2. Definition and Description
0 “Self-mutilation refers to intentional, non-lethal,
repetitive bodily harm or disfigurement that is
socially unacceptable.” (Pearson, 2011, 78)
0 Self-mutilation is not a disorder in itself but a
symptom of other disorders.
0 “Usually begins in late childhood or early
adolescence, and may continue for ten or fifteen
years or more” (Pearson, 2011, 79)
4. Major
0 “extreme acts that occur suddenly and cause
considerable damage” (Pearson, 2011, 79)
0 “associated with a psychotic state or acute
intoxication” (Pearson, 2011, 79)
5. Stereotypic
0 “repetitive, often rhythmic self-injurious” (Pearson, 2011, 79)
0 “found in autistic, mentally retarded, and in about a third of
individuals with Tourette’s syndrome” (Pearson, 2011, 79)
Click on the book above to read an excerpt from Kathryn
Erskine's book Mockingbird about an autistic girl named Caitlin
having an episode with self-harm.
6. Mockingbird
by: Kathryn Erskine
“I touch it. It’s rough. I rub my finger across the wood back and forth harder
and harder until a splinter cuts me. I hit the splinter back.
There is a drop of blood in the wood now. It is red and it spreads… seeping
into a crack and bleeding across the unfinished wood.
Like Devon’s chest.
No! I rub the wood harder and harder to try to erase the blood but it won’t go
away.
Caitlin!
I press my finger against the raw wood and rub faster and faster and it hurts
but I don’t care because I want to stop the blood but it’s still there and I can’t
make it stop!
Caitlin!
I can’t stop it!
Caitlin! It’s Mrs. Brook calling from somewhere and I feel pulling on my arm
but I yank my hand free. No! I have to erase the blood! I have to. I have to. I have
to! I HAVE TO!” (Erskine, 2010, 17-18)
7. Moderate or superficial
0 “type that mental health professionals are most likely
to encounter” (Pearson, 2011, 79)
0 “includes hair pulling, skin scratching, picking,
cutting, burning, and carving” (Pearson, 2011, 79)
0 Compulsive-
0 “repetitive, ritualistic behavior that occurs many times in a
day” (Pearson, 2011, 79)
0 “hair pulling (trichotillomania) and various insults to the skin
(scratching, picking, or digging)” (Pearson, 2011, 79)
0 Episodic- occasional and usually a symptom of another
disorder
0 Repetitive- addictive and a part of their identity
Example of trichotillomania
8. Prevalence
0 Cited as ‘”the next teen disorder’” (Pearson, 2011, 80)
0 Follow the link below:
Demi Lovato Talks About Cutting
0 Most prevalent environments
0 Prisons
0 Inpatient Facilities
0 Borderline personality disorder
0 Individuals with Borderline personality disorder have a
tendency to self-mutilate.
0 Follow the link below to hear an explanation of BPD and the
reasons they cut:
Mental Health Professonal on BPD and Cutting
9. Developmental Influences
0 Loss of parent to divorce or out-of-home placement
0 Serious injury or surgery during childhood
0 Sexual or physical abuse
0 Witness to family violence
10. Functions
0 What does it serve to do?
0Coping mechanism
0Return to awareness from disassociation
0Increase in endorphins
0Allows them to “tell” about the depth of Click on the book
internal pain cover above to read
an excerpt from Cut
0Punishment by Patricia
0Ritual and symbolism McCormick where
her main character
Callie describes her
reaction to cutting
herself for the first
time.
11. Cut
By: Patricia McCormick
“A tingle arced across my scalp. The floor
tipped up at me and my body spiraled away. Then
I was on the ceiling looking down, waiting to see
what would happen next. What happened next
was that a perfect, straight line of blood bloomed
from under the edge of the blade. The line grew
into a long, fat bubble, a lush crimson bubble that
got bigger and bigger. I watched from above,
waiting to see how big it would get before it burst.
