A Manual of Best Practice for Counsellors
Working With Adolescents Who Self-Injure

Judith (Judy) Polysou
B.H.Ec., University of British Columbia, 1978
Education Certificate, University of British Columbia, 1979

Project Submitted in Partial Fulfillment of
The Requirements for the Degree of
Master of Education

In Educational Counselling

The University of Northern British Columbia
April2009

© Judy Polysou, 2009

UNIVERSITY of NORTHERN
BRITISH COLUMBIA
LffiRARY
Prince George, B.C.

11

Abstract
Self-injury (SI) is the intentional harm of oneself in order to manage emotions and provide
relief from unbearable stress. Methods of self-injury include cutting, burning, hitting, and
hair pulling. Many counsellors are working with adolescent self-injurers but are struggling
with how best to provide therapy. The role of counsellors may vary, depending on whether
they are school or community-based. This project presents a manual focusing on adolescent
self-injurers and their psychotherapeutic treatment. The manual presents and interprets
information that is difficult for practicing counsellors to access into a succinct document.
Topics addressed are the nature of adolescent self-injuring behavior, risk factors associated
with SI, strategies for working with self-injurers within the public school system, assessment
of the adolescent self- injuring client, and therapeutic treatment. Working with adolescent
self-injurers is a challenging undertaking and this manual offers information and strategies to
aid the counsellor in providing appropriate client care.

111

TABLE OF CONTENTS.
Abstract

11

Table of Contents

111

List ofTables

Vl

List ofFigures

Vll

Acknowledgements

vm

Dedication

IX

Author's Note

X

Chapter One: Introduction

1

Chapter Two: The Nature of Self-Injury as a Challenging Behavior
SI Versus Suicide
Incidence of SI
Sample SI Case Illustrations
Conclusion

4

Chapter Three: Risk Factors Related to the Incidence of SI
Childhood Trauma and Post Traumatic Stress
Body Image Issues
Borderline Personality Disorder
Anxiety, Despair, and Depression
Disturbed Childhood Attachments
Sexual Identity and Role Confusion
Substance Use
Contagion Effect
Biological Factors
Conclusion
Chapter Four: Working with Adolescents in a Public School Setting
Staff Education Regarding SI
Confidentiality
Developing School SI Procedures
Conclusion
Chapter Five: Assessment of Self-Injuring Adolescents
The Therapeutic Alliance
Confidentiality
The Assessment

6
8
10
13
14
14

16
17
18
19
19
20
21
21
22
24

27

30
34
35
37
38
39

40

IV

Chapter Six: Treatment

Client Safety
Family Situation and Functioning
History of SI
Recent SI
Mental Health
Substance Use
Body Image Issues
Exposure to Contagions
Past Trauma
Functions of SI
Consequences of SI
Conclusion

43
45
46
46
48
49
50
51
56
57
58
59

The Beginning
Counsellor/Therapist Training and Experience
The Client
Therapeutic Boundaries
Assessment
Early Intervention
Treatment Goals
The Therapist and the Therapeutic Relationship
Working With Families
Treatment Approaches
Empirically Supported Therapies
Promising Treatments without Empirical Support
Additional Perspectives
Interventions Not Recommended
Termination Issues
Conclusion

61
62
62
63
64
65
65
66
66
69
71
71
82
85
88
88
90
92

References
Appendix A

Adolescent Self-Injury: A Staff Education Session

107

Appendix B

Recommended School Procedures Regarding
Incidents of Self-Injury

109

Appendix C

Assessment Record

111

Appendix D

Journal

123

Appendix E

Selected and Annotated SI Resources

125

Appendix F

Agency/Counsellor/Medical Care Contact and Release
oflnformation Consent Form

133

v

Appendix G

Frequently Asked Questions - Self-Injury

134

Appendix H

What' s Going On? - A Cognitive Behavioral Strategy

139

VI

List of Tables
Table 1

Comparison of Suicide and Self-Injury

7

Vll

List ofFigures
Figure 1

Factors for school counsellors to consider regarding
confidentiality of adolescents practicing SI.

31

V111

Acknowledgements
I am grateful for the contributions many individuals have made throughout the development
of this manual. During a conversation five years ago with a counselling colleague, Kirk
Elliot, we were discussing the increasing number of self-injurers we were seeing in our
practice and how best to meet their needs. As an aside, Kirk mentioned that self-injury would
be an appropriate project topic and I thank him for starting me on my adolescent self-injury
journey. My project supervisor, Dr. Corinne Koehn, has been incredible. Her experience,
compassion, patience, understanding, knowledge, and editing skills are outstanding. My
other committee members, Dr. Cindy Hardy and Dr. Peter MacMillan, contributed
knowledge, were supportive, and reviewed my work in a very timely fashion. I thank my
committee members for their efforts. Thank you to Marla Spike (school counsellor), Chris
Molcak (high school principal), and Brain Pepper (district school superintendent), all School
District #57 Prince George educators, for their time spent reviewing the chapter on working
with self-injurers within the school setting. Mary Graham, with S.A.F.E BC, spent a great
deal of time critiquing my project and assisted me in producing a more accurate and helpful
document than I would have generated without her expertise. The contributions of my
partner, Nick Polysou, cannot be overlooked. Nick is a great editor and skilled computer
user-I thank him for his invaluable skills.

IX

Dedication
This manual is dedicated to the many adolescents I have worked with over the past 30 years,
as an educator, a counsellor, and a parent. Working with adolescents has taught me well and
this teaching has been valuable in writing this manual. I also dedicate this manual to my
family. While I developed this manual, Nick, Daniel, and Lauren gave up a great deal:
camping trips, holidays, access to the computer, home-cooked meals, and the list goes on. In
particular, my husband has been a trooper while dealing with computer glitches, editing
woes, late nights, and my frustrations. If there is a patience medal, he has earned it.

X

Author's Note
This document is designed to provide information and suggestions for counselling practice.
This manual is developed for use as a resource for counsellors/therapists and not as a
replacement for skilled professional practice. Direction and professional experience are
provided but the reader' s judgment and consultation with other professionals are also
required. It is essential that the client's safety and well-being take precedence at all times and
that users of this manual understand that each client has different needs and recognize that
not all elements of this manual are necessarily appropriate for all clients.

1
Chapter One: Introduction
An indication that self-injury (SI) has become a prevalent condition in the North
American adolescent population abounds in the popular media. There is a proliferation of
Internet websites focusing on SI. Television shows such as Oprah, Beverly Hills 90210, and
Grey's Anatomy have had episodes focusing on SI. Nine Inch Nails, Eminem, and Pearl Jam
are examples of rock music performers who include SI lyrics in their songs. Movies such as
Thirteen and American Beauty have woven SI into their plots. SI has been featured in
Canadian Living (Wysong, 2007), The Times (Kenrick, 2007), Teen People (Booth, 2004),
and Girl's Life (Ryan, 2005). The media attention was one ofthe initial motivating factors
for this project on adolescent SI.
While media coverage of SI has contributed to the development of this project, it was
also inspired by an observation of counsellors that there is an increase in the incidence of
adolescent clients exhibiting self-injuring behaviors. This project was also born out of
secondary school counselling practice-in conversations with colleagues, it is evident that
many school counsellors are struggling with how to effectively deal with the issue of
adolescent self-injury. These conversations were broadened to include other mental health
professionals in the community (physicians, private practice counsellors, psychiatrists, and
government mental health providers) and the same issues were reported.
It seems that many mental health professionals are grappling with adolescent SI

issues. Some questions are:
• Is the incidence of SI increasing?
• What are the safety issues surrounding SI?
• What are the parameters for confidentiality?

2
• How should SI be treated?
• Are there any differences between treating adolescent self-injurers and other selfinjuring populations?
In conducting a review of the literature relating to adolescent SI, it appears that
information is available for mental health professionals working with this population.
However, access is problematic as these references are scattered and hard to locate,
especially if the practitioner does not have access to information databases such as Academic
Search Premier or Psychlnfo.
The goal of this project is to provide the information required by front line mental
health professionals to promote best practice for their adolescent self-injuring clients. To
accomplish this goal, the project is presented in manual format. This includes chapters and
several appendices to support counselling practice. This manual also contains information
useful to school counsellors, who may not provide therapy to self-injuring adolescents, but
play a key role in identifying, responding to, and supporting students who self-injure.
The knowledge offered in this project originates from several sources: empirical
research, case studies, professional insight, and the author's experiences. Wherever possible,
the source of the information presented is revealed.
Chapter Two is a discussion of the nature of adolescent SI. The discussion includes a
definition of SI, incidence, and the differences between suicide and self-injury.
Chapter Three presents risk factors associated with SI. The presence of risk factors
does not necessarily predict self-injurious behavior, however if one or several risk factors are
present, SI is more likely.

3
Chapter Four addresses the issues the public school system faces when dealing with
self-injuring students. Confidentiality and liability issues are discussed. So that the accuracy
of the information was strengthened, this chapter and relevant appendices were reviewed by a
school principal, school superintendent, and a school counsellor.
Assessment of adolescent self-injurers prior to the onset of treatment is the focus of
Chapter Five. Many domains of an adolescent's world should be assessed. Each assessment
domain is presented with a rationale for its inclusion and strategies to assist with assessment.
Chapter Six examines treatment approaches that can be considered when working
with self-injuring adolescents. The approaches are provided in four groups: empirically
supported treatments, treatment approaches without research support, other strategies, and
treatments not recommended.
In addition to the school district employees who reviewed Chapter Four, the entire
manual was reviewed by a layperson, Mary Graham, who was a self-injurer and has a vast
amount of practical experience helping individuals who self-injure. Graham has also cowritten a manual for self-injurers (Haswell & Graham, 2008). The intent behind seeking
input from all external reviewers was to place the suggestions described in the manual under
critical examination and make them available for critique. Discussions with a parent of a selfinjurer informed the writing of this manual.
Throughout this manual the use of the words, "therapist" and "counsellor" are used
interchangeably. Depending on the workplace, either term could be used. It is hoped that this
SI resource facilitates effective counselling practice when therapists work with adolescent
self-injurers.

4

Chapter Two: The Nature of Self-Injury as a Challenging Behavior
Self-injury (SI) is "the deliberate mutilation of the body or a body part, not with the
intent to commit suicide but as a way of managing emotions that seem too painful for words
to express" (Conterio & Lader, 1998, p. 16). SI is also referred to as self-mutilation, selfinjurious behavior, self-inflicted violence, parasuicidal behavior, self-abuse, and deliberate
self-harm. All terms are found in literature; however, self-mutilation is a term that selfinjurers consider less acceptable. Parasuicide can be a confusing term as it often has a
perceived link to suicide, a behavior that is not always comorbid with SI (Carlson, DeGeer,
Deur, & Fenton, 2005; Connors, 2000; Conterio & Lader, 1998; Strong, 1998; Walsh &
Rosen, 1988; White, Trepal-Wollenzier, & Nolan, 2002; Zila & Kiselica, 2001). This chapter
presents SI information so that counsellors can gain understanding as to the nature of selfinjurious behaviors.
Dr. Armando Favazza ( 1996), a significant contributor to the current understanding of
self-injury, reports that incidents of self-injury have been observed throughout history among
many cultures and religions. The first work that identified self-injury as a unique practice
was that of Karl Menninger in 1938 (Favazza, 1996).
The American Psychiatric Association does not identify SI as a disorder in the
Diagnostic and Statistical Manual of Mental Disorders-IV-TR (DSM-IV-TR) (American

Psychiatric Association [APA], 2000). Self-mutilating behavior is listed as one ofthe
diagnostic criteria for Borderline Personality Disorder, a condition often associated with SI.
The Diagnostic and Statistical Manual of Mental Health Disorders- V (DMS- V) is currently
under consideration. A review of articles related to the DSM- V's development did not reveal
any literature regarding either the inclusion or exclusion of SI as a separate disorder. A case

5

has been made for the inclusion of self-injurious behavior as a distinct disorder in the DSM
(Muehlenkamp, 2005; Whitmarsh, Rosencrance, Lynch , & Mullette, 2006), whereas
Conterio and Lader (1998) do not support the inclusion of SI as a separate disorder because
they do not see SI diagnosis as helpful in the treatment of clients. With such contradicting
arguments, the inclusion of SI as a disorder in the DSM is not without controversy.
The most common form ofSI is cutting (Alderman, 1997; Conterio & Lader, 1998;
Favazza & Conterio, 1988; Klonsky & Muehlenkamp, 2007; Ross & Heath, 2002; Selekrnan,
2006; Winkler, 2003). Other forms of SI include self-hitting, extracting hair, head banging,
self-biting, self-burning, interfering with the healing of wounds, bone breaking, and the
ingestion of sharp or toxic objects (Conterio & Lader, 1998). In rare situations, SI can also
include eye removal, amputation of limbs, breasts, digits or genitals, or facial skinning
(Conterio & Lader, 1998). Other acts, such as jumping off low bridges or balconies, can also
be considered SI if the act is not meant to result in suicide and is used to help an individual
cope with emotional difficulties (M. Graham, personal communication, March 9, 2009).
Hitting a wall or object can also be self-injurious behavior, but some mental health
professionals may inaccurately view such acts as anger management problems, not SI (M.
Graham, personal communication, March 9, 2009).
Self-injury is separate from body modification or alteration (plastic surgery, tattooing,
piercing, scarification) (Favazza, 1996; Levenkron, 1998; Walsh, 2006; Winkler, 2003).
Rather than being a psychological syndrome, body modification is often sanctioned by
society and may be viewed as youthful rebellion (Conterio & Lader, 1998). Self-injury is
used as a way to cope with and relieve stress, whereas body modification is not. Self-injury is
self-inflicted whereas body modification often is not. Body modification is often done for

6

beautification and self-expression while the goal of SI is psychological relief. Body
modification is often done publicly and proudly displayed, whereas SI is usually done
privately and shamefully hidden. It must also be recognized that while body modification is
not considered a form of SI, body modification can cross the line and morph into SI if the
practice becomes a coping mechanism for an individual (Conterio & Lader, 1998; Walsh,
2006).
Sf Versus Suicide

Self-injurious behavior is different from suicidal ideation (Applewhite & Joseph,
1994; Carlson et al., 2005; Cavanaugh, 2002; Connors, 2000; Conterio & Lader, 1998;
Favazza, 1996; Klonsky & Muehlenkamp, 2007; McDonald, 2006; Strong, 1998; Walsh,
2006, 2007; White et al., 2002). Zila and Kiselica (2001, p. 47) present an analysis ofSI as a
syndrome and compare SI and suicide. Table 1 summarizes the comparison offered by Zila
and Kiselica.
Other evidence supporting SI as separate and different from suicide can be found in
SI literature; Shaw (2002) uses the term "anti-suicide" in her work and Conterio and Lader
( 1998) state that paradoxically SI is usually life sustaining. Walsh (2007) asserts that SI
forms (e.g. cutting, scratching, carving, self-hitting, and self-burning) tend to have a low
degree of lethality, whereas suicide forms (e.g. firearms, suffocation, poison, and falling)
have a high degree of lethality. SI often keeps the self-injurer functioning because the
behavior provides emotional relief. Endorphins are released into the blood system when pain
is inflicted and these endorphins may soothe the nervous system, ultimately reducing anxiety
and depression (Alderman, 1997; Conterio & Lader, 1998; Favazza, 1996; Levenkron, 1998;
Lukonski & Folmer, n.d.; Selekman, 2006; Strong, 1998). Evidence of suicide being different

7

from SI has been observed in the high school counselling office where it has often been
stated by the client, "I don't think I would be alive ifl didn't cut myself."
Table 1

Comparison of Suicide and Selflnjury
Self-Injury

Suicide
Wants to end life.

Does not want to end life.

Elicits a helping response from others

Others often react with hostility and

and such a response reduces the

disgust, frequency does not diminish.

possibility of further attempts.
Individual's situation often improves

Individual continues SI despite change in

when removed from stressful situations.

the level of stress.

Intent is death.

Low lethality.

Following attempt there is no relief.

Following SI, there is relief.

Has thoughts of death and dying.

Little or no thoughts of death.

Although suicide and SI are different conditions, suicidal ideation and suicide
attempts are sometimes found among the self-injuring population (Cooper, Kapur, Webb,
Lawlor, Guthrie, Mackway-Jones et al., 2005; Favazza, 1996; Lloyd-Richardson, Perrine,
Dierker, & Kelley, 2007; Nock, Joiner, Gordon, Lloyd-Richardson & Prinstein, 2006; Walsh,
2007). It cannot be understated that self-injuring individuals may be at risk of suicide (Walsh,
2007). When working with self-injuring clients, suicide must always be considered and the
risk of suicide must be assessed.

8

Incidence of Sf
The incidence of SI in the adolescent population is in question. In comparing youth
and adult self-injurers, Hjelmeland and Groholt (2005) concluded that adolescents have a
higher incidence of SI than adults and postulate that the reported difference is due to
adolescents being more cognitively immature and having less experience dealing with
problems. Galley (2003) reported that 4% of adolescents practice SI while Ross and Heath
(2002) concluded that 13.9% of high school students practice self-injurious behaviors. In a
community sample of adolescents, Lloyd-Richardson et al. (2007) found that in the past year
46.5% of youth reported having practiced self-injurious behavior but qualified this result by
also indicating that only 28% reported moderate to severe SI. Among adolescents with some
form of psychiatric illness, Winkler (2003) states that the incidence is 20%. When looking
only at people of all ages who are hospitalized for mental illness, 40% to 60% practice SI
(Winkler, 2003).
Although an increase in the incidence of SI is documented (Derouin & Bravender,
2004; Roberts-Dobie & Donatelle, 2007; Ross & Heath, 2002; White Kress, 2003), the
reported incidence of adolescent SI (4% to 60%) varies depending on the methodology,
sample, and date that the study was reported. A closer look at the literature suggests possible
reasons for this variance. One explanation is the time of the study. Ross and Heath's study
was published in 2002 whereas Lloyd-Richardson et al. 's study was published in 2007. Both
research teams reported high rates of SI but the 2007 study concluded a far greater incidence
among adolescents. It is possible that the time difference between the studies is a key factor;
latter studies may report more adolescents engaging in SI as it has become more
"normalized" by peers, the music industry, and the media. Events during the five-year period

•

9

between the two studies may have contributed to the increase in prevalence. Another factor
that could explain a difference in results is the sample (high school, community, outpatient,
or inpatient adolescents). Samples including outpatient or inpatient adolescents (clinical
samples) report higher incidence of SI than in community or school populations (Nixon &
Heath, 2009). The definition of SI (ranging from self-scratching and scab picking to cutting,
burning, and bone breaking) could also influence study results. If superficial (not just
moderate or severe) SI is included, prevalence is likely to be much higher. The age of the
participants (early to late adolescence) in a study could influence prevalence; it is reported
that younger adolescents practice SI less frequently than do older adolescents or young adults
(Nixon & Heath, 2009).
No matter to which research or literature one refers, it is accurate to state that SI is a
behavior with which many adolescents struggle. Evidence indicates that SI is a serious
adolescent mental health issue and this is further compounded by reports that the incidence of
self-injurious behavior is increasing (Carlson et al., 2005; Conterio & Lader, 1998; RobertsDobie & Donatelle, 2007; Walsh, 2006; White Kress, 2003).
The relative incidence of SI among males and females is in question. One reason for
this is that most of the research conducted has focused on adult females in clinical settings.
Literature that includes information on male self-injurers is lacking. Some authors have
concluded that the incidence for both genders is similar (Alderman, 1997; Gratz, Conrad, &
Roemer, 2002; Klonsky, Oltmanns, & Turkheimer, 2003; Marchetta, 2006; Muehlenkamp,
2005; Nock et al., 2006; Swadi, 2004; Tyler, Whitbeck, Hoyt, & Johnson, 2003; White et al.,
2002). Other authors report that the behavior occurs more frequently among females than
males (Conterio & Lader, 1998; Laye-Gindhu & Schonert-Reichl, 2005; Levenkron, 1998;

10

Ross & Heath, 2002; Shaw, 2002). One reason for this discrepancy in research results may be
that adolescent males will not volunteer to participate in research studies after preliminary
screening; male participation in such studies may require disclosure about emotions and a
coping strategy (SI) that they may wish to keep private. Despite the discrepancy in the
literature, evidence indicates that SI is an issue for both male and female adolescents.

