As a DBT trained therapist, I routinely see clients (teens and adults) who are self-injurious. There are a lot of great articles, blogs and tools out there to help guide clinicians through treatment protocols while someone is actively injuring and/or having urges to self-harm. Here are a few tips I have learned along the way while in the “room” with clients or parents who are concerned about self-harm.
- Be open – try to put fear and anxiety aside and focus on the wellbeing of the client in front of you. I was once encouraged to focus on helping the client “have the best life possible.” So I try stay out of the weeds and keep the “main thing the main thing.”
- Ask gentle but direct questions like “Have you thought about self-injuring since I saw you last?” and “Where are you harming?” During an assessment with a minor this symptom can arise and make parents feel uncomfortable. I tend to let parents stay in the room so that they can experience modeling of direct, nonjudgmental and loving questions about the nature of their child’s symptomology. Everyone tends to hold their breath until they realize, “Oh – nothing bad happened when we talked about it!” Often times, teens come back in after that session; they haven’t self injured; and, are now TALKING to their parents about their feelings. Whoohoo!
- Be calm and consistent. I liken this attitude to being “Switzerland.” I’m completely neutral when discussing self-injury. I sometimes say “I am a mom and if you were my daughter, this might make me feel anxious right now. But you’re not mine so I can remain neutral about what we’re talking about here. Let’s try to unpack this. I’m not afraid to go there with you if you want to talk about it.” I also consistently ask about self-injury. I always follow up on frequency, duration, and intensity if it’s an identified symptom.
- Check in but don’t make that symptom the focus of treatment. While I’ve conducted entire sessions around a behavioral chain analysis of self-injurious behavior, it’s still just one symptom. The goal of treatment should always be focused on resolving the systemic issue that is causing the self-injury.
- Discover underlying roots to self-injury for that individual. Often times it comes down to two categories. Self-harming because the person is numb and can’t feel anything at all so injuring jolts them “awake” and they feel “real” again. Or, oppositely, self-harming can temporarily quiet down an overactive parasympathetic nervous system. I’m sure there are other reasons out there that you’ve heard in your office that make sense for that person’s distress tolerance level and life circumstances. But those are often the two “roots” I have encountered in my counseling practice.
- Talk to parents about it. I often have a parents-only session when I’m seeing their child who is self-injurious. Parents need a safe place to exhale. They are often confused, misinformed, and need coaching on how to approach this symptom at home. I always encourage nonjudgment, safety measures at home (like removing sharp objects), and open communication. The goal is to help the child communicate an urge to parents, counselors, etc BEFORE they do it. And they won’t unless they know we’re here waiting with open arms.
- Use technology. Yes, there’s an app for that. The Calm Harm App is a super cool tool that has every behavioral management tool possible to alleviate the urge to self-harm.
- Keep in mind that it’s a symptom of a greater, more systemic problem going on. As stated above, there is a lack of internal resources, namely coping skills, that are on board to combat distress.
I hope you all are doing well in your practice and I am sure you are thoughtfully approaching your clients in a loving and positive manner. I hope these points were helpful to you today as you navigate clients’ distress and monitor your own anxieties and fears. I am sure you all could add your favorite and effective ways that you handle self injury in your office. I would love to see those in the comments!