When it did, I felt awesome, Satisfied, finally. Then
exhausted.” (McCormick, 2000, 3)
13. Biological Theories
0 Low levels of serotonin which can cause depression
0 Addiction to endorphins causing a high feeling
14. Psychodynamic Theories
0 Beliefs
0 Believes that self-mutilation is a return to the early infant state
0 Infants lack the capacity for coping with loss
0 Believes that the skin is the boundary between “me” and “not me”
0 Cuts to reassure themselves that the boundary exists
0 Believed to be post traumatic stress disorder (PTSD)
0 Reasons
0 Life and death instinct conflict
0 Symbolic castration
0 An attempt to identify with the menstruating mother
0 Order of self-mutilating episode
1) The experience or perception of loss
2) The resultant increase in tension that cannot be expressed verbally
3) A state of dissociation or depersonalization
4) An irresistible urge to mutilate oneself
5) The act of mutilation
6) The tension relief and return to pre-incident state (Pearson, 2011, 86)
15. Cognitive Behavioral Theory
0 Seen as a symptom of faulty beliefs stemming from
negative self-image and low self-esteem
0 Cutting is negative reinforcement
0 Reactions of others is positive reinforcement
16. Narrative Theory
0 Reenactments of childhood trauma
0 Common themes
0 Hatred of ones body
0 Belief that talking about things is not acceptable
0 Inability to self-protect
0 Loneliness due to the inability to form relationships
17. Treatment
0 Insufficient evidence to prove efficiency of any treatment
0 Making the self-harm the focus is argued
0 Brief therapies are needed, but also lack in intensity
0 Reluctant participants make therapy difficult
19. Medication
0 Selective serotonin reuptake inhibitors or SSRI’s
(Prozac, Paxil, Luvox, etc.) can reduce self-
mutilation in some clients by controlling the
depression induced by low serotonin levels
0 Must also include psychological treatment
20. DBT (Dialectical Behavioral Therapy)
0 Goal is behavior modification
0 No data collected only with women, but data provides some support for
effectiveness
0 Structure
0 One hour weekly of individual therapy
0 Two and a half hours of weekly group therapy
0 Continued for a year
0 Team approach
0 Phone consultation between sessions
0 Manual available
0 Training
0 Instruction in mindfulness
0 Interpersonal effectiveness
0 Emotion regulation
0 Distress tolerance
0 Pitfalls
0 Finances
0 Time commitment
0 Best for highly motivated clients
21. MACT (Manual Assisted
Cognitive-Behavior Therapy)
0 Response to the need for brief therapy
0 Delivered in maximum of 6 sessions
0 Can be entirely bibliotherapy with 6 booklets
0 Evidence showed depressive symptoms reduced
22. CAT (Cognitive Analytic Therapy)
0 For repeat self-mutilators
0 Very Brief- possible in one session
0 Structure
0 Problem-solving focus
0 Shared role relationship
0 Intervention
0 Self-harm Self Help file for the client (completed before session)
0 Assessor’s Response File for counselor (completed before session)
0 Assessments give focus to the sessions
23. Narrative Therapy
0 Circle Strategies- Outside to Inside Approach
0 Outer circle- learn about the context of the client’s life minus
the trauma and symptoms
0 Middle circle- focus directly on the trauma and symptoms;
build a support system
0 Inner circle- Create a protective presence in place of the non-
protective presence.
24. Group Therapy
0 In conjunction with individual therapy
0 Challenges
0 Loss within the group can trigger self-mutilation
0 Mutilation can be used as a communication technique
0 Mutilation may be used to manipulate the group
0 Members can gain status by self-mutilating
0 Strategies to Deter
0 Labeling SMB
0 Reframe “helpful” behaviors as “harmful” in helping
0 Benefits
0 Communicating about distress
0 Practice skills
0 Receive feedback
25. Inpatient Treatment
0 For extreme situations
0 S.A.F.E. Alternatives program
Click on the webpage above to go to the S.A.F.E Alternatives
webpage for more on their inpatient treatment options,
26. Considerations
0 Do’s (according to client perception)
0 Care about the person beyond the injury
0 Offer compassion for the injuries
0 Be willing to talk about it
0 Help shed light on the origins of the behavior
0 Point out the ambivalence
0 Find different ways to express feelings
0 Create support systems
0 Recognize the behavior can not be dropped immediately
0 Celebrate small gains
0 Don’ts (according to Conterio and Lader)
0 Displaying wounds or scars
0 Prescribe substitute behaviors
0 Anger release techniques
0 Physical activity
0 Hypnosis
0 Heroic Rescue
(Pearson, 2011, 93-94)
27. Diversity Issues
0 Prominent with Caucasian (77%)
0 Prominent with females, bisexual, or questioning
0 Persons with Disabilities
0 Stereotypic type
0 Intellectual disability
0 Expressive communication skills are poor
0 Compulsive behaviors
0 Same treatments as other populations (medication and/or
behavior modification)
28. Assessment
0 No specific assessment
0 MMPI-2 does identify self-mutilating behaviors
0 Click on MMPI-2 above to link to the Pearson summary
of this assessment
0 Observation and direct questioning are the best
methods for identifying self-mutilation
0 Should be apart of initial intake
29. Counselor Issues
0 Hard for the counselor to keep their reactions
neutral
0 Requires serious commitment
0 Specifying with the client how self-mutilation will
be handled beforehand
0 Recognizing their limits as a counselor for this
issue
30. Ethical Concerns
0 Knowing when it is appropriate to hospitalize
0 Refusing therapy without a referral
0 Physically intervene or not if a client self-mutilates
during the session
0 Informed consent needs to address how self-
mutilation will be handled
31. References
Conterio, K. (2011). S.a.f.e. alternatives. Retrieved from
http://www.selfinjury.com/
Demi Lovato Talks About Cutting Herself. Available from:
http://youtu.be/RVq-sLFu6M4. (last accessed 7/1/2012).
Erskine, K. (2010). Mockingbird. Philomel.
Froeschle, J. (2004). Just cut it out: Legal and ethical challenges in counseling students
who self-mutilate. Professional School Counseling, 7(4), 231-235.
McCormick, P. (2000). Cut. Push.
Pearson Custom Education, Counseling COUN 6731. Copyright 2011 by Pearson
Learning Solutions. Boston, MA.
Pearson Education. (2012). Minnesota multiphasic personality inventory®-2 (mmpi®-
2). Retrieved from
http://psychcorp.pearsonassessments.com/HAIWEB/Cultures/en-
us/Productdetail.htm?Pid=MMPI-2&Mode=summary
Personality Disorders: What Is Borderline Personality Disorder?. Available from:
http://youtu.be/1lxdhKhTP1w. (last accessed 7/1/2012).
Zila, L. S. (2001). Understanding and counseling self-mutilation in female adolescents and
young adults. Journal Of Counseling & Development, 79(1), 46.