Sample Sf Case Illustrations
To help the reader understand the scope of adolescent SI, two hypothetical case
illustrations that could surface in the public school system are presented. The case
illustrations are based on experience but are not associated with any one client. Each case
study represents a montage developed over years of experience.

Case Illustration One
Jason is 16 years old. He has passing grades at school but teachers report his
attitude and lack of motivation prevent him from being more successful in school. He
was removed from his mother's home by a government social worker when he was
eight years old. Jason lives with his aunt who has sole custody of him. Jason suffered
physical and sexual abuse while he lived with his natural mother and his mother's
partner and currently has no contact with them.
Initial contact with the school counsellor was made as the result of a student
reporting to the counsellor that Jason was cutting himself The school counsellor
brought Jason into his office to assess Jason's well-being. Jason admits to cutting
himself on his wrists, arms, and thighs. Jason reports that cutting gives him needed
relief He always cuts in private but he often cuts on the Internet using a web camera.

11

The camera only shows his thighs while he cuts to ensure his anonymity. Jason says
he is a loner with no close friends.
Jason admits to three previous suicide attempts. He tells his school counsellor
that he has had recent suicidal thoughts and is considering suicide as the way to end
his unfortunate situation and pain. Although no day has been determined, Jason has
decided that he would kill himself by hanging himself in his aunt's basement and
states that a rafter in the basement would work well.
Jason's safety and well-being are in jeopardy and the counsellor explained to
Jason that he needs immediate medical care. Although Jason did not want the
counsellor to call his aunt, the call was placed. Jason chose to remain in the office
during the phone call. Jason's aunt immediately came to the school. On the
counsellor's recommendation, Jason's aunt took him to the emergency ward of a
hospital where he was admitted to an adolescent psychiatric unit. The counsellor
followed up to ensure that the hospital visit occurred. While in hospital, a medication
that Jason voluntarily and secretly discontinued was re-administered.
Jason has a counsellor with an outside community agency but his contact had
become limited. Regular sessions were reestablished. Jason gave his permission for
the school counsellor to contact his agency counsellor. The school counsellor
reported Jason 's situation from the school's perspective and said he will see Jason
regularly to support him and monitor his mental health. Jason has agreed that this
would be a helpful strategy.

12

Case Illustration Two
Jessica is 14 years old. Jessica is academically successful. She lives with both
her natural parents. She would "pop in " to see her school counsellor sporadically
just to visit. Over time, Jessica stated that she had something important to tell the
counsellor but she could not talk about it. Her counsellor suggested she write it down

if she wanted to share her thoughts. About two weeks later, Jessica came into the
counsellor's office, dropped a note on the counsellor's desk, and left. The note
explained how she had been raped by her cousin six months ago. A !though her
parents knew about the incident, they did nothing and told Jessica not to talk about it.
The counsellor met with Jessica. Jessica was relieved to know that the counsellor was
concerned and that a government social worker would be contacted. While an
investigation was launched by the social worker and police, Jessica was placed in a
group home. Jessica was very happy with this temporary outcome as she was away
from the stress at home. The social worker arranged for out-of-school counselling/or
Jessica. Jessica continued to see the school counsellor, and her visits became more
regular. With Jessica's permission, the school counsellor contacted her outside
agency counsellor.
Several months after the disclosure was made, Jessica went to her school
counsellor and told her she was cutting herself She reported that the stress of the
rape, her family's denial, and the move to the group home had culminated in her
needing an outlet. Cutting was giving her the relief she needed. The counsellor
assessed her risk of suicide and determined that it was very low. With Jessica's
consent, the school counsellor called Jessica's outside agency counsellor to inform

13

her therapist of her cutting. Between Jessica, the outside agency therapist, and the
school counsellor, a treatment strategy was developed. One aspect of the plan was for
Jessica to see her school counsellor when she felt the urge to cut herself
Jessica showed up at her school counsellor 's office one day while classes
were in session and was very distraught. She said she just left the girl's washroom
where she had been contemplating cutting herself with her school mathematics
compass. She chose not to cut herself and instead go to the school counsellor's office.
Jessica and the counsellor determined that Jessica was able to make this positive
choice because of her agency counselling sessions. One coping strategy developed
was to see the school counsellor when her stress and anxiety became intolerable at
school. Jessica proudly left the counselling office; she was able to get through a
challenging situation without cutting herself

Conclusion
Both case illustrations highlight some of the key aspects of this chapter on the nature
of SI. One student struggled with suicidal ideation; the other did not. Suicide and SI are
different and often are not comorbid, but can be. SI is an issue for both genders. In both
cases, SI was practiced in early adolescence, the time when research indicates that most
adolescents start self-injuring behaviors. The illustrations provide two of many possible
situations a counsellor may face and allude to the risk factors related to the incidence of SI.
Risk factors will be addressed in Chapter Three.

14
Chapter Three: Risk Factors Related to the Incidence of SI
Certain risk factors may be present in adolescents who practice SI. It must be noted
that the risk factors discussed in this chapter are not all encompassing and do not necessarily
predict self-injurious behaviors. Although there is a higher incidence of SI among clinical
populations, it is occurring with increased frequency among populations without mental
health diagnoses and that do not exhibit known risk factors (Klonsky, 2007; Walsh, 2007).
Risk factors that may contribute to the incidence of adolescent self-injury will be presented in
this chapter.

Childhood Trauma and Post Traumatic Stress
Past traumatic experiences are often present in the lives of those who practice SI
(Derouin & Bravender, 2004; Marchetta, 2006; Shaw, 2002; Skegg, 2005; Zila & Kiselica,
2001 ). Many of these traumatic experiences relate to child abuse and subsequent post
traumatic stress (Alderman, 1997; Cavanaugh, 2002; Conterio & Lader, 1998; Derouin &
Bravender, 2004; Gratz & Chapman, 2007; Gratz, Conrad, & Roemer, 2002; Muehlenkamp,
2005; Nixon, Cloutier, & Aggarwal, 2002; Polk & Liss, 2007; Strong, 1998; Suyemoto &
MacDonald, 1995; Swadi, 2004; Tyler et al., 2003; Walsh, 2006; White et al., 2002; Zila &
Kiselica, 2001 ). Sexual abuse is one of the most significant forms of child abuse to influence
self-injurious behavior (Strong, 1998). In more recently published literature (Croyle & Waltz,
2007; Heath, Toste, Nedecheva, & Charlebois, 2008; Klonsky & Muehlenkamp, 2007), the
view of the relationship between child abuse and SI has been tempered. It is posited by these
authors that practitioners cannot assume that a person who has endured child abuse is likely
to self-injure nor that individuals without a history of child abuse will not practice SI. This
assertion is made because much of the SI risk factor research conducted has studied clinical

15
samples exhibiting mental health issues and within such samples it is believed that a history
of child abuse is more likely. Klonsky and Muehlenkamp, upon reviewing SI research,
concluded that there is only a modest link between childhood sexual abuse and SI. It can be
concluded that some abused children go on to self-injure while others do not, and that some
individuals without a history of child abuse will practice SI.
Other traumatic experiences besides child abuse have been identified as risk factors.
Strong ( 1998) identifies emotional abuse, emotional deprivation, physical neglect, and
childhood loss as traumatic stressors that could contribute to the onset of SI. Connors (2000)
and Frankel (200 1) state that the traumatic event could be perceived by an outsider as a
relatively minor one, but if the individual harbours significant negative feelings regarding the
event, the event could be a factor contributing to SI. What a counsellor perceives as less
significant trauma can actually have a profound impact on an adolescent and motivate an
adolescent to self-injure as a coping mechanism .
The following hypothetical case illustration describes a situation where trauma
unrelated to child abuse contributed to self-injurious behavior:

Melissa is 16 years old and is a student in grade 10. Recently her grades have
been falling and her teachers have referred Melissa to her counsellor because she
has been skipping school and not doing her academic work, leading to her being in
jeopardy offailing classes. Over time, the counsellor discovered that when Jessica
was seven years old, her mother was injured so seriously in the workplace that she
can no longer work and draws a disability pension. When Melissa was 10 years old,
her father was diagnosed with a chronic and debilitating condition. Melissa's father
was treated and the condition is controlled with medication. Melissa is worried about

16

her parents' long-term health and fears one or both parents could die. As her family
endured two tragic challenges, Melissa spent a great deal of time with her immediate
family and became isolated from her peers. While assessing Melissa 's level of stress
and depression, the counsellor learned that Melissa has been cutting herself since
grade seven. Melissa describes herself as anxious, lonely, isolated, and stressed. She
reports that she craves relieffrom her emotional turmoil and she has learned that
when her stress builds to intolerable levels, cutting provides the relief she needs.
Melissa feels stressed because of her parents' situations. Melissa has difficulty
dealing with her emotions related to her family difficulties and her emotional
dysfunction has carried over to other life situations, both socially and academically.

This illustration clearly demonstrates how traumatic childhood experiences could
have an impact on an adolescent's coping abilities and increase the likelihood of an
adolescent turning to SI for emotional relief.

Body Image Issues
A link between body image issues, including eating disorders, and SI has been
reported in literature (Best, 2005; Castille, Prout, Marczyk, Shmidheiser, Yoder, & Howlett,
2007; Cavanaugh, 2002; Conterio & Lader, 1998; Favazza & Conterio, 1988; Gardner, 2001;
Muehlenkamp, 2007; White et al., 2002; Zila & Kiselica, 2001). Muehlenkamp (2007) found
that negative body regard can be related to male and female adolescent SI. To illustrate the
link between negative body image and SI as a risk factor, a hypothetical case illustration is
provided:

17

Although Laura is not overweight, Laura sees her peers as thinner and more
attractive than herself Laura thinks her body image explains why she is isolated from
other girls. She would like to lose I 0 to I 5 pounds. Occasionally Laura decides that
she is going to go on a "diet ". When she goes on her diet, she tries to stop eating
entirely. This sets Laura up for failure as she becomes so hungry that she "pigs out"
in response to her intense hunger. Laura is now not only perceiving herself as
overweight and ugly but also as a failure because she can't stick to her diet; the
stress and anxiety created result in her cutting herself to relieve the tension and to
escape her emotional turmoil.

From a review of the literature related to body image and the case illustration, it is
apparent that adolescents with body image issues may exhibit self-injurious behaviors. It is
also important to realize that if one issue exists (body image issues or self-injurious
behavior), then the other issue may not be present. If either body image issues or self-injury
is present, assessment is required to ascertain whether both conditions coexist.

Borderline Personality Disorder
Borderline personality disorder (BPD) is defined in the DSM-IV-TR (APA, 2000) as
"a pattern of instability in interpersonal relationships, self-image, and affects, and marked
impulsivity" (p. 685). Brown (1998) simply describes the condition as dysfunctions in
emotions, behavior and cognition. The link between BPD and SI is well documented
(Andover, Pepper, Ryabchenko, Orrico, & Gibb, 2005; Brown, 1998; Favazza & Conterio,
1988; Klonsky et al., 2003; McKay, Gavigan, & Kulchycky, 2004; Nock et al., 2006; Paris,
2005; Swadi, 2004; White Kress, 2003). Self-injury is mentioned only once in the DSM-IV-

18
TR and it is as a symptom ofBPD. Much of the SI research and literature has focused on

participants with a diagnosis ofBPD (Klonsky & Muehlenkamp, 2007; Lukomski & Folmer,
n.d.; Muehlenkamp, 2007; White Kress, 2003). White Kress reports that among people
diagnosed with BPD, 75% are self-injurers. A review of the literature related to SI and BPD
reveals that the incidence of SI is more frequent among adolescents in clinical and
hospitalized populations with a diagnosis ofBPD than in community samples.
Despite evidence linking SI and BPD, research indicates that over time superficial or
moderate SI is occurring more frequently among individuals without symptoms ofBPD than
was previously reported (Muehlenkamp, 2005). Practitioners are cautioned to avoid
considering BPD and SI together and instead to view the conditions as two unique problems
(Muehlenkamp, 2005; Nixon et al., 2002).
In drawing conclusions from available research and literature related to SI and BPD,
the following points can be made:
• Individuals diagnosed with BPD are likely to self-injure.
• SI is observed in populations that have not been diagnosed with BPD.
• Superficial/moderate SI is frequent in community samples with no BPD
diagnosis.
• SI should be considered separately from BPD.
Anxiety, Despair, and Depression

Anxiety, despair, and depression are affective conditions that are often present among
individuals who self-injure (Klonsky & Meuhlenkamp, 2007; Muehlenkamp, 2005; Nixon et
al., 2002; Nixon, Cloutier, & Jansson, 2008; White Kress, n.d.). When these feelings are
experienced by an individual, a situation can become overwhelming and result in turning to

19
SI for immediate emotional relief (Klonsky & Muehlenkamp, 2007). In studies of
hospitalized and community self-injuring adolescents, it was found that participants reported
coping with feelings of depression as the most frequent reason for turning to SI (Andover et
al., 2005; Nixon et al., 2002; Nixon et al., 2008; Ross & Heath, 2002).
Disturbed Childhood Attachments
Disturbed childhood attachments have been cited as a SI risk factor (Carlson et al.,
2005; Conterio & Lader, 1998; Derouin & Bravender, 2004; Gardner, 2001; Gratz &
Chapman, 2007; Gratz et al., 2002; Heath et al., 2008; Levenkron, 1998; Selekman, 2006;
Skegg, 2005; Swadi, 2004; Zila & Kiselica, 2001). Some factors that lead to attachment
disturbances are:
• Childhood separation from a parent (Gratz et al., 2002),
• Loss of a parent, parental depression, marital violence (White et al., 2002),
• Divorced parents, incarcerated parents, parental alcoholism (Cavanaugh, 2002), or
chronic physical or mental illness in the family (Castille et al., 2007), and
• Lack of parental handling and isolation from family (Zila & Kiselica, 2001).
Sexual Identity and Role Confusion
Zila and Kise1ica (2001) identify repugnance toward sexuality, uncertainty regarding
sexual identity, troublesome sexual feelings, adjustment problems with menarche, and
confusion about emerging sexuality as possible issues related to SI. Difficulties with these
issues can create intense negative affect and lead to SI as a way to address the overpowering
stress.
Individuals who are gay, lesbian, bisexual or transgender are at greater risk of SI than
are heterosexuals (Conterio & Lader, 1998; Skegg, 2005; Walsh, 2006). Skegg asserts that SI

20
often occurs around the time when individuals realize that they may not be heterosexual.
Walsh has observed that youth not yet "out of the closet" often struggle with SI issues. A
case illustration helps bring perspective to how sexual identity can be a SI risk factor:

Donald is 17 years old. Donald has told his school counsellor he is gay but
has not disclosed this information to anyone else at school. He has decided that it is
safer and easier for him to keep his sexual orientation confidential while he is a high
school student. Donald is living away from his mother in a group home and endured
a disturbed attachment to his mother as a child. To cope with his stress, Donald has
turned to Sf many times in his life. He began cutting himself when he was I 0 years
old. As Donald nears his high school graduation, he is becoming more optimistic
about his future. He believes that he can start living his life as an outwardly gay man
and the relief surrounding this perspective has contributed to his decision not to
injure himself anymore. Donald thinks that one of the reasons he cut himself was
because he found it necessary to repress his homosexuality.

Substance Use
Substance use has been identified as a SI risk factor (Alderman, 1997; Castille et al.
2007; Conterio & Lader, 1998; Walsh, 2006; Winkler, 2003; Zila & Kiselica, 2001). Zila and
Kiselica conclude that SI can be triggered by substance use because of impaired judgment. It
appears that the link between substance use and SI is stronger for youth than adults (Skegg,
2005).

21
Contagion Effect
Peers, the media, music, and the Internet can influence an individual's SI behaviors.
This influence is called the "contagion effect"; adolescents may imitate the behaviors to
which they are exposed, including SI. Many authors of SI literature cite the contagion effect
as a concern (Derouin & Bravender, 2004; Muehlenkamp, 2005; Nock et al., 2006; RobertsDobie & Donatelle, 2007; Taiminen, Kallio-Soukainen, Nokso-Koivisto, Kaljonen, &
Helenius, 1998; Whitlock, Powers, & Eckenrode, 2006). The contagion effect can account
for "outbreaks" of SI in school populations (White Kress, n.d.). Exposure to contagions
increases the likelihood of adolescent SI. An in-depth review of the contagion effect is
presented in Chapter Five.
Biological Factors
Not much is understood about the link between biological factors and SI.
Neurotransmitters such as serotonin, dopamine, and opiates have been linked to SI (Nixon &
Heath, 2009), but their relevance is not fully understood. Linking dopamine and opiates to SI
has added strength to theories about the addictive nature of SI (Nixon & Heath, 2009); it
appears that self-injuring individuals produce dopamine and opiates at different levels or
develop different transmission pathways than non-self-injurers.
One biological factor important to mention relates to serotonin levels. Depression has
been linked to disruptions of serotonin systems. Low serotonin levels have been linked to SI
(Favazza, 1996; Levenkron, 1998; Muehlenkamp, 2005 ; Walsh, 2006). As one part of a
research study, blood samples of adolescents self-reporting SI and an adolescent control
group without self-injurious behaviors were compared (Crowell et al., 2008). A statistically
significant difference between the two groups was reported with the self-injurious group

22
having significantly lower serotonin levels (p < .001 and p < .05 when the use of
antidepressants was controlled for). Research of this nature has led to the use of selective
serotonin reuptake inhibitors (SSRI's) in the treatment of SI (Nixon & Heath, 2009),
although not without controversy. There appears to be a link between serotonin and selfaggression, but this link is not thoroughly proven or understood. This factor requires more
research before conclusions can be drawn regarding the relevant links between
neurotransmitters and SI.
Conclusion
The following is a summary of the risk factors identified in this chapter:
• Childhood trauma and post-traumatic stress,
• Body image issues,
• Borderline personality disorder (BPD),
• Anxiety, despair, and depression (negative affect),
• Disturbed childhood attachments,
• Sexual identity and role confusion,
• Substance use,
• Contagion effect (peers, media, music, and Internet), and
• Biological factors (neurotransmitters).
As the case illustrations indicate, it is common for several risk factors to be present in
the lives of self-injurers. It is also important to realize that obvious risk factors may be absent
in adolescents; researchers have concluded that the absence of risk factors is common in
superficial/moderate SI.

23
Working with adolescents in the public school system offers challenges that are
different from other counselling situations. Chapter Four provides information and strategies
for individuals working with adolescents in a school environment.

24
Chapter Four: Working with Adolescents in a Public School Setting
The incidence of adolescent SI has increased to the point where self-injurious
behaviors have become an issue that public schools need to address. Working with selfinjuring students in the public school system has unique challenges that may not exist within
non-educational support systems. Evidence of SI is often discovered at school by a staff
member or a peer of a self-injurer. If SI is identified by a school staff member, the employee
often reacts with panic, shock, and anxiety (Best, 2005, 2006a, 2006b). When evidence or
disclosure of SI surfaces in a school, it is often perceived by the community that the school
has an obligation to communicate with parents or guardians about their child's self-injurious
behavior. School personnel will typically be concerned about the legal ramifications of not
informing parents of a self-injurious incident. In addition to the school personnel's legal
obligations, ethical considerations magnify the concerns created when SI is discovered at
school. Whether or not counsellors must respect the confidentiality of students within the
school system remains unclear, even though many students request confidentiality. Thus, a
quagmire of issues difficult for school staffto traverse is created when self-injurious
behavior arises within a school setting. The purpose of this chapter is to address these
confusing challenges so that adolescent self-injurers can be supported appropriately within
the public school system.
A scenario involving SI in the public school system illustrates a situation that a school
could face:

Mr. Carson is an English teacher in a mid-sized urban high school. During
his morning ninth grade class a female student raises her hand to request help. While
helping at the student's desk, Mr. Carson notices that the student's oversized

25

"hoodie" sleeve has slid up her arm; Mr. Carson can see several red, irritated, and
shallow lacerations on the student's wrist.

