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Article Excerpt
Self-injurious behaviors are gaining increased attention in both the media and the professional literature. Despite increased interest, little is actually known about prevalence, diagnoses, and treatment considerations, specifically with outpatient mental health populations. This article presents the results from a national survey of American Mental Health Counselor Association (AMCHA) members regarding the rate at which they see clients who self-injure and their clinical opinions of related diagnoses. Finally, the treatment methods used by counselors with clients who self-injure are also reported.
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For the past few decades, self-injurious behaviors (SIBs) have been a focus of research and writings in professional literature (e.g., Favazza & Conterio, 1988; Naomi, 2002; Stone, 2003; Trepal & Wester, 2006; Wester & Trepal, 2005). A possible reason for the focus on SIB is the increasing prevalence across various settings, including inpatient units, outpatient settings, colleges and universities, and the general public (e.g., Briere & Gil, 1998; Gratz, 2001; Hawton et al., 1997). While prevalence rates are increasing, there remains a dearth of information regarding diagnoses that are associated with non-suicidal self-injury, or information regarding how mental health professionals work therapeutically with clients who self-injure. This article takes a first step in beginning to answer those questions.
PSYCHOLOGICAL CORRELATES OF SELF-INJURY
There is no specific DSM-IV-TR diagnoses for SIB (American Psychiatric Association [APA], 2000; White-Kress; 2003); thus, when working with a self-injuring client, a counselor typically determines if the client exhibits additional characteristics that would qualify him or her for a Borderline Personality Disorder (BPD) diagnosis or if the self-injury is specific enough for a diagnosis of Trichotillomania (i.e., hair-pulling). It has also been argued that a diagnosis of Impulse Control Disorder, not otherwise specified, seems a good match for characteristics associated with non-suicidal self-injury (Favazza, 1996, 1998). Otherwise, the counselor must assign one of a number of other diagnoses to assist in the creation of a treatment plan, refer the client out for other services, or for insurance and payment purposes. However, outside of the relationship found between BPD and self-injury (Clarkin, Widiger, & Frances, 1983; up to 75% of BPD clients self-injure, keeping in mind that not up to 75% of clients who self-injure are diagnosed with BPD), little is known about the relationship between psychological symptoms and SIBs in a community population, specifically among those individuals seeking counseling services.
Although the research is scant regarding diagnosing SIB clients, researchers have examined psychological correlates and have found SIBs to be associated with other diagnoses, such as eating disorders (Favazza, DeRosear, & Conterio, 1989; Stein et al., 2004), adjustment disorder, depression, substance abuse, and anxiety (e.g., Milnes, Owens, & Belnkiron 2002; Yaryura-Tobias, Neziroglu, & Kaplan, 1995). While various diagnoses have been found to co-exist among clients who self-injure, very little is known about the diagnoses or psychological symptoms related to SIB, specifically among clients who reside in the community and are seeking outpatient services by mental health professionals. The information that is known about diagnoses come from studies that have been conducted in inpatient settings (e.g., Clarkin et al., 1983; Milnes et al., 2002) or among mentally retarded or developmentally delayed populations (e.g., Yang, 2003). The few outpatient studies that have been conducted involve military recruits (Klonsky, Oltmanns, & Turkheimer, 2003), clients with eating disorders (Stein et al., 2004), or have extremely small sample sizes (Yaryura-Tobias et al., 1995), and typically include self-injury as a secondary variable. In addition, a formally accepted definition of non-suicidal self-injury does not exist, thus making it a difficult variable to compare across studies (Muehlenkamp, 2005).
Researchers have neglected to ask mental health professionals what they are seeing in terms of clients who self-injure; thus, it is imperative that we seek this information from those working in outpatient settings. Specifically, asking mental health professionals the prevalence of clients they see who self-injure, along with the types of diagnoses they see, use, or associate with self-injury is important for increasing our understanding in this area.
TREATMENT OF SELF-INJURY
Counselors should provide evidence-based practices to their clients. Although many authors have provided treatment plans or ways of working with clients who self-injure (e.g., Conterio, Lader, & Bloom 1998; Cooper & Milton, 2003; Demchak & Halle, 1985; Linehan, 1987a/b; Muehlenkamp, 2006; Wester & Trepal, 2005; White, Trepal-Wollenzier, & Nolan, 2002), repeatedly these are based solely on clinical experiences. Few empirical studies have been conducted to examine how counselors are working with clients who self-injure and if those treatment methods are effective. One study that did empirically examine the effectiveness of a treatment method with clients who self-injure was conducted by Guthrie, Kapur, Mackway-Jones, Chew-Graham, Moorey et al. (2001). Guthrie et al. found that patients who received four sessions of a home-based psychodynamic-interpersonal therapy provided by nurse therapists were less likely to report SIBs at follow-up (5...
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