|
Article Excerpt
Self-injury is an increasing phenomenon among young adult women. This qualitative study explored the counseling experiences of 10 young adult women with a history of self-injurious behavior: It examined the nature of the client-counselor relationship and how self-injury was treated. It also accessed the participants' thoughts and feelings about their experiences in counseling. Implications for training and treatment are set out, as are recommendations for research.
INTRODUCTION
Self-injury is a pervasive and dangerous problem, especially among adolescents and young adults (Nock & Prinstein, 2005; Nock, Teper, & Hollander, 2007). Self-injury typically occurs within the age range of 13-23, a period of developmental significance (Favazza & Conterio, 1989). An estimated 35% of college students report a history of self-injurious behavior (Gratz, 2001), and the prevalence of self-injury in adolescent community samples appears to range from 14% to 39% (Nock & Prinstein, 2005).
The incidence of self-injury has been found to be three to four times more common in women than men (McAllister, 2003). According to Shaw (2002), "self-injury is a gendered and developmental phenomenon" (p. 192), shaped and constructed within the context of multiple forms of gender oppression. Young women are subject to intense sociocultural forces throughout their lives, particularly throughout adolescence and young adulthood (Parker, Bermudez, & Neusitifter, 2007). Images of unattainable physical ideals, the emphasis upon sexual attractiveness and sexual availability, and restrictive power differentials of gender all shape identity formation in conflicting contexts. Simultaneously, young women struggle to learn how "to hear and trust one's own voice at the same time that one attends to the voices of others" (Knudson, 2004, p. 40).
Feminist perspectives have "recast theories of clinical disorders, focusing particularly on problems of high prevalence among women" (Marecek, 2001, p. 306). A social and contextual construction of gender relocates women's problems from the individual and internal to the social and external. This relocation shows how women's problems or symptoms can be understood as methods of coping and surviving rather than as signs of dysfunction or mental illness (Foster & May, 2003). Shaw (2002) argued that direct destruction of the body is symbolic of the struggle against the dominant cultural story of what it means to be female. Thus, the act of self-injury may be a means of expressing feelings of discontent and anger and a form of psychological resistance articulating a need to be heard and to be taken seriously.
In spite of the research on women and self-injury, little is known about self-injury among young women in marginalized or nondominant groups. While many contend that self-injurious behavior may be more common among White European American women (e.g., Bhugra, Singh, Fellow-Smith, & Bayliss, 2002), similarly high rates of self-injury have been found in samples of minority and disenfranchised groups (Marshall & Yasdani, 1991; Whitlock, Eckenrode & Silverman, 2006).
TREATMENT OF SELF-INJURY
Self-injury presents considerable challenges to the mental health counselor because there is a lack of empirical data to support specific treatment protocols (Muehkenkamp, 2006; Trepal & Wester, 2002), and it has been identified as a behavior resistant to treatment. Treating self-injury may be particularly time-consuming and potentially frustrating for mental health counselors, who may feel unable to either form a therapeutic relationship with a client who self-injures or make an impact on the behavior (Dieter & Nichols, 2000; Kiselica & Zila, 2001; Stone & Sias, 2003). Mental health counselors' reactions, if void of empathy specific to self-injury, can have deleterious psychological and emotional effects upon self-injuring clients (Levenkron, 1998; Nafisi & Stanley, 2007).
A review of the literature on empirically supported treatments for self-injury found that, although the results have been mixed, cognitive-behavioral and problem-solving treatment approaches are effective in reducing symptoms (Muehlenkamp, 2006). However, without a trusting therapeutic relationship, treatment is less likely to be successful (Trepal & Wester, 2007). In fact, many individuals who self-injure indicate a high rate of dissatisfaction with the treatment they receive (Favazza & Conterio, 1989; Shaw, 2002). Thus, postmodern approaches that rely on client-informed therapies and include attention to wider sociocultural and sociopolitical realities may offer more nuanced models for treatment of self-injury that invite the voices of young women to be heard (Hansen, 2002). However, such models can be challenging for mental health counselors, who also are obligated to address the risks of self-injury and thus rely more on treatment to reduce symptoms. Moreover, little research on application or outcomes has been done on postmodern frameworks for counseling women who self-injure, further complicating the search for sound treatment models.
CURRENT TRENDS IN RESEARCH RELATED TO SELF-INJURY
Although rates of self-injury appear to be increasing, the research that has been done suffers from three major limitations. First, many of the treatment studies related to self-injury were conducted within an inpatient or medical environment, which may bias the results. For example, in emergency rooms patients who self-injure have reported being subjected to troubling practices, such as increased observation, seclusion, and restraint (Weber, 2002). According to Favazza (1989) and Shaw (2002), these approaches are likely to develop mistrust and fear of helping professionals. Moreover, in a study conducted within an inpatient psychiatric treatment facility, participants expressed both a fear of rejection by treatment providers and a desire to be understood (Crouch & Wright, 2004). Within a general hospital setting, patients reported that sympathy and listening were critical helping components and often lead to less subsequent self-injury (Pierce, 1986; Treloar & Pinfold, 1993). These findings raise valuable points about the proper treatment of self-injury and the value of empathy and listening for clients who harm themselves. However, research is sorely needed to specifically explore outpatient counseling for self-injury in order to identify variables related to that context.
A second research limitation is the variation in nomenclature and definitions of self-injury applied as the dependent variable, such as deliberate self-harm (Gratz, 2001), self-mutilation (Nock& Prinstein, 2005; Haines & Williams, 1997; Favazza & Rosenthal, 1993), nonsuicidal self-harm (Laye-Gindhu & Schonert-Reichl, 2005), self-cutting (Rao, 2006), self-injurious behavior (Favaro & Santonastaso, 2002), and self-soothing (Alderman, 1997; McCallister, 2003). Consequently, participants with a range of behaviors, from cutting to suicide attempts, have been lumped together in the samples. Findings from such studies may not provide an accurate picture of individuals who self-injure.
Third, many studies have failed to access the voices and perspectives of the self-injuring clients themselves. Thus, little is known about how those who self-injure view the treatment they are given (Pierce, 1986). For example, psychological interventions have generally been built on evidence gathered from clinicians rather than clients (Crouch & Wright, 2004). The past two decades have seen only a few studies that speak to individuals' perspectives on the care they received after acts of self-injury and those typically occur within a hospital or...
|