The following is a list of questions the school staff may need to address when faced
with this scenario:
• What should the teacher do?
• Is this SI?
• Whom should the teacher contact?
• To whom should the teacher refer the situation and student, if anyone?
• What are the student's rights in this situation?
• What are the parents' I guardians' rights?
• What is the legal responsibility of the school?
• What are the ethical issues that require consideration?
• Are there any procedures in place to which school staff can refer?
All of these questions are valid when situations of SI arise in a school and each one merits
consideration. A possible reaction to the case study involving Mr. Carson follows:

Mr. Carson called the school counsellor asking her to meet with him during
lunch break. The school counsellor met with Mr. Carson and gathered two pieces of
information: the facts surrounding what Mr. Carson saw and how Mr. Carson was
coping. Mr. Carson was distressed by what he saw and feared that the injuries were
self-inflicted. The counsellor took some time to explain the nature of self-injury and to
thank Mr. Carson for seeking help regarding the incident. The school counsellor

26
concluded the conversation by offering to talk with him again if he needed any further
information or had additional concerns.
After the lunch break, the school counsellor brought the student into her
office. The counsellor told the student that Mr. Carson had seen wounds on her wrist
during class that morning. Although the school counsellor did not ask to see her
wounds, the student volunteered to show them to her. The student confirmed that the
wounds were self-inflicted. Throughout the session, it was ascertained that the
student's parents were aware of her self-injurious behavior, she was receiving
counselling from an outside agency, and she felt very sad and upset due to the stress
created by a recent situation. The school counsellor obtained permission to speak
with the student's parents and the outside agency providing her counselling. The
student was given the option of staying in the school counsellor's office during the
calls or to wait outside. She chose to be present during the calls. During the phone
calls, the school counsellor related what had happened at school and offered support
to both the family and outside agency counsellor. After the calls were made, the
school counsellor worked with the student to develop alternate coping strategies that
would work in her current and similar situations. The student agreed to see the
school counsellor when she needed support, especially when she needed help to get
her through a tough situation without hurting herself The student accepted the offer
of the school counsellor "touching base" with her on occasion to see how she was
doing. The counsellor spoke to Mr. Carson to say that the situation was being
addressed, to thank him for his efforts on behalf of the student, and to see how Mr.
Carson was doing.

27
Within the realm of adolescent SI, this situation was relatively easy to address due to
how the classroom teacher handled the situation, the school counsellor' s knowledge about SI,
the student accepting the school's help, the outside agency counselling already being in
place, and the parents' awareness of the student's self-injurious behavior. What this situation
illustrates is the value of the school counsellor as a supportive conduit for the adolescent,
school staff, family, and outside agencies to work through when incidents of SI are
identified. The value of staff education and support is also illustrated in the scenario. When
adequate staff education is provided, the student is more likely to receive needed assistance
in an appropriate way.
Staff Education Regarding Sf

Research indicates that school staff members want education around the issue of
adolescent SI (Best, 2006a, 2006b; Carlson et al. , 2005; Roberts-Dobie & Donatelle, 2007).
Other literature also supports staff education (Best, 2005; Froeschle & Moyer, 2004; Onacki,
2005). Most teachers do not possess the awareness and knowledge needed to intervene in
situations of SI (Carlson et al., 2005). The shock, panic and anxiety among school staff
identified by Best (2005, 2006a) can be appropriately addressed and reduced with staff
training.
The two target staff groups that require education regarding SI are school counsellors
and other staff members (administrators, teachers, and support staff). The needs of these two
groups are different; school counsellors must deal with the self-injurer directly while other
staff members need to understand the nature of SI, learn how to deal with their feelings
around SI, learn how to support self-injuring students, and understand the importance of
referring students to the appropriate school employee.

28
Staff education serves a two-fold purpose: to inform school employees about what to
do should they identify a possible case of self-injury and to educate employees about the
nature of SI so that understanding is fostered. A staff training session can occur within a staff
meeting or during a professional development session. Teachers may not be the only staff
members exposed to a possible case of SI. It is important to offer staff training to all school
employees and volunteers: teachers, administrators, office support staff, custodians, youth
care workers, bus drivers, and team coaches. A training session should provide information
regarding the nature of SI and what to do if a case of SI is suspected. Appendix A provides a
possible outline of staff training regarding student self-injury. This outline is meant to be a
starting point that a school or school district can use to develop its own training approach;
some school districts may opt for a standardized approach which all district schools could use
as a reference. The person facilitating an information session on self-injury could be a school
counsellor, school nurse, school psychologist, school social worker, or outside professional,
depending on the expertise available to the school. No matter which individual(s) present
information to a school's staff, presenters must have a sound understanding of the nature of
adolescent self-injury and how to support adolescent self-injurers within the school system.
When self-injurious behaviors are identified in the public school system, the school
counsellor often becomes the "conduit" through which the client, their family, staff members,
and members of community support agencies work (Ross & Heath, 2003). School
counsellors can educate themselves around the issues of SI by reading about SI and
participating in training sessions designed for counsellors. Training for school counsellors
needs to be more in depth than training for other school staff members as school counsellors
must also be aware of treatment strategies, community resources, and how to assist those

29
who know the self-injurer (staff members, peers, and family members). It is the school
counsellor's responsibility to access their own training and develop the skills needed to work
effectively with the many possible stakeholders (adolescent client, peers, family members,
school staff, medical professionals, and outside counsellors) identified when an incident of SI
anses.
Treating self-injuring adolescents is a challenging task. Although self-injury is the
observable behavior, there are often underlying issues that come to light during treatment.
Many of these issues relate to past trauma, substance use, eating disorders, and suicide. In
addition, several authors of SI literature assert that treating self-injurious behaviors is lengthy
(Derouin, & Bravender, 2004; Galley, 2003; McDonald, 2006; Onacki, 2005; Strong, 1998;
Winkler, 2003). It is argued that school counsellors usually do not have the time required to
develop a suitable treatment plan and work with the student therapeutically on a long-term
basis. In a school, counsellors work not just with students, but also with teachers, parents,
and administrators. In addition to meeting the needs of these four user groups, school
counsellors have large caseloads that limit the amount of time available for one-on-one work
with students (Rutter, 2007). Further, school counsellors are not available for extended times
during school holidays. The level of school counsellor training can vary from a teacher with
no formal counselling training to a teacher with a Master degree in counselling. These school
realities support the importance of referral to medical professionals and community agencies
better designed to meet the therapeutic needs of self-injuring adolescents. Roberts-Dobie and
Donate lie (2007) and Best (2005) conclude that it is not the role of the school counsellor to
provide therapy for mental health problems. A great deal of literature supports the need for
referral (Best, 2005; Froeschle & Moyer, 2004; Galley, 2003; Lukomski & Folmer, n.d.;

30
McDonald, 2006; Onacki, 2005; Robert-Dobie & Donatelle, 2007; Walsh, 2006). As referral
is often required, counsellors must familiarize themselves with community resources that are
most appropriate, and how to refer to them, so that students' mental health and medical needs
are met (Roberts-Dobie & Donatelle, 2007). This aspect of effective school intervention
should be a part of counsellor SI education. The identified need for referral does not
underestimate the effectiveness of school counsellors. Mary Graham is a previous self-injurer
who helps many self-injuring youth. Graham (personal communication, March 9, 2009)
states that adolescents often report that the school counsellor is one of the most effective
mental health providers- students know their school counsellor, a school counsellor is
readily available, and a student can visit the counsellor' s office as the need arises, even if it is
only for 10 minutes.
Confidentiality
Confidentiality poses challenges for school personnel working with adolescents. As
graphically presented in Figure 1, school counsellors often find themselves involved with
sometimes opposing and unclear factors that contribute to the issues of confidentiality for
adolescents in the school system.
The Canadian Counselling Association (CCA, 2007) addresses the issue of
confidentiality in its Code of Ethics. Confidentiality is to be respected unless one or more of
three conditions are involved (Section B2). The first is when there is client disclosure that
indicates a "clear and imminent danger to the client or others" (CCA, p. 7). The second is
when legal requirements demand that disclosure of confidential information is required. The
third is "when a child is in need of protection" (CCA, p. 7). Although any of these conditions

31

can occur in a school environment, the first and third conditions are the confidentiality
exceptions most likely to be issues when dealing with adolescent SI.

1

School District Liability )
Suicidal Ideation

Age of Student

Canadian Counselling
Association (CCA)
Code of Ethics

[ Rights of Student )<~~~<-----.,

[ Supports Already in Place

[ Rights of Parents I Guardians
School Act

Figure I. Factors for school counsellors to consider regarding confidentiality of adolescents
practicing SI.

An example of "clear and imminent danger" surrounding adolescent SI is suicidal
ideation. Although not all self-injurers are suicidal, suicidal ideation must be assessed when
treating self-injurers. Within a school, the person to conduct a suicide assessment is often the
school counsellor. If a counsellor has reason to believe that either suicide or a suicide attempt
is a possibility, the counsellor is required to break confidentiality to access help necessary to
maintain the student's safety. Accessing help can involve a gamut of possibilities, from
calling a parent to taking the adolescent to the hospital.

32
When client safety is not at risk for adolescent self-injurers, confidentiality becomes
murky. In reviewing the literature related to confidentiality, some authors conclude that
parents or guardians have the right to be informed regarding their child's self-injurious
behaviors (CCA, 2007; Frankel, 2001 ; Froeschle & Moyer, 2004; Galley, 2003; McDonald,
2006; Onacki, 2005). The CCA Code of Ethics qualifies its assertion by stating that "parental
or guardian right to consent on behalf of children diminishes commensurate with the child's
growing capacity to provide informed consent" (p.8). This aspect of the Code of Ethics
suggests that adolescents may be able to make their own decisions around counselling for SI
if the client's well-being is not injeopardy. Applewhite and Joseph (1994) maintain that by
the age of 14 years an adolescent is capable of making many competent decisions about
mental health treatment, including confidentiality. The position regarding confidentiality
presented by Applewhite and Joseph nurtures trust in the counselling relationship, gives the
adolescent dignity, and protects the adolescent's interests. Best (2006b) and Nixon and Heath
(2009) support respecting student confidentiality unless the student is in jeopardy. Walsh
(2006) argues that if the behaviors assessed while interviewing the student are considered
minor or have already been resolved, the behaviors need not be reported. Walsh goes on to
state that if the behavior is significant and requires additional intervention, then parents need
to be contacted. This summary of literature pertaining to adolescent SI and confidentiality
illustrates how confusing the issue of confidentiality can be; everything from respecting
confidentiality unless personal safety is in question to informing parents/guardians whenever
an incident arises is advocated. This confusion reflects the quagmire of issues pertaining to
adolescent SI in the school system.

33
An important confidentiality factor is the location at which self-injuring behaviors
occur. For example, within the province of British Columbia (BC) public school system, the
School Act (Revised Statutes ofBC, Chapter 412, Part 1, Division 2, 1996) includes a
statement that ensures a parent's right to information regarding a child's attendance,
behavior, and progress in school. This brings into question confidentiality if a student is
practicing SI at school. It can be interpreted from the School Act that parents are entitled to
SI information if the behavior occurs on school property. Failure to inform parents may result
in serious legal ramifications due to contravention of the BC School Act.
School counsellors and their schools need to develop procedures regarding the
confidentiality of adolescents who practice self-injurious behaviors. It is suggested that the
issue of adolescent confidentiality be addressed in school procedures before SI issues arise.
My stance on adolescent SI, confidentiality, and the school system is that provided the
student's safety is not in question and the behavior is not conducted at school, confidentiality
should be respected. A therapeutic goal is often to work towards a point where the student is
ready to tell parents/guardians about their self-injurious behavior. Although informing
parents is usually not accepted by students at the beginning of a counsellor/student
relationship, experience has indicated that students will eventually disclose their selfinjurious behaviors to their parents. This strategy places the onus of disclosure on the student
and allows the counsellor to respect the student's confidentiality.
If it is decided that parents/guardians need to be contacted, it is essential to remember
that adolescent self-injurers do not like surprises (Malikow, 2006). Removing the element of
surprise requires informing the student of the impending contact with parents and describing
the actions that will occur. It also means giving the student options (Onacki, 2005). Giving

34
options allows the student to have some control throughout an intense situation while
decreasing the chance of surprises. One choice is allowing the student to decide to stay in the
room or wait outside while a phone call is made to parents/guardians or when parents come
into the school to discuss their child's behavior (Galley, 2003). Letting the student choose the
timing of contact is another way to let the adolescent self-injurer have some control. For
example, a student may request that the counsellor wait until a parent/guardian is off work
before making contact. Another choice is asking the student which parent/guardian to
initially contact. Choice is also facilitated by asking the student whether there is another
support person in addition to the parents/guardians that the student would also like involved;
another relative, school staff member, or peer may be requested to provide support for the
student.

Developing School Sf Procedures
Not all adolescent SI cases are as easy to address as the one described earlier in this
chapter. Often the student does not want help, parents are unaware of their child's selfinjurious behaviors, the student wants the self-injurious behavior to remain confidential, and
school staff members are repulsed by the behavior or fail to respond when evidence of SI is
presented. Such challenging situations demonstrate the need for school procedures that bring
clarity to murky SI situations that present to school personnel.
Further supporting the need for procedures, Best (2005) asserts that schools cannot
wait for a tragedy to happen before addressing SI concerns. Kenrick (2007) powerfully states
that the incidence of SI among the adolescent population should be "setting off alarm bells
for teachers, parents and anyone who comes into contact with young people" (p. 23).

35
Despite a need for SI procedures in public schools, they are usually lacking (RobertsDobie & Donatelle, 2007). The absence of school procedures reflects a lack of understanding
and knowledge around SI.
An example of school procedures is included to help schools develop their own
approaches (Appendix B). It is understood that each school works within its own
microenvironment and that each school is likely to have different needs and resources. Thus,
the sample document presented is meant to be a starting point from which schools and/or
school districts can develop their own procedures. The development of procedures related to
SI is likely to require the input of school staff, school counsellors, school administrators, and
school district staff (such as a superintendent, school board member, or district school
psychologist). Once procedures have been established, it is more likely that all staff will be
aware of how to appropriately handle an incident of SI.
The sample procedures in Appendix B encourage the use of the school counsellor as
the conduit through which the school, community, and family connect. Many school
counsellors have access to accurate SI knowledge through their professional development but
also have professional training regarding how to provide support when sensitive and intense
situations occur. It is understood that not all school counsellors have such background and it
may be more appropriate to have a school psychologist, school nurse, or school social worker
designated as the key individual.
Conclusion

Self-injuring students are often identified in the public school system. When an
incident of SI is suspected, it is imperative that school personnel act appropriately. The
school personnel ' s ability to act effectively hinges on the education ofstaff(teaching, non-

36
teaching, and counsellors) and volunteers and the development of suitable procedures.
Paramount when an incident of SI is identified is the student's safety. The issue of
confidentiality requires special consideration so that ethical and legal expectations are
balanced with meeting the needs of the self-injuring student. Due to the nature of a school
counsellor's professional role, providing adequate therapy in the school setting is likely not
possible, although school counsellors can play an integral and supportive role. Referral of
self-injuring students to an appropriate outside agency is strongly recommended.
With a sound background that includes an understanding of SI, the risk factors related
to the behavior, the issues particularly relevant to adolescent self-injurers, and the school's
role in responding to the behavior, client assessment can begin. Chapter Five offers a
discussion of assessment procedures.

37
Chapter Five: Assessment of Self-Injuring Adolescents
The assessment of adolescent self-injurers prior to treatment is essential; treatment is
likely to hinge upon the reasons a client practices SI. This chapter will present elements of SI
to consider during assessment, the rationale for considering these elements in assessment,
and strategies that can be used during assessment.
When an adolescent is self-injuring, safety must always be assessed. Although most
self-injurers are not suicidal, suicide risk must still be determined (Harriss & Hawton, 2005;
Harriss, Hawton, & Zahl, 2005). Depending on the level of self-injury (superficial or
moderate versus major), serious unintended injury can occur, even leading to accidental
death. Assessment can indicate that a referral to other health care or mental health providers
(e.g. psychiatrist, physician, social worker, hospital emergency room) is needed. Assessment,
therefore, serves four purposes: to determine the risks involved in the self-injurious behavior,
to assess risk of suicide, to determine the need for referral, and to develop an appropriate
treatment plan that meets the needs of the self-injuring client. While meeting the four
purposes, an opportunity to nurture a strong therapeutic alliance is also created.
Validated assessment tools for adolescent SI are lacking (Walsh, 2007) and the DSM-

IV- TR (APA, 2000) does not recognize SI as a disorder. The reality is that counsellors must
assess self-injuring clients without many resources. Further, more counsellors are dealing
with an increasing number of adolescents who self-injure, reflecting a growing need for
information about assessment. The primary goal of this chapter is help fill this void by
providing rationales for including a variety of domains (e.g. peers, family, substance use, and
functions of SI) and offering assessment strategies particularly relevant to adolescent SI. For

38
the purposes of this chapter, it is assumed that counsellors have acquired basic counselling
skills, including general assessment skills.
When assessing an adolescent client with self-injuring behaviors, a combination of
tools should be considered (Appendices C and D). A multi-method approach using
interviews, rating scales, and journaling can reveal many aspects of the client's world such as
emotional experiences, the nature of self-reported behaviors, level and frequency of
behaviors, suicide risk, inter-relational experiences, and mental health disorders. This
information will increase understanding and provide direction during therapy. To assist with
the organization of counsellor notes during the assessment phase of treatment, an
"Assessment Record" has been developed (Appendix C) and suggestions for its use are
included.

The Therapeutic Alliance
A strong alliance between the adolescent and counsellor is necessary to facilitate an
informative assessment. Adolescents have an uncanny ability to detect counsellors lacking
genuineness. Nixon and Heath (2009) encourage counsellors to use a "matter-of-fact, calm
response ... which focuses on listening to the youth's perspectives" (p. 146). Dealing with
adolescent self-injury can generate strong emotions within the therapist. To support a strong
alliance, counsellors must keep these emotions in check. Disgust, repulsion, frustration, and
anger are examples of emotions a counsellor could experience and if the adolescent client
senses such feelings, the therapeutic alliance may be compromised.
Assessment provides the opportunity to begin establishing a strong alliance. This can
be done by encouraging a collaborative relationship. Some questions of the client that
reinforce collaboration are:

39
• What do you want out of counselling?
• What changes are you hoping to achieve?
• What, if any, changes do you want to make in your self-injury?
• How will you benefit from changes in your self-injurious behaviors?
When communicating with an adolescent, the wording of probe statements and
questions needs careful consideration. For example, Nixon and Heath (2009) consider a
question like "Why do you self-injure?" unhelpful. Instead, they encourage the use of a
statement like "Help me understand what is going on with you." (p. 147). Nixon and Heath
assert that the "craftsmanship" of a counsellor is at the foundation of an effective and useful
assessment.
An adolescent will not respond well to a barrage of questions. Asking a few probe
questions and letting clients tell their stories is encouraged. Listening actively and
empathically helps to develop a collaborative alliance and meet the needs of self-injuring
adolescents.
It is relatively easy to understand what information is required during an assessment;

it is more difficult to gather the relevant information in a way that builds a strong
relationship. The success of assessment hinges on the quality of the therapeutic relationship
and how the therapist communicates with the client.

