treating self injury

Editor's Note: the content of this Web article may be triggering for those who self-injure.

Treating SI

Obviously, the first line of care is to treat any medically significant injuries the SI sufferer inflicts in a setting that does not threaten her or his dignity or autonomy. Since self-injurers are often seen repeatedly in emergency rooms and other urgent care settings, they are often seen as problem patients, and even, in some instances, refused treatment or treated harshly, dismissively or judgmentally. [36]

All such approaches intensify the self-injurer's already high level of distrust of authoritarian and manipulative people. Avoiding such attitudes can be crucial to the patient's long-term well being, since resistance to seeking help for a significant injury at a future date might prove health endangering if not life threatening. While SI is not a suicidal behavior, it is potentially hazardous enough to cause an unintended death.

A recent study of 233 adults, a majority of whom had experienced childhood abuse and/or had self-injured, concluded that there were four guiding principles for emergency workers to follow in dealing with SI sufferers:

1. Return control to the patient, to whatever degree is possible. The goal is not to assume control, but to help the patient regain control.
2. Help the patient assess self-capabilities. (See following section).
3. Help patient shore up self-capabilities.
4. Help patient determine the precipitating event to the self-injury. This can help the patient see the behavior as explicable, and not hopelessly uncontrollable.[37]

Deiter, et. al. consider it central to the treatment of SI among survivors of trauma and childhood abuse that three self-capabilities be established or re-established in the patient:

· The ability to tolerate strong affect (emotional states)

· The ability to maintain a sense of self-worth

· The ability to maintain a connection with others[38]

The key to treatment of SI is teaching the client new ways of addressing the stresses that precipitate incidents of self-injury. For that reason, brief hospitalization to control the behavior is one of the least successful approaches. While it prevents the SI sufferer from self-injuring during the duration of the hospital stay, it may well allow the stresses that brought on the SI event to build. That is likely to cause another SI event once the patient leaves the hospital.

One obvious caveat is that the patient is determined not to be suicidal. Suicidality is present in SI populations as well as most other definable patient populations, and must be excluded as a possibility. One possible determinant is the method of injury that brought the patient to the emergency room. Those who practice SI rarely use the same technique in attempting suicide.

There is no consensus on how best to treat SI.  A review of studies by a team of British researchers found that there were no large-scale trials or replication of results to favor any particular approach.[39]

Some anecdotal or small-scale successes have been shown for a variety of interventions:

• Hospital-based inpatient treatment programs specifically for SI are rare.  One, SAFE Alternatives at Edwards Hospital in Napierville, IL, is reserved for patients whose self-injury has reached a life-threatening level. The Menninger Clinic in Topeka, KS, lists self-harm among its programs and Rock Creek Hospital in Lemont, IL, offers an inpatient self-injury program.[40]
• Studies to date on psychopharmacological treatment of SI have focused primarily on stereotypic SI in autistic and retarded individuals.  The efficacy of selective serotonin reuptake inhibitors (SSRIs) atypical neuroleptics and opiate antagonists –the classes of drugs used in those trials—has not been established in moderate/superficial SI treatment.
• Dialectical Behavioral Therapy (DBT) in SI patients diagnosed with BPD is a highly structured, intensive, psychotherapy technique focusing on emotional regulation and behavioral self-ntrol that shows promise of reducing the incidence of SI events.  It was pioneered at the University of Washington in Seattle, and there are DBT trained therapists elsewhere in the country.
• Individual psychotherapy with a knowledgeable and patient therapist can help alleviate SI behavior
• Hypnotic relaxation techniques employed by a qualified hypnotherapist as an adjunct to other treatments have been used with some reported success.
• Other techniques not specifically related to SI, but relevant for addressing conditions that underlie self-injuring behavior include Interpersonal Group Therapy for treatment of BPD; Rational-Emotive Therapy for anger control, and therapies directed at the treatment of Complex Post Traumatic Stress Disorder. [41]