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Article Excerpt
The authors advance motivational interviewing and the transtheoretical model of change as a conceptual framework for counseling clients who engage in nonsuicidal self-injurious behaviors. The major principles of motivational interviewing are applied in a case study of a client who self-injures. Recommendations are made for mental health counseling practice.
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Non-suicidal self-injury (NSSI), or self-injury (SI), is often defined as "a volitional act to harm one's own body without intention to cause death" (YaryuraTobtas, Nezirogula, & Kaplan, 1995, p. 33). Although the relationship between suicide and SI is complex, the behavior is by definition discrete from suicide; it is an act intended to injure the body without causing death (Simeon & Favazza, 2001; Yaryura-Tobias, Neziroglu, & Kaplan). Examples of SI are self-cutting, self-burning, and deliberate self-hitting--behaviors generally considered intermittent, discrete acts of self-directed self-harm (Simeon & Favazza).
It is estimated that 1%-4% of the general population and 21%-66% of clinical samples engage in SI (Darche, 1990; DiClemente, Ponton, & Hartley, 1991); there is evidence that prevalence rates are equally distributed among men and women in community samples (Briere & Gil, 1998). An average of 13% of high school students report having engaged in SI at least once (Ross & Heath, 2002), and one recent study of college students found the lifetime prevalence rate of college students having at least one SI incident was 17% (Whitlock, Eckenrode, & Silverman, 2006), suggesting that a significant number of adolescents and young adults self-injure.
SI has attracted considerable attention in recent years, not only in clinical environments but also in a number of recent television episodes, movies, and popular music (see Rayner, Allen, & Johnson, 2005). The depiction of SI in aspects of popular culture and the press, and the significant prevalence of SI, highlight the need for further comprehension of the topic.
SI is a complex behavior. People who self-injure have both a variety of mental health diagnoses and a variety of developmental and personal contexts that can contribute to the behavior (Klonsky & Muehlenkamp, 2007). Thus, SI serves a myriad of functions for different people at different times (Kress, 2003). The multifarious nature of the behavior makes it difficult for many mental health counselors to determine the best interventions to use (Muehlenkamp, 2006). The possible health risks secondary to SI also contribute to many counselors feeling beleaguered at the prospect of working with this population (Deiter & Pearlman, 1998). Many people who self-injure do not have concerns about the behavior and do not wish to stop. This lack of interest in ceasing the behavior can frustrate mental health providers and may explain their reporting that SI is one of the most frustrating client behaviors they encounter (Deiter & Pearlman).
Mental health counselors may wonder how best to facilitate a client's desire to change while avoiding potential power struggles and attempts to control the client (e.g., forcing clients to stop injuring, demanding they stop injuring; White, McCormick, & Kelly, 2003). In general, attempts to control clients typically increase resistance to change (Miller & Sanchez, 2004) and are often considered unethical for counselors (Kress, Costin, & Drouhard, 2006; White et al.). Some counselors may want the cessation of the SI to be the primary treatment goal, yet clients may not be ready to change. Often clients have ambivalence about disengaging from SI, and counselors may want to facilitate the client's desire to discontinue the behavior.
In order to best help clients who self-injure, it is imperative that mental health counselors have a clear framework with which to conceptualize their work with this population, draw up effective treatment plans, and implement interventions. In counseling people who self-injure, a treatment approach that recognizes client ambivalence toward change may be helpful.
Motivational interviewing (MI) is one model that may be helpful in counseling people who self-injure. This is a "directive, client-centered counseling style for eliciting behavior change by helping clients explore and resolve ambivalence" (Rollnick & Miller, 1995, p. 326). In many ways, MI's basic tenets are consistent with a professional counseling philosophy (e.g., the focus on change as a normal human growth and development process and the understanding that people have the capacity to move forward, to change, to adapt, and to attain optimal mental health or wellness [Fitzsimons & Fuller, 2002; Myers, Sweeney, & Witmer, 2001]).
MI and the transtheoretical model (TTM; Prochaska & Norcross, 2001) can be applied to this population in individual, group, or family counseling. The model can also be used in conjunction with many other theoretical models and interventions and in a variety of settings. For example, school counselors typically serve a supportive role with their students and do not implement a treatment plan. Yet because they are often among the first people to become aware of a student's SI (Kress et al., 2006), they can use basic MI techniques to help enhance readiness to make changes as the student begins--ideally--to receive community-based counseling services (Kress et al.). Even if student and family do not follow up on accessing community-based services, the school counselor can continue to use basic MI principles to help facilitate the student's change process.
This article briefly reviews the functions and correlates of SI; presents MI and TTM as a possible treatment/intervention model that may be helpful when working with people who self-injure; and then provides a case example and practice recommendations.
SELF-INJURY: FUNCTIONS, CORRELATES, AND TREATMENT
In this section, we do not provide an exhaustive review of SI. For more detailed information, we suggest the following resources: for information about diagnosis and assessment, see Kress (2003) and Walsh (2007); for information about evidence-based practices, see Muehlenkamp (2006) and Klonsky and Muehlenkamp (2007); and for the meanings or behavioral functions of SI, see Nock and Prinstein (2005).
In the current Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Press, 2000), SI is typically conceptualized as being related to an Axis I or Axis II disorder (Kress, 2003). In research on relationships between SI and several DSM-IV-TR (2000) Axis I disorders, for instance, SI has been associated with eating disorders (Favazza & Conterio, 1989), childhood sexual abuse and subsequent posttraumatic stress disorder (PTSD; Favazza & Conterio, 1989; Parker, Malhi, Mitchell, Kotze, Wilhelm, & Parker, 2005), anxiety and depressive symptoms (Ross & Heath, 2002), borderline personality disorder (BPD; Bohus et al., 2004), and depressive and PTSD symptoms (Nock & Prinstein, 2005).
It is estimated that 70%-80% of clients meeting the criteria for BPD engage in some form of self-injury (Bohus et al., 2000). Diagnostic criteria for BPD identify the presence of SI in criterion five for the diagnosis, stating "frantic efforts to avoid abandonment may include impulsive actions such as self-injury or suicidal behaviors" (DSM-IV-TR, 2000, p. 706).
The relation between SI and suicide attempts can be especially complicated when counseling people with BPD. While it is important not to overreact to self-injurious behaviors, it is even more important not to underreact. Some counselors, perceiving clients diagnosed with BPD who self-injure as being manipulative, may not take potential suicide attempts seriously. For some counselors, this negative reaction to clients may be rooted in personal frustrations secondary to a perceived inability to be helpful (Nafisi & Stanley, 2007; White et al., 2003).
Suicide and SI have a complicated relationship. SI should only be viewed as suicidal if the client indicates an intent to die (Simeon & Favazza, 2001). However, one can have suicidal ideation and self-injure without being considered suicidal (Simeon & Favazza). In fact, while self-injuring, 28%-41% of people reported suicidal ideation (Gardner & Gardner, 1975; Pattison & Kahan, 1983). Welch (2001) reviewed...
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