Confidentiality
Confidentiality is always an important consideration in a client/counsellor
relationship; however, confidentiality is more challenging to address when working with
adolescents due to parent/guardian expectations, ethics, and legal obligations. Legally, the
parent is the client, however ethically the client is the adolescent (Best, 2005 , 2006b; Frankel,

40
2001; Froeschle & Moyer, 2004). There is great fear among adolescents that their
parents/guardians will be informed of their self-injurious behavior (McVey-Nobel,
Khemlani-Patel, & Neziroglu, 2006). SI is usually a private act and parents/guardians are
often unaware of their child's behavior. Self-injuring adolescents may feel embarrassed about
their behavior and want to keep the behavior confidential, especially where parents are
concerned.
The confidentiality information presented in Chapter Four can be reviewed for further
clarification regarding this important aspect of counselling adolescents who practice SI. In
summary, respecting confidentiality hinges on the age of the adolescent (the older the
adolescent client, the more likely confidentiality can be respected), severity of the SI
(ensuring that the client's safety is not in jeopardy), the policies and ethics of organizations
with which the counsellor is associated (certifying professional associations and employer
policies), and legal responsibilities. It is recommended that whenever possible the
confidentiality of the adolescent be respected. It is also suggested that an appropriate
counselling goal is to work towards the client speaking with a parent or guardian about the
self-injuring behavior.
The Assessment
SI assessment should not be conducted unless the counsellor has a strong
understanding of SI (Zila & Kiselica, 2001 ). If assessment is inadequate, there is a risk of
client harm. Harm could result from countertransference, judgment, criticism, a punitive
stance, or subtle reinforcement of self-injuring behaviors (by giving a great deal of attention
to the act of SI rather than the well-being of the client). The knowledge needed to work with
self-injuring clients can be learned through a variety of sources: published literature

41
(Appendix E), consultation with colleagues and supervisors, and adolescent SI counselling
training.
An important aspect of assessment is determining if the client is receiving service
from any other mental health professionals. For example, adolescents can be simultaneously
involved with a school counsellor, a community agency counsellor, and a social worker. If a
client reveals that another professional is involved, it is recommended that a discussion with
the client occur regarding continuing or terminating counselling. Seeking the names of
professionals who are involved as well as consent to consult should be a routine aspect of
counselling practice (Canadian Counselling Association, 2007; Schulz, Sheppard, Lehr, &
Shepard, 2006). With consent, consultation can determine if additional counsellor
involvement is in the best interests of the client. If other health care professionals are
involved, an adolescent is often required to tell personal stories more than once. Pushing a
client to reveal personal information when the client has already endured such disclosure
with another practitioner may be unethical- it could result in client harm because of the
resulting stress.
Appendix F provides a sample client consent form that can be used when contact with
other professionals is required. To complete this form, client and guardian signatures are
required. It is suggested that consent by a guardian may not be essential, depending on the
client's age and situation. Some adolescent clients do not have a guardian because they are
living independently. As well, an adolescent client may be able to solely give consent if it is
determined that the client is capable (see Chapter 4); there is a vast difference between the
capabilities of a client that is 13 years old and one that is 18 years old.

42

To conduct a thorough assessment, many domains of the client's world are worthy of
inclusion. The key domains addressed in this chapter are:
• Safety and suicide risk,
• Seriousness of wounds,
• Family situation and functioning,
• History of self-injurious behavior,
• Details of recent SI, including triggers and antecedents,
• Mental health (self-esteem, depression, anxiety, stress),
• Substance use,
• Body image issues,
• Exposure to contagions (Internet, peers, media),
• Past history and trauma, including child abuse,
• Functions and meaning of SI, and
• Consequences of SI.
As each domain is presented on the following pages, both the rationale to support its
inclusion and strategies to assist with the assessment are provided. It is important to
recognize that there is no one best approach to use when conducting assessment (Nixon &
Heath, 2009) and that the strategies offered are not necessarily the best nor the only ones that
counsellors can use.
The Assessment Record (Appendix C) can be used to record and organize
information gleaned from the client's conversations over several counselling sessions. Once
completed, it portrays a detailed picture of the adolescent's world. The assessment tool
should never be applied in one session in the form of a series of questions; most adolescents

43
would respond unfavourably to such an approach and the therapeutic alliance would likely be
impeded. If an adolescent is bombarded by question after question, discouragement,
frustration, and anger are possible emotions that can surface. This can lead to the adolescent
client "shutting down" and cause damage to the client/counsellor relationship. Instead, the
tool can be used to document relevant information disclosed by the adolescent client. To use
the Assessment Record effectively, it should be considered as a method to record and
organize client responses, not as an assessment script. It may take several sessions before all
the information required for a thorough assessment has been disclosed.
Many agencies expect some form of assessment report be placed in a client's file and
the Assessment Record may facilitate the writing of such a report by documenting and
organizing information disclosed during the assessment. This assessment tool can also be
used to develop treatment strategies and serve as a method of review by a supervisor or as a
reference during agency team meetings (Nixon & Heath, 2009).
Walsh (2007) is an advocate of sound and thorough assessment and states that "the
heart of a good assessment is 'in the details"' (p. 1066). Gathering the information suggested
in this chapter will provide the details required to generate a comprehensive assessment that
can be used to develop a treatment approach that meets an adolescent client's unique need.

Client Safety
Rationale. Of utmost concern is the safety of self-injurers. This includes the
assessment of wounds resulting from SI. Medical intervention is required when wounds are
serious or when the form of SI indicates possible serious risk. For example, when an
adolescent has long gaping wounds that require stitches or when risk of infection is a
concern, medical intervention is needed. Some self-injurers choose a serious form of self-

44

injury that can result in life-threatening injury. An example of this would be a person
jumping from a height to cause injury while not wanting to attempt suicide.
Suicide assessment is a vital aspect of assessment. There is an increased risk of
suicide among self-injurers (Harriss & Hawton, 2005; Harriss et al., 2005). Although most
self-injurers are not suicidal, a thorough suicide assessment must be conducted.
Strategies. A visual inspection of wounds is sometimes a challenge. If a counsellor
wants to see self-inflicted wounds, the counsellor should always ask for permission (Walsh,
2007). Some adolescents may volunteer to show a counsellor their wounds; other adolescents
may be unwilling. Sometimes the wounds inflicted are on parts of the body where viewing is
inappropriate (breasts, thighs, genitals). Dwelling on injury sites may bring attention to the
self-injury rather than the functions of the injury and intervention. For these reasons, viewing
wounds can be questionable and uncertain at best. The rule should be that if it is believed a
wound needs medical treatment then such treatment must be accessed. If wounds are on an
area of the body where viewing is inappropriate, it is likely that the wounds need medical
attention due to the vulnerability of such locations (e.g. breasts and genitals).
Suicide assessment is an essential aspect of assessment. Assessment of suicide risk
can be accomplished by using a suicide rating scale such as the Beck Suicide Intent Scale
(Beck & Weishaar, 1990; Spirito, Sterling, Donaldson, & Arrigan, 1996), the Beck Scale of
Suicidal Ideation (Cochrane-Brink, Phil, Lofchy, & Sakinofsky, 2000), Linehan's Reason for
Living (Berman, Jobes, & Silverman, 2006), or the Beck Hopelessness Scale (Beck &
Weishaar, 1990). Research conducted by Harriss and Hawton (2005) examined the
effectiveness of The Beck Suicide Intent Scale in predicting suicide intent of self-injurers
who presented to a hospital after an incident of SI. The authors conclude that this rating scale

45
is useful in gathering client information regarding suicide intent, particularly in the short
term, but was not able to predict suicide in any one individual. Based on a review of
literature, Berman, Jobes, and Silverman recommend Beck's Scale for Suicide Ideation and
Linehan's Reason for Living because both instruments have been found to be reliable for
adolescents. It is recommended that a rating scale be administered orally rather than in
written form (clients are more receptive to an interview format) and that relying only on a
rating scale for suicide prediction is poor practice because the scale may be inaccurate for
any given individual, despite having statistical validity (Cochrane-Brink et al., 2000). The
American Psychiatric Association (2003) has produced practical guidelines for assessment
and treatment of suicidal clients. No matter what form of assessment applied, medical
intervention should be accessed immediately if results indicate the client's safety is at risk.

Family Situation and Functioning
Rationale. Working with adolescents usually means working with families. A
"family" can refer to anything from a two-parent nuclear family situation to a homeless
adolescent living on the streets with other people in similar situations. Understanding the
dynamic of a client's family through assessment can indicate familial challenges and
strengths. Insight into the client's family situation can impact a treatment plan. For example,
if the family lives chaotically and communicates poorly, working with the family system may
be a priority.

Strategies. During assessment, family functioning, communication style, supports
available, and family structure should be ascertained. Interviewing other family members can
increase understanding of the client's family situation. Client and family input can inform
treatment by developing an approach for the inclusion of the family. For example, if the

46
family situation is strained, the client and therapist may decide to work separately with the
adolescent client and family in the initial stages of treatment so that stress is not
compounded.
History of Sf
Rationale. Learning about past adolescent SI practices can help a counsellor plan for

future treatment. Walsh (2007) asserts that the longer an adolescent self-injures, the more
difficult it is to treat. A counsellor may need to commit to a long term counselling
relationship to address the client's needs if SI is a longstanding issue.
Strategies. Walsh (2007) recommends that the following historical information be

ascertained during assessment:
• Onset,
• Types of Sl,
• Tools used for SI,
• Duration of self-injuring episodes,
• Frequency of SI,
• Number ofwounds during an episode ofSI, and
• The amount of damage self-inflicted during an episode of SI.
Recent Sf
Rationale. Knowing the history of a client's past SI information is helpful but it is

not enough. It is argued that recent self-injuring behavior (within the last 2 months) can vary
greatly from past practices. For example, a parent may discover that their child is selfinjuring and then place many controls on the adolescent in the hopes that the SI will stop.

47
This could result in the adolescent hiding tools, self-injuring in more secretive locations than
before, and self-injuring on areas of the body where parents cannot view the wounds.
Strategies. The historical information listed in the previous section can serve as a

guide for accessing current client self-injuring information. While assessing recent SI
practices, information about triggers and antecedents can be gathered. Triggers and
antecedents are events in an adolescent's life that can motivate SI. A few possible examples
are:
• Arguing with a parent, other family members, or peers,
• Doing poorly on a school assignment or test,
• A friend self-injuring,
• A relationship issue with a boyfriend/girlfriend,
• Viewing SI in the media or on the Internet,
• An addicted parent returning home under the influence of a substance, or
• Feeling lonely or abandoned.
Triggers and antecedents can provide valuable direction for generating new coping skills and
SI alternatives during treatment.
Clients can be asked to keep a journal of their self-injuring practices in order to help
the counsellor gather information (Appendix D). However, some adolescent clients do not
respond well to journals. In such cases, the client's wishes should be respected and the use of
a journal may need to be discontinued (Walsh, 2007). The self-injury journal is designed to
document information while not requiring a great deal of time. Journals that require lengthy
writing can frustrate youth so much that they will abandon their journal. For adolescents who

48
want to write more, an area to write notes is also provided. When reproducing the form, the
notes page can be copied onto the back of the journal.
The sample of a SI journal provided in this manual is simply entitled "Journal" in
order to help a client maintain privacy. Ifthe sheet of paper were found by others, it would
not be immediately apparent what the document is for, something adolescents appreciate.
The name portion of the journal could be left blank until it is returned to the counsellor for
discussion and filing. Anonymity would therefore be maintained if the adolescent were to
misplace the document.
When the client returns to a counselling session with the completed journal, it is
recommended that the journal be discussed to determine if it is an accurate and typical
reflection of the client's self-injurious behaviors. For example, some adolescents may selfinjure less than is typical because the behavior is being charted, and some may self-injure
more, perhaps because frustration related to the journal is experienced. If it is ascertained that
the adolescent is self-injuring more frequently when using a journal, its use should be
immediately discontinued.

Mental Health
Rationale. It is helpful to learn about any past and current serious mental health
issues. Previous or current mental health diagnoses and treatments (clinical or in-hospital)
can shed light on the client's situation and provide valuable information regarding other
practitioner involvement. Some relevant conditions that can be revealed during the mental
health portion of the assessment are: anxiety, depression, emotional dysregulation, BPD,
unmanageable stress, and poor self-esteem.

49

Strategies. Ask clients if they have been diagnosed or treated for any mental health

issues, either currently or in the past. Based on experience, the answer to this is often yes. If
diagnosis or treatment is identified, determine the nature of condition(s) diagnosed or treated.
It is recommended that any medications administered for mental health issues be

documented for future reference. The use of prescribed medication is an indication of the
severity of a mental health condition; enough medical concern was generated for
pharmacological intervention.
Contacting other professionals involved in the adolescent's care can inform treatment.
Any contact with other professionals requires written consent from the client and guardian(s).
Appendix F provides an example of a consent form to use for interagency sharing of
information. This form records the client's and guardian's consent to contact other
counsellors, agencies, or health care providers when it is learned that other professionals are
involved. The professional being contacted will require a copy of such a consent form prior
to the release of information.
Substance Use
Rationale. Adolescents who misuse substances are more likely to self-injure than

those who do not misuse substances (Nixon & Heath, 2009). Because substance use is a SI
risk factor, it is important to assess. Nixon and Heath argue that substance abuse and SI are
similar in that both can cause physical harm. In addition, there is evidence that SI has an
addictive aspect similar to that of substance dependence (Nixon & Heath, 2009).
There is often a perception that street drugs are the most commonly misused
substances among adolescents. A reality for adolescents is that alcohol is the most commonly
misused substance and is used by 58% of British Columbia adolescents (Tonkin, Murphy,

50
Lee, Saewye, & The McCreary Center Society, 2005). Alcohol is a central nervous system
depressant, produces a sense of euphoria, and is an addictive substance (Stevens & Smith,
2001). Considering that many self-injurers have depression issues, it stands to reason that
some may tum to alcohol as a way of self-medicating. A further complication is that
depression and suicidal symptoms may be aggravated when an individual is withdrawing
from a substance, such as alcohol (Daley & Moss, 2002). The thorough assessment of all
substance use, including alcohol, is essential.

Strategies. The Assessment Record (Appendix C) includes a chart that the therapist
can use to effectively organize and document substance use. For an adolescent to openly
discuss substance use, a strong therapeutic alliance is required so that the client feels the
counsellor can be trusted. It is suggested that substance use be assessed later in the
assessment phase when a trusting alliance is more firmly established.

Body Image Issues
Rationale. A link between poor body image and SI has been established
(Muehlenkamp, 2007; Nixon & Heath, 2009; Walsh, 2006). It is believed that eating
disorders such as anorexia and bulimia or negative body regard (Muehlenkamp, 2007)
increase the risk of SI. Nixon and Heath assert that disordered eating helps relieve negative
emotions in much the same manner as SI. During assessment, if poor body image or regard is
an identified issue, then treatment should encourage body awareness and positive body
regard (Muehlenkamp, 2007).

Strategies. An adolescent may not currently be dealing with an eating disorder, but
may have struggled with one in the past, so it is important to assess current and past
disordered eating and problematic body image issues. It is also useful to determine whether

51
the client has received previous treatment for any body image issues. If so, that therapist may
be contacted to provide information, with the client's permission. When assessing body
image issues, the following questions could be helpful:
• Have you ever been treated for body image issues or disordered eating? What did
the treatment involve?
• Do you have an eating disorder such as anorexia, bulimia, or compulsive
overeating? Have you had one in the past?
• Are you happy with your view ofyour body? If not, what is your concern? What
aspects would you like to change if you could?
• Do you feel pressure to change your body image? Where does this pressure come
from?
• What is your view of an ideal body image? From where does this view originate?
• Do you see body image or disordered eating as an issue for you? How?

Exposure to Contagions
Rationale. When an adolescent self-injures, the behavior is often introduced or
supported in music lyrics, on television, in movies, on the Internet, and by peers who are selfinjuring (Muehlenkamp, 2007; Roberts-Dobie & Donatelle, 2007; Whitlock, Lader, &
Conterio, 2007; Whitlock et al., 2006). This phenomenon is called the SI contagion effect,
referring to the direct or indirect influence exerted on an individual. This influence increases
the likelihood of an individual practicing SI and is powerful during adolescence. A direct
contagion occurs when the source of influence is known by an individual (e.g. a friend or
classmate) and an indirect contagion results from accounts or word of mouth (Taiminen et
al., 1998). Whether indirect or direct, the contagion is often not blatantly obvious and is more

52
likely to be subtle. For example, a song may not suggest that cutting should be attempted, but
when relief is described in the lyrics, an individual may turn to cutting to manage stress or
emotions.
Determining if contagion factors are contributing to the self-injuring dynamic during
assessment can guide treatment; if they are a contributing factor, adolescents need to become
aware of the impact of contagions on their behavior as well as learn how to cope with the
influence of contagions.
Nock and Prinstein (2005) conclude from their research that male and female selfinjuring adolescents often have peers who also self-injure; the authors coined this effect as
the "positive reinforcement function" of SI. The researchers assert that if an adolescent
perceives friends' SI behavior as a helpful coping mechanism, the adolescent is more likely
to engage in the behavior. This standpoint is supported by McVey-Nobel et al. (2006) who
note that self-injuring adolescents often cluster together. For adolescents practicing SI, such
clustering may provide understanding, and a way to disclose their SI without fear of negative
reactions. This may appear helpful, but more healthful coping options are often not
encouraged in these peer relationships. McVey-Nobel et al. suggest that clustering leads to
"copycat cutting". Walsh (2006) maintains that peers can be a contagion and that the
contagion effect results from a desire among adolescents for group cohesiveness, which leads
to a "special bond" among self-injuring peers.
Therapeutically, dealing with the influence of peers is challenging. Adolescents are
trying to develop independence; they are unlikely to accept that they are mirroring the selfinjuring behaviors of their peers as this implies dependence. Treatment is impeded when
adolescent clients will not acknowledge the influence of self-injuring peers. The positive

53
aspect of adolescents searching for their adult independence is that once self-injuring
adolescents come to accept that their behavior is influenced by peers, they may consider SI as
less appropriate because they do not want to be perceived as following their peers.
Among adolescents, Internet use is common. In a review of research on SI and
Internet use, Whitlock et al. (2007) found that 78% of adolescents use the Internet on a
regular basis and of these users, more than half connect to the Internet daily. The reviewers
also report that the prime reason most adolescents turn to the Internet is for social contact.
Given the proliferation of adolescent Internet use, one can conclude that adolescents who
self-injure are also frequent Internet users. Whitlock et al. (2006) reported almost 10,000
members on one SI Internet message board-the bulk of users of such sites being
adolescents-and concluded that SI sites are a social contagion for some youth.
When adolescents visit SI sites on the Internet, the impact of such use can be
negative. The virtual world offers an arena where anonymity can be assured and emotional
attachments can be easily built or broken. The Internet also offers sites that glamorize,
normalize, and promote SI while discouraging help from family and professionals. Some
sites explain how SI can be performed, show pictures of SI, and encourage SI as an
acceptable coping strategy. These sites can have a triggering effect on adolescents and bring
about self-injurious behaviors.
Self-injuring adolescents often lack healthful and supportive relationships with peers,
family members, or other adults. When a self-injuring adolescent turns to the Internet for
relationships, these social connections can replace contact with "real" people and actually
reinforce social problems in the adolescent's non-virtual world (Whitlock et al., 2007).

54
Use of the Internet can be addictive (Whitlock et al., 2007). As SI also has addictive
aspects, counsellors could find themselves dealing with clients with two addictive conditions.
Furthermore, counsellors may not be aware of a client's Internet use nor the complications
that this use can generate for treatment and recovery.
In a study oflnternet use conducted by Murray and Fox (2006), participants reported
positive aspects oflnternet SI sites; the majority of self-injurers reported less SI or no change
in their self-injurious behaviors. However, the age of participants is worthy of note: the 95
participants in this study ranged from 12 to 47 years old with a mean age of21.4 years. The
study included both adolescents and adults and one could argue that adults may be able to use
the Internet more prudently than can adolescents. Further research is needed regarding the
difference between how adolescents and adults use and respond to self-injuring web sites.
Internet use among self-injurers is an important aspect of many adolescent lives. Web
sites, message boards, YouTube, and chat rooms focusing on SI can negatively impact selfinjuring adolescents. SI web sites are continually changing; they morph, are discontinued,
and new ones are generated. In the resource section of this manual (Appendix E), a few
valuable and reliable sites current at the time of publication are highlighted. Counsellors are
encouraged to become aware of SI web sites, understand the impact sites can have on clients,
and assess a client's use of the Internet and SI web sites. It is also suggested that when a
client is accessing SI web sites that the counsellor monitor that access throughout treatment,
not just at the beginning of therapy when initial assessment occurs.
Many music performers have produced songs that include messages about SI. When a
Google search of "self-injury" songs was conducted on Aug. 18, 2008, over 73,000 hits were
displayed. One ofthese sites was accessed and 217 self-injury songs were listed (Self-injury:

55
A struggle, n.d.). Among the musicians listed were Eminem, Indigo Girls, Korn, Linkin Park,
Nine Inch Nails, Nirvana, and Pearl Jam, all popular within adolescent music culture. Such
music can have a contagion effect, particularly with adolescents, because exposure to SI can
increase the chance that an individual will adopt the behavior. In the counselling office,
adolescents continue to inform me about performers from several music genres (rock, punk,
grunge, rap, hip hop, alternative, indy) that include SI lyrics in their songs.
Some famous people have admitted to practicing SI. These include Angelina Jolie,
Johnny Depp, Fiona Apple, and Princess Diana. Whitlock et al. (2007) report 14 pop icons
who self-injure. SI has been included in movies such as Fatal Attraction, American Beauty,
Secretary, and Thirteen. Television shows have featured episodes on SI: Beverly Hills 90210,
DeGrassi, Grey's Anatomy, MTV's The Real World, Oprah, and Seventh Heaven. Role
modeling of self-injuring behaviors by the media in movies and television shows coupled
with famous performers admitting to SI is likely to normalize and glamorize SI. This
exposure could increase the likelihood of an adolescent turning to SI.
The contagion effect generated by peers, the Internet, music, and the media cannot be
overlooked when working with self-injuring adolescents. Counsellors should understand the
subtle and not so subtle influences to which adolescents are exposed.
Strategies. Information about contagions can easily be gathered by asking

exploratory questions. A few questions to facilitate this aspect of assessment are:
• How did you first become aware of SI?
• How did you learn that SI can be used as a coping strategy?
• Tell me about any friends you have who self-injure.
• What has the Internet taught you about SI?

