I remember the first time I saw a client who engaged in “cutting,” or what professionals now refer to as self-injurious behavior or SIB. I was working in a university counseling center in the mid-1990s and had recently completed all the requirements for becoming a licensed psychologist.
The client exhibited several of the signs that are now associated with self-injury: She had a history of sexual abuse and wore clothing that covered much of her body. Yet I did not ask her specifically about self-injury; it was not yet a part of my usual assessment. I just asked how she dealt with her feelings about the abuse.
When she told me about the cutting, my first reaction was one of fear, followed by a series of questions: Why would someone do this? Was the cutting a suicide attempt? How can I treat this behavior? I had recently taken the licensure exam and had spent months poring over clinical studies and memorizing the third edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, which supposedly contained everything I needed to know. Yet I had not come across anything about self-injury. I had heard stories and read a few case studies of its occurring in hospitals, but not at a college-counseling center. I was perplexed.
SIB continues to confuse many people who become aware of it. They often have the same reactions and questions that I did as a clinician. I know a great deal more about SIB now than I did when I first saw this client; in fact I was a collaborator on a recent study on SIB — the largest in this country — organized by Janis L. Whitlock, a developmental psychologist at Cornell University. I understand that self-injury is a strategy to manage painful emotions. Generally self-injury is not about attempting suicide. SIB and suicidality can existin the same client, and the same underlying emotional instability can contribute to both, but they are separate phenomena.
My client talked about how she needed to see how she felt inside. When I assessed her suicide risk, she vehemently denied that the cutting was done to end her life. The cuts and the blood made tangible the intense pain that was part of her internal emotional landscape.
Her experience illustrates how self-injury operates in complex ways. On one level, it is a method of communicating feelings when the self-injurer lacks other skills with which to express them. People who self-injure often come from families in which direct communication is avoided and sometimes punished. They learn that the way to get noticed is to act, rather than to talk about or accept difficult feelings.
On another level, SIB helps people crystallize and clarify nebulous emotional feelings into tangible physical sensations. In that way, cutting makes the internal pain feel more real and more justified. In addition, on a basic physical level, self-injury initiates the release of endorphins, naturally occurring opiates in the body that provide a numbing or a high feeling that can relieve the emotional pain. SIB has also been linked to changes in neurotransmitter levels that are believed to play a role in self-injury. Like the use of alcohol and other drugs, self-injury provides an effective immediate escape from emotional pain but brings with it other problematic consequences.
Understanding the dynamics and motives of self-injurers is one thing; providing treatment to them is another matter. A person who engages in SIB doesn’t fit any single profile. Moreover, treating SIB is challenging because it frequently occurs in conjunction with eating disorders, depression, and other issues.
I treated my client over the course of about six months by consulting with colleagues, managing my own fear, and doing a lot of listening and learning in sessions. She and I built a strong therapeutic relationship while I made use of various cognitive, behavioral, and interpersonal approaches. I would have liked to refer her to someone who specialized in SIB treatment, but no one in the immediate area did; in fact, few people anywhere were treating self-injury at that time. By our final session, my client had stopped cutting herself and had made good progress in therapy dealing with the past abuse.
That is the good news about self-injury: Treatment does work. In the early to mid-1990s, when we began seeing self-injury with greater prevalence in higher-education settings, however, little professional literature existed on how to treat it, and clinicians often had to rely on their instincts and creativity.
I once consulted with a colleague who was treating a woman struggling with SIB. She had tried for some time to stop but had not been successful. In therapy she would often hold onto a stuffed animal that the therapist kept in his office, while she discussed painful emotions. At the end of one session, when the client was placing the stuffed animal back on the shelf, the therapist suggested that she take it home and cut it the next time she thought of cutting herself. She never cut herself again. That intervention represents an effective component of most SIB treatments: symptom interruption. SIB occurs when emotions are immediately manifested as cutting, burning, and other forms of physical self-abuse. Symptom interruption seeks to break that cycle by replacing self-injury with healthier coping skills. A second component of that treatment is some type of verbal expression of emotions.
Outpatient therapies for SIB have gotten better and more systematized since the time of those earlier interventions. One example is dialectic behavior therapy, developed by Marsha M. Linehan, a professor of psychology at the University of Washington. It involves individual cognitive-behavioral therapy coupled with educational groups conducted by professionals that focus on developing the client’s skills for modulating emotions, tolerating distress, and interacting more effectively with others.
Inpatient programs have also proven to be effective. Wendy Lader, the clinical director of S.A.F.E. Alternatives, in Chicago, reports that 75 percent of people who complete their programs are injury-free two years after treatment. That treatment includes the use of impulse-control logs (a mechanism for placing a thought between the impulse to self-injure and the behavior), writing assignments, and individual and group therapy. In addition to such psychological interventions, medications can also be helpful.
Although treatment is often effective, for colleges and universities SIB can sometimes be an intractable problem that presents distinct challenges because it is so easily and often confused with suicidal intent. Self-injury can range from a private behavior to one that indirectly involves whole floors in a residence hall or a significant part of the student body at a small college. That involvement can range from worrying about and taking care of the self-injurer to being scared or disturbed by the self-injury and invoking others to get the person removed from the hall or college. It is often at the heart of the difficult dilemma that institutions of higher education regularly confront: balancing the freedoms and privacy rights of individual students with creating and maintaining a safe and healthy learning environment for all.
To respond effectively, higher-education institutions should first ensure that their counseling services’ clinical staff members are trained to assess and treat SIB. Recent studies found that three-fourths of college and university counselors agreed with the statement “Self-injury is a subject those of us who work with young adults and adolescents generally need to know much more about,” and that only one-fourth of students who had self-injured more than once and were in therapy ever reported it to a mental-health professional. College and university counseling services are on the front line of responding to SIB and must be supported in their efforts to improve how they work with such students.
Second, colleges and universities would benefit from developing administrative protocols for responding to self-injury. SIB affects the entire campus and often operates outside the reach of the counseling service, which may not have any contact with the self-injurer. Research has found that just under half of those students who had self-injured more than once reported never being in therapy for any reason. Such protocols would ideally be crafted to meet the distinct needs of each institution and would include education and training about SIB. They should also establish mechanisms and processes to help key administrators who come in contact with the behavior — staff members from student affairs, residential life, and other areas — to respond consistently.
Because the line is not always clear between a private act of self-injury and one that involves numerous students, professors, and staff members, college officials should also include clear behavioral definitions of what actually constitutes a disruption to the campus. Colleges and universities can’t keep students from injuring themselves, but they can make clear what’s acceptable in the public sphere.
Policies should encourage students to seek help and should not be punitive. In some cases, however, SIB can be disruptive enough to other people at the institution to warrant suggesting that the student take a voluntary medical leave of absence. That should never be the first response, but occasionally it’s the best way to assist a student on the road to recovery. Leave policies should also include guidance on when to involve significant others, such as family members and good friends, in facilitating treatment.
Many people at colleges and universities, myself included, now know a great deal more about self-injury. We know more about the supporting dynamics and what treatment helps self-injurers find better ways to manage their emotions. We should use that knowledge to work together to help such students, who are struggling with difficult and painful feelings.
Gregory T. Eells is director of counseling and psychological services at Cornell University.
http://chronicle.com Section: The Chronicle Review Volume 53, Issue 16, Page B8
