between the urges and the acting on those urges are vital. Clients will find their own best ways. A "safe box" may be helpful. The safe box can contain self-soothing items and items that help the patient become more grounded, especially when intrusive symptoms are present. One client included a picture of her dog, a koosh ball, a card received from her best friend, a ball of modeling clay, a small journal and pens, a smooth rock found on a hike, a button from her school play, and an insert from her favorite CD – Tori Amos. When she began to feel the overwhelming stimulation, the client would go to the safe box. The goal of the safe box was to help June identify the feeling state earlier and earlier in the cycle, and intervene in that cycle.
Behaviorally, June needed to find other self-soothing rituals that were healthy. Some possibilities were telephoning friends, going for a walk, journaling, giving herself a manicure, dying her hair, working on a project, drawing and changing her patterns.
If individuals want to quit smoking, their patterns need to be identified: when the urge is strongest, when they reach for a cigarette, when they feel the most frustrated... It is then helpful to insert different behaviors in those slots identified as difficult. The addiction to SIB is potentially more compelling than the addiction to cigarettes, and it needs similar attention. It takes six weeks to extinguish one behavior and six weeks to replace it if the total focus can be on the behavior. The PTSD-complicated addiction to SIB makes it much more difficult to change.
The treatment for June would be protracted and tedious. Helping a managed care company or other insurer understand that SIB is often a way the client avoids acting on suicidal ideations may be advantageous to the client's treatment. Many clients who self-injure also have suicidal ideations; but most of the time, SIB is NOT an expression of suicidal ideations. That was the case with June. The adolescent would begin to flood with affect, quickly escalate to suicidal ideation, and intervene with self-injurious behavior – which would stop the flood of affect. In effect, she had already begun to intervene in the cycle of suicidal ideations – just not in the manner society would prefer.
To guarantee consistency and structure, June needed to be in a safe environment during the course of her treatment. She, of course, would initially act out more, but would eventually accept the security offered by the limits. The placement could involve therapeutic foster care or residential care, but had to be secure. Its goal would be to help June identify why she self- injures and what alternative methods she could use to communicate the information, rather than to prevent her from self-injuring.
SIB and OCD
At a young age, Lillian began to exhibit compulsiveness about her appearance, her room, her schoolwork, her belongings and her home. She would bathe several times a day, and become irate if anything in her room was moved. She believed that in order for everything to be "perfect," she had to remain completely in control of her environment. This thinking was extended to her emotions, as well. Lillian learned that she could stop any emotions that made her feel undesirable by pinching herself. When she would inevitably fall short of "perfect," her efforts would escalate: She would become more and more obsessive about her environment, her person and her feelings.
As the pinching became less effective at helping her avoid feelings of undesirability, Lillian experimented with different methods of self-injury. She eventually settled on cutting herself with a razor blade as the most satisfactory. To avoid being too obvious, the child would cut herself over and over in the same place. And she learned just how deeply to cut to reach the desired effect without requiring stitches. (In the event stitches are needed, they need to be administered with as little interaction with the client as possible to avoid reinforcing the stitching as SIB. The medical personnel involved need to understand the behavior and avoid shaming or raging at the patient, or mislabeling the behavior as suicidal.)
SIB followed Lillian into adulthood. Though in medical school and on her way to an exciting career, she continued to hurt herself. Her self-injury had become so ritualistic that she developed a "schedule" of acting on it. Increased frustration with the challenges of a medical education and conflicts with her schedule eventually rendered her techniques ineffective (which is what brings some into therapy). She then took on other forms of SIB, including restricting food and sleep, and carefully drawing blood with sterile syringes. It was only when confronted by a colleague who had observed some of her behaviors that Lillian decided to get help.
Lillian's treatment included an immediate medication evaluation for obsessive-compulsive disorder (OCD). The medications most commonly used with OCD are Luvox and Anafranil, with Prozac the backup if side effects are too offensive. The ritualistic nature of her acting out indicated how strong the habit and obsessive portion of her disorder were. They had to be addressed. Because she was high functioning in her daily life and capable of cognitive restructuring, she was expected to respond well to cognitive behavioral therapy with a strong psychoeducational component. Anxiety – a component of both OCD and SIB – also needed to be addressed. Lillian needed to find alternative coping tools for anxiety, as well as ways to avoid taking on situations that would exacerbate anxiety. The bulk of Lillian's therapy was aimed toward the effects the OCD and resulting behaviors had on her life, and its development – especially in regards to interpersonal skills.
The long road to recovery
To summarize, "self-injurious behavior" is a broad term that includes any self-destructive or self-defeating behavior used to express or communicate something that is otherwise perceived as unacceptable. The treatment involves helping the patient:
- *IDENTIFY the patterns in the SIB;
*DEVELOP alternative coping skills to replace the SIB;
*RESOLVE any underlying issues;
*REGAIN or enhance daily functioning;
*IMPROVE interpersonal skills.
It is an incremental process of slowly letting go of the SIB while adding the more acceptable behaviors and communication skills. Structure, safety and consistency are vital. Understanding the dynamics of SIB is also vital. Reinforcing positive action is the primary response of those involved in treatment as they help the patient develop intervention techniques to break the cycle.
The treatment of SIB requires the patience to allow the client to move through the process as slowly as necessary to reach mastery at each new level of behavioral change. Please give yourself permission to feel frustrated, scared, angry, manipulated, useless, nervous, irritated, sad or upset without expressing these emotions to the patient. Take care of yourself; this is tedious and painful therapy for the therapist, and requires developing your own healthy coping tools!
For those reading this who are self-injuring, please seek help. This article is an overview of dynamics and ideas – NOT therapy. There is help in many different settings. I urge you to find it.