56
• Have you heard about SI in music lyrics, movies or television? Tell me about it.

Past Trauma
Rationale. Many adolescent self-injurers have experienced trauma in the past. The
trauma (e.g. child abuse, a death, divorce, parental substance abuse, family financial issues)
can be profound or subtle, but if the adolescent perceives the event as traumatic then it needs
to be addressed. A thorough assessment helps the counsellor to identify and inform an
appropriate treatment plan.
A connection between abuse, particularly sexual abuse, and SI has been documented
(Cavanaugh, 2002) and it is thus important to assess current or prior abuse.

Strategies. Many adolescents will not voluntarily and spontaneously disclose
previous child abuse (Cavanaugh, 2002). When working with adolescents who have been
abused, sensitivity is of the utmost importance. Youth will be more responsive and forthright
in an atmosphere of trust, genuineness, empathic understanding, and collaboration. As with
substance use, this crucial aspect of the youth's story should be left until later in the
assessment so that the therapeutic alliance has had more time to develop.
The subject of child abuse needs to be addressed but finding the words to use with an
adolescent client can be difficult. A useful approach is to tell the client that SI is sometimes
linked to child abuse and knowing whether abuse has occurred (emotional, verbal, physical,
or sexual) is helpful during treatment. Experience indicates that this "up front" approach
works well with adolescents. Some questions that can be used during assessment are:
• Has anyone hit you or hurt you physically?
• Has anyone touched you on parts of you body that made you feel uncomfortable?
• Have you been forced or pressured into sexual contact with anyone?

57
Evidence of emotional or verbal abuse may surface during assessment when
adolescents disclose information regarding their peer and family relationships. However,
evidence of physical or sexual child abuse is often shrouded in many layers of shame, guilt,
confusion, fear, embarrassment, and secrecy- disclosure of this information is not likely
without using "pointed" questions.

Functions of Sf
Rationale. Research indicates that there are several functions of SI. In a review of the
empirical evidence, Klonsky (2007) identified seven reasons to explain why individuals will
choose SI:
1. Affect regulation- SI leads to the alleviation of negative affect. When
negative feeling become unbearable, SI provides relief.
2. Anti-dissociation- feelings are generated when self-injuring. This interrupts
the dissociation by "shocking the system" into feeling again.
3. Anti-suicide- the effects generated by SI enable an individual to resist the
urge to attempt suicide by replacing suicidal thoughts; SI is keeping the
person alive.
4. Interpersonal influence- SI is done to influence or manipulate people in the
self-injurer's world. Interpersonal influence can be viewed as a cry for help.
5. Interpersonal boundaries- the self-injurer sees the behavior as a way to assert
one's identity or autonomy. SI helps the individual feel separated from others.
6. Self-punishment- SI is an expression of anger against oneself.
7. Sensation seeking- SI is seen as a way to generate excitement, much like
extreme recreational pursuits such as skydiving.

58
Klonsky (2007) concludes that affect regulation is the most common function
reported by individuals with or without BPD and by adolescents and adults. He also notes
that self-punishment is a function reported more frequently among adolescents than other
research populations, although this function is secondary to the affect regulation function.
Despite affect regulation being the most common function of SI, individuals injure
themselves for various reasons. A counsellor cannot assume that a client self-injures for a
particular reason; function(s) need to be assessed. Once function(s) have been identified, an
appropriate treatment approach can be developed.
Nock and Prinstein (2005) identify a further reason to assess the function(s) of a
client's SI. Their research led them to conclude that adolescents who self-injure to alleviate
negative affect have feelings of hopelessness and suicide attempts are more likely than
among adolescents who self-injure for other reasons. Therefore, during assessment a
practitioner should be aware that SI practiced to reduce negative affect increases the
likelihood of a suicide attempt.
Consequences of Sf
There are consequences when a client self-injures. Some consequences can be
generated within the individual. For example, along with a short-term intense feeling of
relief, negative feelings such as guilt, shame, and disappointment can be experienced. Such
feelings can be intensified if family members are aware of the self-injurious episode and this
can, in turn, lead to intensifying one's negative feeling (e.g. an adolescent could feel that
one's family has been let down).
When parents are aware of an adolescent's SI, the consequences can be intense. They
may constantly monitor or frequently inspect their child for evidence of SI. They may react

59
powerfully and negatively, and impose punishment. Such negative consequences can be
identified during assessment and inform treatment planning.
Not all consequences are perceived as negative. Some adolescents have peers who
bestow status on self-injurers. SI induces emotional relief. Knowing about any perceived
positive consequences of SI is helpful. If positive consequences are reported by a client, such
consequences require exploration so that positive influences of SI can be minimized or
replaced by acceptable alternatives. For example, other methods of generating emotional
relief can be developed (such as exercise, talking to a friend, reducing faulty thinking, or
journaling).
Conclusion
Developing and implementing an effective treatment plan requires comprehensive
assessment. It includes many aspects of a client's world. In addition to generating a treatment
plan, the assessment can reveal safety issues (risk of suicide or unintentional serious selfinjury) and indicate the need for referral to other professionals.
Conducting an effective assessment requires a strong therapeutic alliance.
Conversely, an assessment appropriately conducted will nurture a strong alliance. The
counsellor needs to consider how questions and statements are worded, and present a
therapeutic stance that is supportive and nonjudgmental.
Using a variety of assessment techniques is useful: interviewing, rating scales, and
journaling are strategies that help a counsellor gather information related to the self-injurer's
world.
There is no "cookie cutter" approach to assessment. Each self-injuring adolescent
comes to counselling with unique characteristics and situations. Comprehensive assessment

60
provides a window into the adolescent's life and helps generate a treatment plan that meets
the adolescent client's needs.
Following assessment, the treatment process can begin. Chapter Six describes
treatment approaches to consider when working with adolescent self-injurers.

61
Chapter Six: Treatment
Treating adolescent self-injurers is challenging. Many practitioners and researchers
assert that treatment is a long-term process (Derouin & Bravender, 2004; Hawton et al.,
1999; Levy, Yeomans, & Diamond, 2007; McDonald, 2006; Suyemoto & MacDonald,
1995). Self-injuring clients can present with other mental health issues (e.g. suicidal ideation,
eating disorders, trauma, BPD, and substance misuse issues). The condition is often shrouded
in shame, embarrassment, and secretiveness. Self-injuring behavior may have an addictive
aspect. These possible elements of adolescent self-injury treatment are evidence of the
challenges that counsellors can face when working with this population.
There is no treatment panacea for adolescent self-injury (Nock & Prinstein, 2005).
Evidence supporting the efficacy of particular treatment strategies is lacking (Hawton et al.,
1999; Muehlenkamp, 2006; Nixon & Heath, 2009). In Muehlenkamp ' s meta-analysis (2006)
of research related to SI treatment effectiveness it is reported that there is insufficient
evidence to indicate that any one particular approach is more effective than other treatments.
In addition to limited empirically supported evidence, some of the literature highlighting
treatment approaches is based on case studies or practical experience. Despite the lack of
empirical evidence supporting particular treatment approaches, therapists must rise to these
challenges and provide the best care possible to meet the needs of their clients. The
adolescent SI treatment approaches presented in this chapter are categorized as :
• Empirically supported therapies,
• Treatments without empirical research support,
• Additional strategies, and
• Treatments not recommended.

62
The use of the treatment approaches offered in this chapter depends on two factors :
the skill and knowledge of the counsellor and the needs of the adolescent client. What works
in one therapeutic situation may be ineffective in another situation.
The Beginning
Counsellor/Therapist Training and Exp erience
When working with adolescent self-injurers and their families, the degree of
knowledge and experience of the therapist must be considered (Comtois, 2002; Hollander,
2008; McVey-Nobel eta!. , 2006). If a counsellor has limited theoretical and practical
background working with self-injuring adolescents, the counsellor may not be able to provide
adequate therapy. Counsellors working outside the limits of their professional skill would be
unethical and client harm could be a possible outcome. For example, a therapist could
unknowingly alienate an adolescent client by insisting on family therapy at the onset of
therapy when this approach would be more effective later in the therapeutic process.
Hollander states that the therapist should have several years of experience treating adolescent
SI; this experience should include training in the area of SI, consultation with other
professionals, and extensive work with adolescents . If expertise related to either SI or
adolescents is lacking, a counsellor should consider referring adolescent self-injurers to more
appropriate treatment situations until the necessary skills have been acquired.
Morrissette's literature review (2000) and Sutton and Pearson ' s research (2002)
address the challenges school counsellors face in rural communities. It is assumed that many
of these challenges also exist for other rural mental health professionals. Working with selfinjurers can be stressful for any counsellor- if a counsellor is working in a rural community,
the stress can be compounded for many reasons. The counsellor is often isolated from

63
professional support, supervision, and collaborative opportunities (Morrissette, 2000). The
community can be physically isolated and a counsellor may be viewed as "from away",
resulting in the closely-knit community not accepting the counsellor (Morrissette, 2000;
Sutton & Pearson, 2002). The counsellor may struggle with unclear personal boundaries
(Morrissette, 2000; Sutton & Pearson, 2002), making it difficult to establish and maintain
separation between professional and personal life in small communities, something
Morrissette describes as living in a "fish bowl". This is due to overlapping relationships,
visibility, and scrutiny. For example, it is likely a counsellor could not go to a bank, post
office, or grocery store without some community members being aware of the action. This
lack of anonymity can result in many community members readily labeling a counsellor' s
"reputation", be it good or bad. Lack of mental health referral options place added demands
on the counsellor and requires creativity and flexibility (Morrissette, 2000; Sutton & Pearson,
2002). A community with few counsellors and limited referral options can lead to stress from
overwork (Morrissette, 2000). Professional development opportunities are limited and
expensive to assess because this usually requires leaving the community. It is important that
counsellors be aware of the added challenges generated by working and/or living in a rural
community. Physical, emotional, and professional isolation gives rise to the added
importance of self-care in rural communities to reduce the likelihood of burnout.
The Client
It is essential to establish which professionals are involved in the treatment of a self-

injuring adolescent. Find out about the client's existing mental health diagnoses and
treatments to assess the appropriateness of the counsellor's further involvement.

64
Another factor to consider at the beginning of therapy is the client's motivation for
attending counselling sessions. When self-injurious behavior becomes evident to family
members, counselling is often initiated by the adolescent's family. An adolescent may
therefore be an unwilling participant, which can provide little motivation for behavioral
change. In this situation, the value of continuing therapy must be determined by the client
and therapist.
Therapeutic Boundaries

The establishment of client/therapist boundaries must to be addressed (Alderman,
1997; Conterio & Lader, 1998). Will client/therapist contact be restricted only to counselling
sessions? Are client telephone calls to the therapist between sessions appropriate? Will
emergency contact with the therapist be acceptable? What procedures should a client follow
if personal safety is likely to be jeopardized? Clearly defining client and therapist roles and
expectations assists in the development of the client/therapist relationship. It is particularly
important for the client to have awareness of where support can be found if severe
depression, suicidal ideation, or serious SI is pervasive and counsellor contact is not possible.
For example, a client should be informed about how to access emergency care at a hospital.
Client Contracts. Some therapists may consider the implementation of safety rules

that requires a client to commit to no SI while in therapy. This strategy is often referred to as
a safety contract or a no harm contract. Several authors conclude that no harm contracts are
ineffective and possibly dangerous (Alderman, 1997; Favazza, 1996; Mangnall & Yurkovich,
2008; Shaw, 2002; Walsh, 2006). Such an approach can "set a client up for failure"; when
the client signs a contract and then self-injures, the client can experience intense guilt and a
feeling of"letting the therapist down". Guilt and disappointment may lead to feelings of

65

inadequacy, undermining self-esteem. This can induce stress and to cope with the stress, the
client may turn to SI because it is a well-established source of relief. This cycle of SI
generated by no harm contracts can fuel self-injurious behavior, rather than reduce the
incidence of SI.
Instead of a no harm contract, a contract that focuses on expectations and behaviors
of the client and therapist is more useful (Alderman, 1997; Conterio & Lader, 1998). Such a
contract can clarify therapeutic approaches, list the responsibilities of the client and therapist
during treatment, list alternatives to SI that should be accessed, formalize boundaries and
goals, and address emergency care procedures. Conterio and Lader refer to this strategy as a
"treatment participation agreement" and they recommend that a contract of this nature be
implemented and then reviewed and revised throughout treatment.
Assessment

Prior to the establishment of treatment goals and the onset of therapy, a thorough
assessment of the client's situation is required (see Chapter Five). A comprehensive
assessment indicates the issues that need to be addressed, brings attention to safety issues,
and helps to determine the function(s) of the client's self-injuring behaviors-all valuable
pieces of information for the treatment process.
Early Intervention

The younger the client and the earlier the SI is identified and treated, the greater the
chance of treatment success (Conterio & Lader, 1998; Kenrick, 2007). This fact reinforces
the efforts of those working with adolescent self-injurers: there is a greater likelihood of
successful treatment with youth than with adults because the behavior may be less firmly
entrenched and thus less difficult to surrender. Kendrick (2007) summarizes this point well

66
by stating, "If people don't learn to deal with stress as a teenager, how can they be expected
to deal with stress as an adult? Perhaps it is time we looked at prevention at 15 rather than
cure at 35" (p. 23).
Treatment Goals

Treatment goals are best established through collaboration between the client and the
therapist (Muehlenkamp, 2006). Issues that the therapist might not consider important could
be overwhelming to an adolescent client. For example, a self-injuring female adolescent may
not want to address family communication, opting instead for ways to cope with how peers
are negatively impacting her life. It stands to reason that adolescents will work towards a
treatment goal if the goal is significant and relevant to their own situations.
The goals collaboratively established at the onset of treatment should be reviewed and
adjusted throughout treatment. As therapy progresses, insight can result in the revision of
treatment goals. For example, loneliness and isolation can surface as triggers for self-injuring
behaviors and development of strategies to cope with these emotions and to decrease
loneliness and isolation would become important.
The Therapist and the Therapeutic Relationship

The therapeutic relationship has been identified as an effective therapeutic strategy on
its own (Nafisi & Stanley, 2007). A grounded theory study conducted by Huband and
Tantam (2004) explored the effects of treatment interventions with 10 women. The
researchers concluded that a long-term relationship with a therapist who is competent and
neither under-concerned nor overprotective is most helpful in treating SI. In her metaanalysis of adolescent and adult empirically supported treatments, Muehlenkamp (2006)
asserts that a strong therapeutic relationship is the greatest single therapeutic technique for

67
successful treatment. In light of published research, it is sound therapeutic practice for the
counsellor to concentrate efforts on nurturing a strong therapeutic alliance when treating
adolescent self-injurers.
Therapist characteristics that are conducive to working with self-injurers have been
identified by researchers and practitioners. The effective counsellor:
• Provides validation, understanding, support, and respect (Muehlenkamp, 2006;
Nafisi & Stanley, 2007).
• Uses a collaborative approach that avoids power struggles (Muehlenkamp, 2006;
White et al., 2002).
• Recognizes that SI is an effective way to cope with acknowledged pain/emotions
(Muehlenkamp, 2006; Nafisi & Stanley, 2007; Skegg, 2005).
• Commits to long-term therapy that requires perseverance, creativity and flexibi lity
(Huband & Tantam, 2004; Muehlenkamp, 2006).
• Is not under/over protective (Huband & Tantam, 2004).
• Understands and manages countertransference and emotions (Deiter, Nicholls, &
Pearlman, 2000; Trepal, Wester, & MacDonald, 2006; White, TrepalWollenzier & Nolan, 2002).
• Considers cultural and social norms (Skegg, 2005).
• Makes use of ongoing clinical supervision/consultation (Deiter et al. , 2000; White
et al. , 2002).
• Ensures balance in life as working with self-injurers is stressful (Deiter et al, 2000).
• Works from a not-knowing stance and lets client educate the therapist (Zila &
Kiselica, 2001 ).

68
Countertransference warrants further consideration. Corey (2005) states that
countertransference occurs when therapists see themselves mirrored in clients, identify too
strongly with clients, or seek to meet their own needs through clients. Gardner (2001) simply
states countertransference as "the psychotherapist's unconscious reaction to the patient" (p.
106). Countertransference is likely when working with individuals who self-injure and can
result in strong feelings and reactions including panic, fear, misunderstanding, anger,
helplessness, pessimism, guilt, and disgust (Whitmarsh et al., 2006). Many clinicians who
work with self-injuring adolescents warn of countertransference and encourage its control
(Favazza, 1996; Hollander, 2008; Swadi, 2004; White Kress, 2003).
Countertransference is likely to be more powerful and harder to overcome when
working with adolescents due to how difficult SI is to understand and treat in the adolescent
population (Gardner, 2001). Counsellors may be particularly vulnerable to
countertransference when working with adolescent clients because of feelings that arise when
witnessing the effects of SI on a young person. Counsellors need to self-analyze, identify,
and control their negative feelings towards SI if a positive therapeutic relationship is to
develop.
In schools, SI might be identified by teachers or other school staff who have little
understanding of the behavior. School employees often experience a great amount of
emotional upheaval upon the discovery of a self-injuring student. Students are likely to sense
the negative feelings that teachers and other staff experience. It is not just
counsellors/therapists, but also other school professionals who are involved, who need
awareness and control of their negative feelings (e.g. frustration, repulsion, and anger) in
order for countertransference to be reduced.

69

If a journal is being used during either assessment or treatment, the journal should
only be referred to for a portion of any session. If an entire session were to focus only on a
journal of self-injuring behaviors, the adolescent may think that is all you are interested in
(M. Graham, personal communication, March I 0, 2009). The focus of treatment should be on
positive change and not on self-injurious behavior. Ifthe focus was on SI, the behavior could
be reinforced by such attention-the client may think that they need to self-injure to have
something to talk about.
Working with Families

Treating a self-injuring adolescent usually entails dealing with the adolescent' s
family. When a family member is practicing SI, an array of intense emotions may be present.
Some possible emotions are confusion, fear, anger, frustration, hurt, pain, embarrassment,
guilt, and helplessness-all strong emotions that can interfere with an adolescent' s recovery
and give the family a sense of upheaval. Dealing with family aspects of SI are challenging
because the adolescent often has little or no control over family behaviors and decisions.
Therefore, when an adolescent shows up at a counsellor's office, the family's struggles also
surface--communication difficulties, conflict, and unclear expectations are some family
stressors the adolescent can experience (Derouin & Bravender, 2004).
When a family operates chaotically and communicates poorly, family group
involvement, particularly at the start of therapy, may not be appropriate. Working with the
family together may place the adolescent in the middle of a great stressor, create emotional
tension, and generate more problems than solutions (the adolescent could "shutdown", tum to
SI for emotional relief, or rebel during and after sessions) (Hollander, 2008). The client and

70
the family both need help, but that help may need to be given in separate sessions until
progress has been made and all members are ready to cope with family sessions.
Many people have never heard about SI and if they have, it has usually not been
considered as a possible issue in their family. Families must be provided with information
about SI. Frequent questions are:
• Is our family member safe?/How can our family member be kept safe?
• Why is this happening?
• How can this be stopped?
• How can we help?
• Is this our fault?
• Is our family member crazy?
• What do we tell other people (other family members, the school, friends)?
These challenging questions can be addressed by providing family education, training
and SI resources (Trepel et al., 2006). Books written to provide family support are available
(Hollander, 2008; McVey-Nobel et al. , 2006; Penner, 2008). Prior to providing a printed
reference, ensure that the book has information that is accurate and comes from an
appropriate perspective (see Appendix E for an annotated resource list). For example,
Penner's book presents SI information from a Christian perspective, yet there is little
indication that this perspective is offered by viewing the book's front and back covers. If a
Christian perspective does not fit with the spiritual and cultural practices of a family, this
book would not be useful. A counsellor needs to be familiar with publications before they are
recommended to clients and their families .

71

Appendix G provides SI facts and answers to frequently asked questions and is a
"take away" resource for family members. Adolescent SI is overwhelming for a family and
even if accurate information has been provided in the counselling office, the family may find
a reference for later perusal helpful.
Treatment Approaches

Hawton et al. ( 1999) and Muehlenkamp (2006) have reviewed the empirical research
relating to adolescent SI treatment approaches. The conclusion emerging from both reviews
is that there is insufficient statistical evidence to state that any one treatment approach is
more effective than is any other. Regardless of the intervention used, effective treatment
requires a strong a strong therapeutic alliance, adequate therapist skill and knowledge
(regarding SI treatment, adolescent treatment, and the approach used), collaboration between
the client and therapist, and a focus on meeting the needs of the client. Despite the lack of
definitive research results, some approaches show promise and their use should be
considered (Muehlenkamp, 2006).
Empirically Supported Therapies
Cognitive Behavioral Therapy. Reviews of the research indicate that cognitive

behavioral therapy (CBT) shows the greatest promise in addressing self-injuring behaviors
and emotional regulation (Fortune & Hawton, 2005 ; Muehlenkamp, 2006; Portzky, & van
Heeringen, 2007; Slee, Arensman, Garnefski, & Spinhoven, 2007; Tillotson, 2008). CBT
approaches are structured, directive, active, and time-limited (Corey, 2005). The focus of
CBT approaches is on faulty thinking and how it impacts emotions (feelings) and behaviors.
Treatment goals include learning new skills (e.g. anger management and distress tolerance),
ways of thinking (with attention to faulty thinking/cognitive distortions), and coping

72

strategies that can replace self-injurious behaviors. At their foundation, CBT treatments
identify and address a client's rigid, faulty and automatic thoughts and beliefs, resulting in
positive emotional and behavioral changes.
CBT techniques are structured. Clients are often asked to journal thoughts, emotions
and behaviors (Appendix D). Along with journaling, homework assignments, developing
alternative ways of thinking, role-playing, and learning new coping skills are other aspects of
CBT.
Included in this manual is a CBT -based counselling strategy that has been used with
self-injuring clients (Appendix H). This resource, based on my clinical experience, was
developed to help adolescents generate insight into the thoughts, emotions, and behaviors
that result in SI. Once the relationship between thoughts, emotions and behaviors and SI is
established, faulty thinking can be addressed. Faulty thoughts, also called cognitive
distortions, are those that the client believes are unconditionally true without evidence to
support the beliefs.
To address faulty thinking, the therapist defines the concept of faulty thinking for the
client. Next, faulty thinking that occurs in the client's world is identified as it arises during
therapy. Because faulty thoughts and beliefs are often deeply ingrained in the client's world,
it takes time and effort to change such thoughts and requires the therapist to challenge false
I

thinking when it arises. For example, a client may state that SI is the only way to deal with
stress. To address this faulty thought, the therapist may ask the client to suggest ways to deal
with stress besides SI. When the client generates alternatives, the client is asked again if SI is
the only way to deal with stress. At this point, the client will often agree that the thought is
faulty and can correct the statement by saying something like, "I choose to self-injure when I

73
am stressed, but I see that there are other ways to cope. " At this point, the client may be
ready to try alternate coping strategies that are more healthful. After some practice at
identifying and labeling faulty thinking, the adolescent client can become adept at identifying
and correcting faulty thinking.
Although Aaron T. Beck was the first to identify cognitive distortions (Corey, 2005),
Burns ( 1980) has expanded on his work. Burns refers to the example of faulty thinking
highlighted in the previous paragraph as "ali-or-nothing thinking". The client is asserting that
SI is the only way to cope with stress. In addition to all or nothing thinking, other examples
of faulty thinking or cognitive distortions presented by Burns are:
• Overgeneralization: One negative situation can be applied to many other situations.
Example: "Because I failed this test, I know I'm going to fail them all."
• Jumping to conclusions: Without evidence to support a negative interpretation, a
conclusion is made. Example: "I failed the test therefore the teacher doesn't
like me."
• Should, must or ought statements: Because people say they should do something,
they feel guilty when it is not accomplished. Example: "I should be a better
friend."
• Extreme labeling: Making an extreme overgeneralization when an error is made.
Example: "I am a failure."
• Catastrophizing (magnifying) or minimizing: The importance of something is
negatively exaggerated when the person is unsuccessful or minimized when
the person is successful. Catastrophizing example: "I failed math and now I
will never amount to anything." Minimizing example: After getting a raise at

74
work, the client says, "It was not no big deal, everybody eventually gets a
raise."
• Personalization: Self-blame for events that the person is not responsible for.
Example: "It is my fault that my parents fight so much."
Dialectical Behavior Therapy (DBT). DBT is a therapeutic approach that has its roots
in CBT. Hollander (2008, p. 72) describes DBT as "the best treatment" for SI and "more
successful than other forms of psychotherapy or medication". This assertion is tempered by
conclusions in literature reviews where it is noted that research focusing on adolescent SI
treatment is limited and includes small samples in unique situations such as hospitalized
female patients (Hawton et al., 1999; Meuhlenkamp, 2006). Based on the empirical research
available, Hawton et al. and Muehlenkamp conclude that DBT is a treatment worthy of
consideration. Comtois (2002) did not limit her literature review to adolescents, but her
conclusions about efficacy are similar. Other practitioners and researchers also support the
use ofDBT (Brown & Bryan, 2007; Chapman, Gratz, & Brown, 2006; Gratz, 2007; Nock,
Teper, & Hollander, 2007). Although definitive conclusions about the efficacy ofDBT for SI
cannot be drawn, DBT is a promising treatment option.
DBT was originally developed by Linehan to treat female suicidal patients with BPD
(Hollander, 2008; Nixon & Heath, 2009). It emerged out of Zen Buddhism, CBT, problem
solving therapy (PST) and skills training (Meuhlenkamp, 2006). Unlike CBT, which focuses
on changing thoughts, emotions, and behaviors, DBT is an attempt to validate the client's
suffering while motivating change (Lynch, Chapman, Rosenthal, Kuo, & Linehan, 2006).
From this tenet emerged the dialectical approach, a core aspect of DBT that addresses not
just the disorder, but also the whole person by accepting the client's painful situation while

75

motivating change (Lynch et al. , 2006). Meuhlenkamp describes simultaneous change and
acceptance as a therapeutic balancing act. With this approach, SI is not considered a
character flaw or a sign of weakness; instead, the problem is emotional dysregulation and
DBT helps the client develop the skills to cope with their emotions (Hollander, 2008). DBT
is used during individual and group sessions. Group counselling focuses on skill
development and individual counselling focuses on the client's unique situation. DBT skills
are also taught to the client's family.
Some DBT strategies include stimulus control, cognitive restructuring, mindfulness,
emotion regulation, distress tolerance, problem solving, validation, modeling, and phone
consultation.
Adolescents often have a strong urge to self-injure when emotional stress is
overwhelming. Stimulus control is often beyond a client' s perceived abilities. To curb the
influence of a stimulus (trigger) leading to SI, clients develop insight during therapy
regarding which stimuli generate self-injurious behavior and then identify healthful coping
methods. These alternative coping methods are practiced in therapy and are applied outside
of the counselling office. Their failure or success is reviewed in future counselling sessions.
Effective strategies are encouraged and ineffective ones are modified or changed,
strengthening stimulus control.
Cognitive restructuring focuses on self-defeating thinking, how that thinking is
impacting emotions and behaviors, and how that thinking can be changed. Faulty thinking or
distorted beliefs are common among adolescent self-injurers. For example, an adolescent
may believe that because of failing grades in school, self-injury is justified. Minimizing this
faulty thought could become a therapeutic goal. The client actively works towards

76
understanding that faulty thoughts are self-defeating and negatively impact feelings and
behaviors. Another example of addressing faulty thinking is to reduce the client's use of
"extreme" words such as "always", "never", or "must". For example, a client could believe
that rejection by peers is always happening. Other examples of faulty thinking are:
• "I am weak and can't resist the urge to cut myself"
• "Nobody cares that I am hurting myself."
• "When I fail, it shows others that I am a failure."
• "When I feel rejected, I have to cut myself."
• "Everybody thinks I am a loser."
Mindfulness is "the quality of awareness that an individual contributes to the present
situation" (Lynch et al., 2006, p. 463). Although mindfulness is found in other therapeutic
approaches, this skill is considered essential in DBT. To be conscious of the present reality
involves an individual "letting go of attachments and becoming one with current experience,
without judgment or any effort to change 'what is"'(Lynch et al., 2006, p. 463). This is
accomplished by teaching the client behavioral skills of "observing, describing, and
participating fully in one's actions and experiences, in a nonjudgmental and one-mindful
manner (i.e., attending to one thing at a time), with a focus on effective behavior" (Lynch et
al., 2006, p. 463).
Mindfulness requires a shift from trying to control such things as thoughts and
emotions to rather controlling the attention given to those thoughts and emotions. Unlike
other behavioral interventions that strive for change in behaviors, mindfulness encourages
acceptance; acceptance of what is being experienced without trying to change or avoid the
experience (Lynch et al., 2006). Nonjudgmental acceptance of emotions teaches the client to

77

see emotions as just "being there", not as being fearful , threatening, or debilitating. The
outlook generated by mindfulness culminates in the client experiencing emotions
nonjudgmentally and enables the client to experience but not act on emotions.
In addition to supporting thought appraisal and emotion regulation, mindfulness also
teaches the client how to reduce literal belief in rules. An example of a "rule" is a belief that
if I am failing in school, I am a hopeless failure. Such beliefs can lead to thoughts that
perpetuate dangerous situations (e.g. suicidal ideation, SI). The client learns that literal
beliefs are not literally true.
Adolescent self-injurers often show deficits in emotional regulation (Gratz &
Chapman, 2007; Heath et al. , 2008). If emotions are not appropriately regulated, they can
become intense and intolerable and adolescents can tum to SI as a way of managing these
feelings. Individuals who regulate their emotions effectively recognize that emotions are
present but they are capable of dealing with them in a healthful way.
Mindfulness is a skill that can address emotional regulation. Developing and using
mindfulness allows the adolescent to accept emotions as natural feelings that "just are" rather
than regarding emotions as good, bad, or incapacitating. The outlook generated by
mindfulness culminates in the client experiencing emotions nonjudgmentally and enables the
client to accept the emotions but not act on them.
All individuals struggle with uncomfortable events or thoughts while dealing with
distressful life experiences. However, when adolescent self-injurers have such experiences,
they often become overwhelmed and incapable of dealing with the stress, culminating in selfinjury to cope (Nock & Mendes, 2008). Furthermore, self-injurers often perceive events that
other people would consider minor to be intense and debilitating. Developing distress

78
tolerance skills enables the adolescent to accept stress as part of life's experiences. Distress
tolerance allows the client to recognize emotional stress, but also enables the client to view
the stress as tolerable and manageable.
Developing distress tolerance entails putting distress into manageable perspective.
This begins with the therapist teaching a client that distress is a "normal" aspect of life
experience-something that all individuals need to manage. Managing life's inevitable
stressors becomes a therapeutic goal. For example, when an adolescent has a verbal "fight"
with a parent, this distressful incident can trigger SI. Through therapy, a client can learn that
uncomfortable and stressful situations are sometimes inevitable but can be managed using
coping skills that do not involve SI. An adolescent in the situation described may decide to
call a trusted aunt to talk through the stressful situation. Feeling empowered to deal with
inevitable distress without resorting to SI becomes the new perspective.
Adolescent self-injurers who learn problem-solving skills are empowered to cope
with challenging situations. The steps involved in problem solving are taught and then
applied to the client's life experiences. Later in this chapter, detailed problem-solving
information is provided when PST is addressed.
Another cornerstone ofDBT is validation, a skill that focuses on therapist acceptance
of client behaviors, thoughts, or feelings (Lynch et al., 2006). Skills related to validation are
active listening and empathy (Brown, 1998). The therapist can provide further validation by
nurturing an appropriate therapeutic alliance that includes genuineness. The appropriate
client/therapist relationship is identified as essential of DBT (Muehlenkamp, 2006).
DBT recognizes the value of therapist modeling of skills with which clients are
deficient. The client can see and learn various ways to react appropriately to intense emotions

79
when the therapist models the skills required: acceptance of intense emotions, talking
through a difficult situation, and identifying and altering irrational or faulty thoughts are a
few skills a therapist can model in the counselling office.
Phone consultation is an essential aspect of DBT and is particularly valuable for crisis
management. Further, the client is also encouraged to seek coaching from the therapist or
another team member outside of treatment sessions, an approach that reinforces the client
accessing useful resources when needed (Nock et al., 2007).
The difficulty a therapist faces in learning the intricacies of DBT must be considered.
DBT includes many treatment strategies, requires an understanding of the philosophy
supporting the approach, and requires long-term commitment to the therapy (typically one
year). Learning all the skills required to use DBT effectively requires a great deal of time,
commitment, and financial expense (Walsh, 2006)-requirements that not all therapists can
access.
DBT is a treatment approach that relies on dialectical philosophy, emotional
awareness and acceptance, mindfulness, emotional regulation, distress tolerance, validation,
problem-solving skills culminating in client change. The bulk of these goals are
accomplished by encouraging mindfulness skills. The resource section of this manual
includes annotated DBT resources (Appendix E).
Problem Solving Therapy. PST is another treatment approach based of CBT used in

the treatment of adolescent SI (Hawton et al., 1999; Muehlenkamp, 2006; Raj, Kumaraiah, &
Bhide, 2001 ). Based on a review of six studies using PST, Hatcher (2002) reports that PST
improves depression, hopelessness and personal problems for self-injurers. Other authors

80
report some optimism for this approach; however, there is insufficient research available to
support its use (Hawton et al., 1999; Muehlenkamp, 2006).
Problem-solving deficits and SI go hand in hand (Haines &Williams, 2003;
McAuliffe et al., 2006; Nock & Mendes, 2007). PST can address this deficit as it identifies
and resolves problems using the problem-solving process. The problem solving process
involves the following steps (McNamara, 2004):
1. Define the problem,
2. Review potential causes of the problem,
3. Identify alternatives to resolve the problem,
4. Select an alternative to resolve the problem,
5. Plan the implementation of the alternative (action plan),
6. Implement the plan, and
7. Evaluate the solution to determine if it has resolved the problem.
Like DBT, PST is time-limited, structured, and skills oriented. PST concentrates on
remedying cognitive and behavioral functioning. This approach regards the client as having
poor problem-solving skills and thus the goal of PST is to resolve the client's problem(s) by
teaching coping skills and problem-solving skills (Muehlenkamp, 2006).
For PST to be used effectively, Muehlenkamp (2006) recommends a multifaceted
approach that includes cognitive, interpersonal and behavioral aspects. Similar to DBT, this
approach also requires a strong therapeutic alliance and collaboration.
Manual-Assisted Cognitive-Behavioral Therapy (MACT). MACT is a cognitive-

behavioral therapy that combines PST, DBT and CBT. The skills taught focus on managing
emotions and negative thinking. Lukomski and Folmer (n.d.) identify MACT as an effective

81
approach while Muehlenkamp (2006) reports that it has potential as a treatment approach.
Klonsky and Muehlenkamp (2007) conclude that MACT can significantly reduce SI and
delay SI acts over a 12-month post-treatment period. Leyshon (2005) reports that MACT has
the same efficacy as "treatment as usual" (medical care and long term counselling) over 12
months.
The difference between MACT and other CBT treatments is that the former includes
a manual based on the principles of CBT for clients to use at home. An advantage of this
approach is cost effectiveness (Leyshon, 2005). A client working at home with a manual and
attending a few therapy sessions is inexpensive when compared to usual treatment
approaches which often require a great deal of one-on-one contact with counselling and
health care professionals. Treatment manuals that adhere to the MACT approach are
referenced in Appendix E.
Pharmacological Treatments. Using medications to treat SI is controversial. Because

other mental health conditions (e.g. depression, anxiety, obsessive compulsive disorder,
bipolar disorder, BPD) can be comorbid, SI clients are sometimes treated with medication.
Medications include selective serotonin and serotonin-norepinephrine reuptake inhibitors
(SSRis). Some SSRis are fluoxetine (e.g. Prozac), sertraline (e.g. Zoloft), paroxetine (e.g.
Paxil), fluvoxamine (e.g. Luvox), citalpram (e.g. Celexa), and descitalopram (Lexparo)
(Walsh, 2006). Prescribing medications for youth is controversial because there is evidence
that SSRis can increase problem behaviors such as suicidal ideation (Walsh, 2006).
Depending on the comorbid disorder, other medications that are considered are
antipsychotics, anticonvulsants, alpha2-adrenergic drugs, and opiod antagonists (Nixon &
Heath, 2009). Reviews of pharmacological treatments have lead authors to conclude that

82
there is no empirical evidence to support their use specifically for SI (Hawton et al., 1999;
Klonsky & Muehlenkamp, 2007) but evidence does support their use for comorbid mental
disorders.

Psychodynamic Therapy. Psychodynamic approaches are based on psychoanalytic
psychotherapy. Empirical evidence supporting the use of psychodynamic therapy is limited
and the evidence that exists identifies only modest support for the approach (Klonsky &
Muehlenkamp, 2007; Skegg, 2005). Rather than treating SI specifically, the psychodynamic
approach has been used to treat comorbid conditions or symptoms such as BPD, poor selfimage, and relationship difficulties (Klonsky & Muehlenkamp, 2007). Applying
psychodynamic/psychoanalytical approaches to the treatment of adolescent SI requires a high
degree of psychoanalytic knowledge and skill. In addition, this approach requires a great deal
of time. Adolescents often do not want to commit to such a time-demanding treatment.
Further attention must also be given to the commitment of the therapist; the therapist must be
able to commit to the self-injuring client for the duration of therapy (usually one to two
years). Information regarding psychodynamic treatment of SI is difficult to access. For
information on the psychodynamic approach for SI, the reader can refer to Gardner (200 1)
and Levy et al. (2007).

Promising Treatments without Empirical Support
Group Therapy. Group therapy can be used with many theoretical approaches (e.g.,
DBT). No matter which treatment perspective is utilized in group therapy, caution is
encouraged. This caution relates to the contagion factor that is well documented in SI
literature (Carlson et al., 2005; Conterio & Lader, 1998; McDonald, 2006). Placing
adolescent self-injurers together for group psychotherapy is risky because any discussion

83
surrounding SI behaviors could stimulate further SI. Group participants could also learn
about forms of SI that they are unfamiliar with and open the door to more self-injurious
behaviors. It is possible for participants to progress from moderate to major SI when exposed
to the practices of other self-injurers. Allowing the contagion effect to occur in group therapy
would be dangerous, unethical, and counterproductive.
Some authors state that group therapy is not successful with adolescent self-injurers
(Lukomski & Folmer, n.d.; Zila & Kiselica, 2001); however, the authors do not provide a
rationale for their claims. Perhaps the contagion effect contributes to the reticence about
group therapy. From his experiences treating self-injuring clients, Walsh (2006) concludes
that group discussions around SI antecedents and behaviors can have a triggering effect on
participants.
If group therapy is used with self-injuring adolescents, it is suggested that the focus of
the group be on skill development (e.g. distress tolerance, coping skills, communication, and
emotional regulation) rather than on group processing (Favazza, 1996; Walsh, 2006). This is
precisely what DBT does and may be one of the reasons to explain why DBT is identified as
a promising treatment approach. Structure, skill building, and avoiding emotionally stressful
situations are suggested elements of adolescent group work (Hollander, 2008).
When group therapy is an aspect of treatment, the sessions must begin with clear
rules about the discussion of self-injurious behaviors; any talk of SI should be prohibited
(Conterio & Lader, 1998; Walsh, 2006) no matter what treatment approach is used. This rule
keeps group work focused on skill development, not SI behaviors. SI needs to be discussed
with clients, but to avoid the contagion effect and triggering conversation, this should be
conducted during individual therapy.

84
Family Therapy . There is no empirical evidence assessing the effectiveness of family
therapy for SI (Nixon & Heath, 2009). Family dysfunction is often one of the factors
contributing to adolescent SI and the family situation may actually reinforce and maintain
adolescent SI (Conterio & Lader, 1998). In a case of family dysfunction, family therapy
throws an adolescent into a situation that is stressful and emotion laden. It is widely accepted
that emotional dysregulation is a significant issue for self-injurers (Gratz & Chapman, 2007;
Heath et al., 2008; Klonsky, 2007; Laye-Gindhu & Schonert-Reichl, 2005) and family
therapy requires adolescents to utilize skills they often do not have (Hollander, 2008). It is
suggested that family therapy may be most effectively used after individual therapy has
improved emotional regulation skills (Crowe & Bunclark, 2000; Hollander, 2008).
Instead of family therapy, an alternative way of including family members in the
therapeutic process can be considered. One possible alternative is to facilitate parental/family
guidance sessions that provide information, teach family members needed skills, and
encourage the development of characteristics such as emotional management, flexibility and
caring, and communications strategies that improve family dynamics. A second alternative is
to establish a group for parents of self-injurers in which SI information and communication
skills training is facilitated.
Working with adolescents usually means working with families. Meeting the needs of
a client and family members requires careful consideration of what is in the best interests of
the client. This is best done collaboratively with the client. Family therapy may be delayed
until the client has first had an opportunity to participate in individual therapy.
Bibliotherapy. Providing reading materials for self-injuring adolescents and their
families can be an aspect of treatment. Non-fiction books, self-help books, and even videos

85
can be used. Suggesting a video for the client, the client's family, or both to watch is a
strategy that can be effective in encouraging communication, either in a session or between
family members. An example of a video that has been used during SI treatment is Pay It

Forward (2000). This video highlights the power one child has when he makes a difference
in the lives of other people. This video is suggested for viewing to illustrate the concepts of
empowerment, determination, and self-motivation and can be suggested for family viewing.
Appendix E includes a list of printed and electronic resources appropriate for adolescents and
parents.

Additional Perspectives
Although they are not psychotherapies, two perspectives that can help when working
with adolescent self-injurers are the feminist approach and narrative restructuring. Based on
anecdotal evidence, I believe these strategies warrant consideration.

Feminist Approach. Feminist therapy is a treatment approach that focuses on the
impact of oppression, politics, multicultural issues, and socialization on women (Corey,
2005). Within a feminist framework, SI is seen as a way to break women's silence in an
oppressive society. SI and cultural standards of "feminine beauty" are linked in feminist
therapy. Cultural expectations of what a woman "is" can lead to SI as a source of
empowerment and a way to regain bodily control (Walsh, 2006). To treat SI from a feminist
perspective requires the analysis of gender, power and social influences to understand the
emotional distress and behavioral dysfunction of clients (Brown & Bryan, 2007). Personal
distress, not psychopathology, is at the heart of treatment. SI is viewed as a way to repel the
oppression the client faces and a way to address powerlessness. Two references that highlight
feminist therapy and SI are Brown and Bryan (2007) and Shaw (2002).

86
In counselling practice with adolescents, feminist issues often arise. For example, a
female adolescent will state that weight loss is imperative to achieve a desirable body image.
This distress related to body image can be one of the contributors to the client's self-injurious
behaviors. A discussion regarding the factors that motivate a woman to pursue a body image
that is culturally defined can give the client new perspective, possibly generating insight into
how distorted the objective of weight loss can be.
Another example relates to sexuality. Some female adolescent clients have been hurt
in relationships. They report that they feel pressured into sexual involvement to maintain
their relationships with their partners. Because female adolescents sometimes think that they
"need" a partner to fit into their adolescent social network, they become involved in
undesired sexual contact in order to keep their partners. The confusion and possible partner
rejection surrounding this dilemma can contribute to distress and SI. In counselling, talking
about social pressures, healthful relationships, autonomy, and empowerment can provide
insight that results in the adolescent feeling capable of making decisions based on personal
values and beliefs instead of cultural and social pressures.

Narrative restructuring. Information or research regarding narrative therapy and SI is
absent. A search of books, journal articles, and computer web sites did not locate any
information. This dearth of literature could be due to how recently the narrative
postmodernist approach was developed. Despite the absence of empirical evidence, I have
found narrative restructuring to be helpful in the treatment of adolescent SI.
Once a therapeutic alliance has been established, adolescents like to tell their stories.
Storytelling and the construction of healthful alternative stories is a narrative approach to
which adolescents may respond well. A major technique in the use of narrative restructuring

87
is questioning to gain an understanding of the client's experiences; however, it has been
observed that adolescents do not like to be bombarded with questions. The skill of the
therapist in asking questions is therefore likely to be a pivotal aspect in the delivery of
narrative treatment strategies.
Asking questions is not enough. The therapist must also listen nonjudgmentally and
with an open mind. While listening to a story, the therapist is searching for evidence of
success or competence. When successful glimmers are shared by the adolescent, the therapist
presents them as evidence of the client's capability. Client empowerment results when the
new perspective is presented.
SI can be viewed as an external coping mechanism used to deal with internalized
problems. The narrative approach externalizes the problem by labeling the problem so that
the problem is the problem, rather than the client. To facilitate the externalization of the
problem, the problem is labeled using a word(s), often a noun. A student may identify the
problem as "depression" and therapy can then focus on the depression, not the client. The
therapist may ask a question such as "When depression takes over, what does it look like?"
The important aspect of externalizing the behavior is to allow the adolescent client to choose
the word(s) that accurately label the problem. Self-injuring behavior can be a symptom of
another problem and the client may focus on a problem other than SI and choose to label it
accordingly. For example, an adolescent may view body image as an issue and choose to
label the problem "the skinny model". In therapy, the skinny model can then be investigated
through narrative questioning.
I have found narrative strategies are helpful because:
• There is no blame placed on the client,

88
• The approach nurtures self-esteem and client empowerment when the problem is
the problem, rather than the client,
• A goal is to discover exceptions that highlight success and contradict the
problematic story, and
• Negative and problem focused stories can be reconstructed into alternative stories
of competence when exceptions are identified and presented.

Interventions Not Recommended
In addition to the cautions expressed earlier in this chapter around group therapy,
family therapy, and the risk involved in the use of no-harm contracts, other treatments have
been identified as unsuccessful (Lukomski & Folmer, n.d.: Whitmarsh et al., 2006; Zila &
Kiselica, 2001 ). These include physical restraint, hypnosis, faith healing, relaxation therapy,
and electroconvulsive therapy.
Huband and Tantum (2004) conducted a grounded theory study that examined
women' s perceptions of which treatment interventions were of value. Women reported that
relaxation techniques worsened SI because relaxation reduced self-control and diminished
personal fortitude to fend off SI urges. Based on the research, the authors state that
supporting this technique would be considered unethical.

Termination Issues
Deciding when to terminate treatment is difficult. The absence of self-injurious
behavior should not be considered the only benchmark to indicate that treatment should end;
when an adolescent surrenders self-injuring behaviors, other problems are likely to remain
because SI is usually a symptom of other difficulties in the adolescent client's life. For
example, child abuse, substance misuse, eating disorders, self-esteem issues, inadequate

89
communication skills, peer pressure, or family dysfunction could be difficulties identified
during treatment. Therefore, therapy is likely required to continue even when the client's
self-injurious behaviors have ceased.
It is recommended that the decision to terminate treatment is a collaborative decision

between the client and counsellor. Termination should occur in such a manner that the client
does not feel abandoned. Long before termination occurs, the client should be aware of the
coming event. Adolescents do not like surprises; termination should be planned. In addition
to removing the element of surprise, planned termination helps the client feel supported.
Prior to termination, continued wellness must be considered. It is possible that the
client could relapse into a cycle of SI when experiencing overwhelming distress. A plan
should be developed in the event that self-injurious behaviors return. The client requires
access to resources that provide support and help to maintain the client' s safety. This can
include how to access medical care (physician or hospital), how to initiate further
counselling, encouraging the client to communicate with family members when the need to
self-injure surfaces, and how to access printed resources (Appendix E).
Terminating treatment should also involve family members if the client accepts this
strategy. Including the family in the termination plan is recommended if there is family
involvement. Inviting the family to a termination session can open the door to ways the
family can continue to support the adolescent once treatment ceases.
It is helpful to formalize the termination plan in writing so that the client has a "take

away" document to review. Such a plan should highlight healthful coping strategies the client
has identified throughout therapy, resources to access, and what do if the urge to self-injure
returns.

90
Borrowed from narrative therapy, an effective way of supporting the client beyond
the termination of therapy is by sending the client a letter several weeks after the last session.
The letter can again summarize the treatment process experienced by the adolescent. Such a
letter shows continued support, reminds the client about what was accomplished, and
generates self-reflection so that the client can monitor progress beyond treatment.
Conclusion

In synthesizing information regarding adolescent SI treatment, one predominant
theme is at the forefront, that of a multifaceted approach that includes several treatment
approaches and skills training (e.g. anger management, emotional regulation, problemsolving, coping techniques, and modeling) (Zila & Kiselica, 2001). Zila and Kiselica assert
that no one approach can serve the client's treatment needs.
Several other themes also emerge when therapeutic treatments are reviewed:
1. A strong therapeutic alliance is essential and is considered a significant
treatment strategy on its own.
2. Therapist/client collaboration is important.
3. SI is a multi-dimensional behavior and therefore treatment should address the
family system, peer influences, societal issues, and the cultural context.
4. Treatment is usually long-term.
5. No one treatment is most effacious in the treatment of SI, although several
show promise.
6. Clients are heterogeneous and each self-injuring client has unique treatment
needs.
7. Assessment should inform treatment.

91

8. To be effective, the therapist must have competence working with SI,
adolescents, and the treatment approaches used.

92
References
Alderman, T. ( 1997). The scarred soul: Understanding and ending self-inflicted violence.
Oakland, CA: New Harbinger.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental

disorders-IV-TR (4th ed., Text Revision). Washington, DC: Author.
American Psychiatric Association. (2003). Practical guideline for the assessment and

treatment ofpatients with suicidal behaviors. Washington, DC: Author.
Andover, M., Pepper, C., Ryabchenko, K., Orrico, E. , & Gibb, B. (2005). Self-mutilation and
symptoms of depression, anxiety, and borderline personality disorder [Electronic
Version]. Suicide and Threatening Behavior, 35, 581-591.
Applewhite, L. , & Joseph, M. (1994). Confidentiality: Issues in working with self-harming
adolescents [Electronic Version]. Child and Adolescent Social Work Journal, 11,
279-294.
Beck, A., & Weishaar, M. (1990). Suicide risk assessment and prediction. Crisis: The

Journal of Crisis Intervention and Suicide Prevention, 11(2), 22-30.
Berman, A., Jobes, D., & Silverman, M. (2006). Adolescent suicide: Assessment and

intervention (2nd ed.). Washington, DC: American Psychological Association.
Best, R. (2005). An educational response to deliberate self-harm: Training, support, and
school-agency links [Electronic Version]. Journal of Social Work Practice, 19, 275287.
Best, R. (2006a). Deliberate self-harm in adolescence: A challenge for schools [Electronic
Version]. British Journal of Guidance and Counselling, 34, 161-175.

93

Best, R. (2006b, September). Educational response to deliberate self-harm in adolescence.
Paper presented at the conference of the British Educational Research Association,
London, England.
Booth, S. (2004). Cutting clubs: What's the latest and most shocking "friendship" ritual?
Teen People looks at how a growing number of kids are bonding with their peers by
slicing themselves with razor blades. Teen People, 7 (1), 98. Retrieved December 27,
2005, from Infotrac database.
Bowman, S., & Randall, K. (2006). See my pain!: Creative strategies and activities for

helping young people who self-injure (2"d ed.). Chapin, SC: YouthLight.
Brown, L., & Bryan, T. (2007). Feminist therapy with people who self-inflict violence
[Electronic Version]. Journal of Clinical Psychology: In Session. 63, 1121-1133.
Brown, M. (1998, August). The behavioral treatment of self-mutilation. Paper presented at
the Self-mutilation, Treatment, and Research Symposium, Congress of the World
Association of Social Psychiatry, Vancouver BC, Canada.
Burns, D. (1980). Feeling good: The new mood therapy. New York: Avon.
Canadian Counselling Association. (2007, January). Code of Ethics. Ottawa, Ontario,
Canada: Author.
Carlson, L., DeGeer, S., Deur, C., & Fenton, K. (2005). Teachers ' awareness of self-cutting
behavior among the adolescent population [Electronic Version]. Praxix, 5, 22-29.
Castille, K., Prout, M., Marczyk, G., Shmidheiser, M., Yoder, S., & Howlett, B. (2007). The
early maladaptive schemas of self-mutilators: Implications for therapy [Electronic
Version]. Journal of Cognitive Psychotherapy: An International Quarterly, 21, 58-71.

94
Cavanaugh, R. (2002). Self-mutilation as a manifestation of sexual abuse in adolescent girls
[Electronic Version]. Journal of Pediatric Gynecology, 15, 97-1 00.
Chapman, A., Gratz, K., Brown, M. (2006). Solving the puzzle of deliberate self-harm: The
experimental avoidance model. Behavior Research and therapy, 44, 371-394.
Retrieved June 20, 2007, from ScienceDirect database.
Cochrane-Brink, K., Phil, D., Lofchy, J., & Sakinofsky, I. (2000). Clinical rating scales in
suicide risk assessment [Electronic Version]. General Hospital Psychiatry, (22), 445451.
Comtois, K. (2002). A review of interventions to reduce the prevalence of parasuicide.

Psychiatric Services, 53, 1138-1144. Retrieved October 22, 2006, from Psyclnfo
database.
Connors, R. E. (2000). Self-injury: Psychotherapy with people who engage in self-inflicted

violence. Northvale, NJ: Jason Aronson.
Conterio, K., & Lader, W. ( 1998). Bodily Harm: The breakthrough healing program for self

injurers. New York: Hyperion.
Cooper, J., Kapur, N., Webb, R., Lawlor, M., Guthrie, E., Mackway-Jones, K., et al. (2005).
Suicide after deliberate self-harm: A 4-year cohort study [Electronic Version].

American Journal of Psychiatry, 162, 297-303.
Corey, G. (2005). Theory and practice of counseling and psychotherapy (8 1h ed.).
Brooks/Cole-Thompson Learning: Belmont, CA.
Crowe, M., & Bunclark, J. (2000). Repeated self-injury and its management [Electronic
Version]. International Review ofPsychiatry, 12, 48-53.

95
Crowell, S., Beauchaine, T., McCauley, E., Smith, C., Vasilev, C., & Stevens, A. (2008).
Parent-child interactions, peripheral serotonin, and self-inflicted injury in adolescents
[Electronic Version]. Journal of Consulting and Clinical Psychology, 76, 15-21.
Croyle, K., & Waltz, 1. (2007). Subclinical self-harm: Range of behaviors, extent, and
associated characteristics. American Journal of Orthopsychiatry, 77, 332-342.
Daley, D., & Moss, H. (2002). Dual disorders: Counseling clients with chemical

dependency and mental health illness (3rd ed.). Centre City, MN: Hazelden.
Deiter, P., Nicholls, S., & Pearlman, L. (2000). Self-injury and self- capacities: Assisting an
individual in crisis [Electronic Version]. Journal of Clinical Psychology, 56, 11731191.
Derouin, A., & Bravender, T. (2004). Living on the edge: The current phenomenon of selfmutilation in adolescents. The American Journal of Maternal/Child Nursing, 29(1),
12-18. Retrieved October 14, 2006, from Ovid database.
Favazza, A. R. (1996). Bodies under siege: Self-mutilation and body modification in culture

and psychiatry. Baltimore: Johns Hopkins University Press.
Favazza, A., & Conterio, K. (1988). The plight of chronic self-mutilators [Electronic
Version]. Community Mental Health Journal, 24(1). 22-30.

Focus Adolescent Services: What is self-injury? (n.d.). Retrieved February 13, 2009, from
www.focusas.com
Fortune, S., & Hawton, K. (2005). Deliberate self-harm in children and adolescents: A
research review. Current Opinion in Psychiatry, 18, 401-406. Retrieved January 3,
2009, from Ovid database.

96
Frankel, J. (200 1). A witness breaks his silence: The meaning of a therapist's response to an
adolescent's self-destruction [Electronic Version]. American Journal of

Psychoanalysis, 61(1), 85-99.
Froeschle, J., & Moyer, M. (2004). Just cut it out: Legal and ethical challenges in counseling
students who self-mutilate. Professional School Counselling, 7, 231-235. Retrieved
October 16, 2006, from Psyclnfo database.
Galley, M. (2003). Student self-harm: Silent school crisis. Education Week, 23(14), 1-15.
Retrieved June 10, 2007, from Academic Search Premier database.
Gardner, F. (200 1). Self-harm : A psychotherapeutic approach. New York: Taylor and
Francis.
Gratz, K. (2007). Targeting emotional dysregulation in the treatment of self-injury
[Electronic Version]. Journal of Clinical Psychology: In Session, 63, 1091-1103.
Gratz, K., & Chapman, A. (2007). The role of emotional responding and childhood
maltreatment in the development and maintenance of deliberate self-harm among
male undergraduates [Electronic Version]. Psychology of Men and Masculinity, 8(1),
1-14.
Gratz, K., Conrad, S., & Roemer, L. (2002). Risk factors of deliberate self-harm among
college students [Electronic Version]. American Journal of Orthopsychiatry, 72,
128-140.
Haines, J., & Williams, C. (2003). Coping and problem solving of self-mutilators [Electronic
Version]. Journal ofClinical Psychology, 59, 1097-1106.

97
Harriss, L., & Hawton, K. (2005). Suicidal intent in deliberate self-harm and the risk of
suicide: The predictive power of the Suicide Intent Scale [Electronic Version].

Journal ofAffective Disorders, 65, 225-233.
Harriss, L., Hawton, K., Zahl, D. (2005). Value of measuring suicidal intent in the
assessment of people attending hospital following self-poisoning or self-injury.

British Journal of Psychiatry, 186, 60-66. Retrieved November 15, 2008, from
http/ /bjp.rcpsych.org/cgi/content/full/ 186/ 1/60
Haswell, D., & Graham, M. (2008). Overcoming self-abuse: Step by step to success (5th ed.).
Hamilton, Ontario, Canada: S.A.F.E. BC.
Hatcher, S. (2002). Review: Problem-solving treatment after deliberate self-harm improves
depression, hopelessness, and personal problems. APC Journal Club, 136, 64.
Retrieved February 21, 2009, from Academic Search Premier database.
Hawton, K., Townsend, E., Arensman, E., Gunnell, D., Hazell, P., House, A., et al. (1999).
Psychosocial and pharmacological treatments for deliberate self harm. Cochrane

Database of Systematic Reviews, Issue 4. Art. No.: CD001764.DOI:10.1002/
14651858.CD111764.
Heath, N., Toste, J., Nedecheva, T., & Charlebois, A. (2008). An examination of nonsuicida1
self-injury among college students [Electronic Version]. Journal of Mental Health

Counselling, 30, 137-156.
Hjelmeland, H., & Groholt, B. (2005). A comparative study of young and adult deliberate
self-harm patients. Crisis: The Journal of crisis intervention and suicide prevention,

26, 64-72. Retrieved June 15, 2007, from EBSCOhost database.

98
Hollander, M. (2008). Helping teens who cut: Understanding and ending self-injury. New
York: Guilford Press.
Huband, N., & Tantam, D. (2004). Repeated self-wounding: Women's recollection of
pathways to cutting and of the value of different interventions [Electronic Version].

Psychology and Psychotherapy: Theory, Research and Practice, 77, 413-428.
Kenrick, J. (2007, February 16). 'Ifl didn't self-harm, I'd probably kill myself. Times, 4724
(Educational Supplement), 20-23. Retrieved October 19, 2007, from LexisNexis
database.
Klonsky, E. (2007). The functions of deliberate self-injury: A review of the evidence
[Electronic Version]. Clinical Psychology Review, 27, 226-239.
Klonsky, E., & Muehlenkamp, J. (2007). Self-Injury: A research review for the practitioner
[Electronic Version]. Journal of Clinical Psychology: In Session, 63, 1045-1056.
Klonsky, E., Oltmanns, T., & Turkheimer, E. (2003). Deliberate self-harm in a nonclinical
population: Prevalence and psychological correlates [Electronic Version]. American

Journal of Psychiatry, 160, 1501-1508.
Laye-Gindhu, A., & Schonert-Reichl, K. (2005). Nonsuicidal self-harm among community
adolescents: Understanding the "whats" and "whys" of self-harm [Electronic
Version]. Journal of Youth and Adolescence (34), 447-457.
Levenkron, S. (1998). Cutting: Understanding and overcoming self-mutilation. New York:
W. W. Norton.
Levy, K., Yeomans, F., & Diamond, D. (2007). Psychodynamic treatments of self-injury
[Electronic Version]. Journal of Clinical Psychology: In Session, 63, 1105-1120.
Leyshon, S. (2005). Deliberate self-harm [Electronic Version]. Primary Health Care, 15, 8.

99
Lloyd-Richardson, E. , Perrine, N ., Dierker, L. , & Kelley, M. (2007). Characteristics and
functions of non-suicidal self-injury in a community sample of adolescents
[Electronic Version]. Psychological Medicine, 37, 1183-1192.
Lukomski, J., & Folmer, T. (n.d.). Self-mutilation: Information and guidance for school
personnel. Guidance Channel Online. Retrieved April 16, 2006, from
http://www. guidancechannel. com/defaul t.aspx ?index= 13 28&cat213
Lynch, T., Chapman, A., Rosenthal, M ., Kuo, J., & Linehan, M. (2006). Mechanisms of
change in dialectic behavior therapy: Theoretical and empirical observations
[Electronic Version]. Journal of Clinical Psychology, 62, 159-480.
Malikow, M. (2006). When students cut themselves [Electronic Version]. Condensed from

Tennessee Education 34, 31-34. The Education Digest, 1 7(8). 45-50.
Mangnall, J. , & Yurkovich, E. (2008). A literature review of deliberate self-harm [Electronic
Version]. Persp ectives in Psychiatric Care, 44(3), 175-184.
Marchetta, M . (2006). Repetitive skin-cutting: Parental bonding, personality and gender
[Electronic Version]. Psychology and Psychotherapy : Theory, Research and

Practice, 79, 445-459.
McAuliffe, C., Corcoran, P. , Keeley, H., Arensman, E., Bille-Brahe, U., DeLeo, D., et al.
(2006). Problem-solving ability and repetition of deliberate self-harm: A multicentre
study [Electronic Version]. Psychological Medicine, 36, 45-55.
McDonald, C. (2006) . Self-mutilation in adolescents [Electronic Version]. Journal of School

Nursing, 22, 193-200.

100
McKay, D., Gavigan, C., & Kulchycky, S. (2004). Social skills and sex-role functioning in
borderline personality disorder: Relationship to self-mutilating behavior [Electronic
Version]. Cognitive Behavior Therapy, 33(1), 27-35.
McNamara, C. (2004). The seven steps of problem-solving [Electronic Version].

Administrator. 23(5), 3.
McVey-Noble, M., Khemlani-Patel, S., & Neziroglu, F. (2006). When your child is cutting: A

parent 's guide to helping children overcome self-injury. Oakland, CA: New
Harbinger Publications.
Morrissette, P. (2000). The experiences of the rural school counsellor. Professional School

Counselling, 3, 197-208. Retrieved March 4, 2009, from Academic Search Premier
database.
Muehlenkamp, J. (2005). Self-injurious behavior as a separate clinical syndrome [Electronic
Version]. American Journal of Orthopsychiatry, 75, 324-333.
Muehlenkamp, J. (2006). Empirically supported treatments and general therapy guidelines
for non-suicidal self-injury [Electronic Version]. Journal of Mental Health

Counseling, 28, 166-185.
Muehlenkamp, J. (2007). Body regard and risk for self-injurious behavior in a sample of
clinical and non-clinical adolescents (Doctoral dissertation, Illinois University, 2005).
UMI Dissertation Services.
Murray, C., & Fox, J. (2006). Do Internet self-harm discussion groups alleviate or exacerbate
self-harming behavior? Australian e-Journalfor the Advancement of Mental Health,
5(3), 1-9. Retrieved March 17, 2007, from www.auseinet.com/journal/vol5 iss3/
murray.pdf

101
Nafisi, N., & Stanley, B. (2007). Developing and maintaining the therapeutic alliance with
self-injuring patients [Electronic Version]. Journal of Clinical Psychology: In

Session, 63, 1069-1079.
Nixon, M., Cloutier, P., & Aggarwal, S. (2002). Affect regulation and addictive aspects of
repetitive self-injury in hospitalized adolescents [Electronic Version]. Journal of

American Academy of Child and Adolescent Psychiatry, 41, 1333-1341.
Nixon, M., Cloutier, P., & Jansson, M. (2008). Nonsuicidal self-harm in youth: A populationbased survey [Electronic Version]. Canadian Medical Association Journal. 178, 30612.
Nixon, M., & Heath, N. (Eds.). (2009). Self-injury in youth: The essential guide to

assessment and intervention. New York: Routledge.
Nock, M., Joiner, T., Gordon, K., Lloyd-Richardson, E., & Prinstein, M. (2006). Nonsuicidal self-injury among adolescents: Diagnostic correlates and relation to suicide
attempts. Psychiatry Research, 144, 65-72. Retrieved October 14, 2006, from
ScienceDirect database.
Nock, M., & Mendes, W. (2008). Physiological arousal, distress tolerance, and social
problem-solving deficits among adolescent self-injurers [Electronic Version]. Journal

of Consulting and Clinical Psychology, 76, 28-38.
Nock, M., & Prinstein, M. (2005). Contextual features and behavioral functions of selfmutilation among adolescents [Electronic Version]. Journal ofAbnormal Psychology,

114, 140-146.

102
Nock, M., Teper, R., & Hollander, M. (2007). Psychological treatment of self-injury among
adolescents [Electronic Version]. Journal of Clinical Psychology: In Session, 63,
1081-1089.
Onacki, M. (2005). Kids who cut: A protocol for public schools [Electronic Version].

Journal of School Health, 75, 400-401.
Paris, J. (2005). Understanding self-mutilation in borderline personality disorder [Electronic
Version]. Harvard Review of Psychiatry, 13, 179-185.
Penner, M. (2008). Hope and healing for kids who cut. Grand Rapids, MI: Zondervan.
Polk, E., & Liss, M. (2007). Psychological characteristics of self-injurious behavior
[Electronic Version]. Personality and individual differences, 43, 567-577.
Portzky, G., & van Heeringen, K. (2007). Deliberate self-harm in adolescents. Current

Opinion in Psychiatry, 20, 337-342. Retrieved January 3, 2009, from Ovid database.
Province of British Columbia ( 1996). British Columbia School Act; Revised Statutes of

British Columbia, Chapter 412. Victoria, British Columbia, Canada: Queen's Printer.
Retrieved March 15, 2009, from www.bced.gov.bc.ca/legislation/schoollaw/revised
statutescontents. pdf
Raj, A., Kumaraiah, V., & Bhide, A. (200 1). Cognitive-behavioral intervention in deliberate
self-harm [Electronic Version]. Acta Psychiatrica Scandinavica, 104, 304-345.
Roberts-Dobie, S., & Donatelle, R. (2007). School counsellors and student self-injury
[Electronic Version]. Journal of School Health, 77, 257-264.
Ross, S., & Heath, N. (2002). A study of the frequency of self-mutilation in a community
sample of adolescents [Electronic Version]. Journal of Youth and Adolescence, 31,
67-77.

103
Rutter, M. (2007). Group supervision with practicing school counsellors [Electronic
Version]. Guidance and Counselling, 21, 106-167.
Ryan, S. (2005). The silent scream: Sari Grossman, now 16, is creative, funny and very
smart. So smart, in fact, that it's hard to understand why she decided to cut her arms
and legs on a daily basis. An inside look at the heartbreaking world of girls whose
emotional pain has lead to torture themselves. Girl's Life, 12( I), 68-73. Retrieved
December 27, 2005, from Infotrac database.

S.A.F.E. in Canada: Your resource for self-abuse prevention, support, education, and
resources. (n.d.). Retrieved February 13, 2009, from www. safeincanada.org
Schulz, W., Sheppard, G., Lehr, R., & Shepard, B. (2006). Counselling ethics: Issues and

cases. Ottawa, Ontario, Canada: Canadian Counselling Association.
Selekman, M. (2006). Working with self-harming adolescents: A collaborative, strengths-

based therapy approach. New York: W. W. Norton.
Self-injury: A struggle. (n.d.) Retrieved August 18, 2008, from http://self-injury. net
Self-injury: You are not the only one. (n.d.). Retrieved February 13, 2009, from http://crystal
.

.

~

.html

Shapiro, L. (2008). Stopping the pain: A workbook for teens who cut and self-injure.
Oakland, CA: New Harbinger Publications.
Shaw, S. (2002). Shifting conversations on girls' and women's self-injury: An analysis of the
clinical literature in historical context [Electronic Version]. Feminism and

Psychology, 12, 191-219.
Skegg, K. (2005). Self-harm [Electronic Version]. Lancet, 366, 1471-1483.

104
Slee, N., Arensman, E., Garnefski, N., & Spinhoven, P. (2007). Cognitive-behavioral therapy
and deliberate self-harm [Electronic Version]. Crisis, 28(4), 175-182.
Spirito, A., Sterling, C., Donaldson, D., & Arrigan, M . (1996). Factor analysis of the Suicide
Intent Scale with adolescent suicide attempters [Electronic Version]. Journal of

Personality Assessment, 67( 1), 90-1 01.
Stevens, P., & Smith, R. (2001). Substance Abuse Counseling: Theory and Practice (2nd ed.).
Upper Saddle River, NJ: Prentice Hall.
Sutton, J., Jr. & Pearson, R. (2002). The practice of school counseling in rural and small
town schools. Professional School Counseling, 5, 266-277. Retrieved March 4, 2009,
from Academic Search Premier database.
Strong, M. (1998). A bright red scream: Self-mutilation and language ofpain. New York:
Penguin.
Suyemoto, K., & MacDonald, M. (1995). Self-cutting in female adolescents [Electronic
Version]. Psychotherapy: Theory, Research, Practice, Training, 32, 162-171.
Swadi, H. (2004). Self-mutilation among adolescents and youth: Some clinical perspectives
[Electronic Version]. New Zealand Family Physician, 31, 374-377.
Taiminen, T., Kallio-Soukainen, K., Nokso-Koivisto, H., Kaljonen, A., & Helenius, H.,
(1998). Contagion of deliberate self-harm among adolescent inpatients. Adolescent

and Child Psychiatry, 37, 211-21-7. Retrieved October 14, 2006, from OVID
database.
Tillotson, K. (2008). Is cognitive behavior therapy useful for people who self harm?
[Electronic Version]. Mental Health Practice, 11(5), 28-31.

105
Tonkin, R., Murphy, A., Lee, Z., Saewye, E., & The McCreary Center Society (2005).

British Columbia Health Trends: A retrospective, 1992-2003. Vancouver, British
Columbia, Canada: McCreary Center Society.
Trepal, H., Wester, K., & MacDonald, C. (2006). Self-injury and postvention: Responding to
the family in crisis [Electronic Version]. The Family Journal: Counseling and

Therapy for Couples and Families, 14, 342-348.
Tyler, K., Whitbeck, L., Hoyt, D., & Johnson, K. (2003). Self-mutilation and homeless
youth: The role of family abuse, street experiences, and mental disorders [Electronic
Version]. Journal of Research on Adolescence, 13, 457-474.
Walsh, B. (2006). Treating self-injury: a practical guide. New York: Guilford.
Walsh, B. (2007). Clinical assessment of self-injury: A practical guide [Electronic Version].

Journal of Clinical Psychology: In Session, 63, 1057-1068.
Walsh, B. & Rosen, P. (1988). Self-mutilation: Theory, research, and treatment. New York:
Guilford.
White, V., Trepal-Wollenzier, H., & Nolan, J. (2002). College students and self-injury:
Intervention strategies for counselors [Electronic Version]. Journal of College

Counseling, 5, 105-113.
White Kress, V. (n.d.). Adolescents who self-injure: Implications and strategies for school
counsellors. Retrieved March 7, 2008, from http//www.findarticles.com/p/articles/
mi_mOKOC/is_3_7aj_11478735/print
White Kress, V. (2003). Self-injurious behaviors: Assessment and diagnosis [Electronic
Version]. Journal of Counseling and Development, 81, 490-496.

106
Whitlock, J., Lader, W., & Conterio, K. (2007). The Internet and self-injury: What
psychotherapists should know [Electronic Version]. Journal of Clinical Psychology:
lnSession, 64,1135-1143.

Whitlock, J., Powers, J. , & Eckenrode, J. (2006). The virtual cutting edge: The Internet and
adolescent self-injury [Electronic Version]. Developmental Psychology, 42, 407-417.
Whitmarsh, L. , Rosencrance, J., Lynch, M., & Mullette, J. (2006). Adolescent selfmutilation: Research review and case presentations. Retrieved April 16, 2006, from
http://www.njcounselling.org/NJCA-Journallsubpages/whitmarsh.html
Winkler, K. (2003). Cutting and self-mutilation: When teens injure themselves. Berkeley
Heights, NJ: Enslow.
Wysong, P. (2007, September). Bodily harm: Understanding self-injury. Canadian Living,
32, 105-110.

Zila, L. , & Kiselica, M. (2001). Understanding and counseling self-mutilation in female
adolescents and young adults [Electronic Version]. Journal of Counseling and
Development, 79(1), 46-52.

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Appendix A
Adolescent Self-Injury: A Staff Education Session
Goal: School staff will understand the nature of adolescent self-injury (SI) and what their role
is in the identification and support of self-injurers.
I. Explain what behaviors are considered self-injurious.
-cutting, self-burning, self-hitting, breaking bones
2. Explain why a student may self-injure.
-to deal with emotional pain
-many self-injurers have had a traumatic experience
-often have body image issues
-tension builds up and is relieved by SI
-self-soothing behavior
-may be introduced and/or reinforced by peers (contagion effect) and/or media (TV,
web sites, movies, popular music)
3. Explain the difference between self-injurious and suicidal behaviors.
-a suicidal person feels helpless and hopeless and is looking for a way to end these
feelings
-a person who self-injures is looking for a way to relieve the tension and thus sees SI
as a way to cope and stay alive.
4. Explain what is not SI (body modification).
-tattooing and body piercing are socially accepted and not considered SI unless the
behavior becomes compulsive and is used to relieve tension.

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5. How to respond to and support a self-injurer.
-calm, patient, respectful, nonjudgmental, optimistic
-do not normalize or minimize the behavior
-provide some flexibility in school assignments, as self-injurious students may be
academically overwhelmed.
6. What should be done if possible self-injurious behavior is suspected or identified.
-refer to school procedures, if they exist
-seek the help of a designated person in the school. This person is often the school
counsellor.
-ensure that the student is assessed to determine the extent of the SI and risk of
suicide.
-support the student.
7. Discussion and questions

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Appendix B
Recommended School Procedures Regarding Incidents of Self-Injury
School District:
School Name:
Procedures:
1. The counsellor will have a conversation with the school principal about how incidents
of self-injury (SI) are handled in the school so that administrative input and approval
are included.
2.

All school staff/volunteers will be given the opportunity to participate in a training
session related to adolescent SI so that all employees and volunteers have an
understanding of SI issues.

3. The school counsellor will ensure that adequate education has been accessed so that
he/she can deal appropriately with incidents of adolescent SI. This includes
knowledge related to SI and community SI resources available. The trained school
counsellor is the person that students, staff, volunteers and family members can
access when an incident of SI occurs.
4. When an incident of SI is suspected by a school staff member or volunteer, the school
counsellor will be informed.
5. The school counsellor will seek information from the staff member related to the
suspected SI.
6. With discretion and in a confidential manner, the school counsellor will interview the
student to determine if SI is involved.

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7. If it is assessed that SI has occurred, the counsellor will also assess if the student's
safety is at risk. If student safety is at risk, the school counsellor will inform
parents/guardians and access appropriate community resources to support the student.
This may include immediate and appropriate medical care provided by a physician or
hospital emergency department.
8. If the counsellor assesses that the self-injuring student's safety is not at risk, the
school counsellor will respect the student's confidentiality when it is requested by the
student. The school counsellor will continue to monitor the student.
9. While working with a self-injuring student, the counsellor will encourage the student
to develop healthful alternatives to SI, inform their parents/guardians of their
behavior, and access appropriate community SI support.
10. The school will support the student, community agencies, health care providers,
family, and peers involved when an incident of SI arises.
11. Through the entire process while working with a student practicing SI, the school
counsellor will consult with other counselling colleagues, school administration, the
school nurse, school district psychologists, and outside agencies to provide the best
course of action possible for the student.

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Appendix C
Assessment Record

Demographic Information
Client _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Date of birth _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Age _ _ __
Mailing address._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Phone - - - - - - - - - - - - - Cell - - - - - -- - - - - Email address - - - - - - - - - - - - - - - - - - - - - - - - - - - Physician _ _ _ _ _ _ _ _ _ _ _ _ _ Phone _ _ __ _ _ _ _ _ _ _ _ ____
Other health care providers _ _ _ _ _ _ _ _ _ _ _ _ _ _ Phone ______ ___
_______________ Phone _ _ _ _ _ ___
Social worker - - - - - - - - - - - - - - - - - - - - Phone- - - - - - - - Legalissues _ _ _ _ _ _ _ __ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Family Information
Legal guardian(s) _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ __

Parent(s) _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _

Siblings (ages) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ __

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Other individuals living in home _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Other information (separations, divorce, group home, foster care

0

0

o) _ _ _ _ _ _ _ __

School Information
School attending _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Grade_ _ _ _ _ _ _ __
Previous schools attended- - - - - - - - - - - - - - - - - - - - - - - - -

School subjects/marks _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Favourite subject/Why _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Most disliked subject/Why _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

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Other information:

Friends/Peers
Best friend(s) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Friends at school - - - - - - - - - - - - - - - - - - - - - - - - - - -

Boyfriends/Girlfriends (history) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Activities with friends - - - - - - - - - - - - - - - - - - - - - - - - - -

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Other information:

Mental Health
Previous or current mental health conditions (depression, anxiety, suicide ... )/Describe
(when, how often, how it was treated, ongoing): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Client's description of his/her mental health

Does the client have another counsellor/therapist?

Who _ _ _ _ _ _ _ _ _ __

Client consent to contact other counsellor/therapist _ _ _ _ _ __
Results of suicide assessment - - - - - - - - - - - - - - - - - - - - - - -

115

Prescribed medications (name, dose, frequency, reason for prescription) ________

Other information:

Past Trauma
Past traumatic events (death, violence, parental substance abuse, divorce

0

0

0

)/Describe

Child Abuse (physical, sexual or emotional) _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _

Other information: - - - - -- - - - - - - - - - - - - - - - - - - - -----

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Internet Use
Regular access to the Internet _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
SI web sites frequently accessed _ _ _ _ __ __ _ _ _ _ _ _ _ _ _ _ _ _ __

Other information: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Substance Use
Record of substance use:

Substance
Alcohol

Tobacco

Marijuana

Amphetamines

Depressants

Onset of Use

Currently Used/
Amount

Frequency of Use

117

Cocaine

Ecstasy

Other (Include any
prescription
medication misuse)

What client thinks about his/her substance use; is it seen as a problem/damage to health or
lirescyle _____________________________________________________________

Family history of substance use -----------------------------------------:--------

Other information:

-------------------------------------------------------

Body Image Issues
Client considers self:
_ _ Underweight

_ _ Average

_ _ Overweight

118
Describe --------------------------------------------------------------

History of disordered eating (anorexia, bulimia, compulsive overeating)/Describe ________

Concerns about body image/Describe _______________________________________

Other information: -------------------------------------------------------

Self-Injurious Behavior
Age at onset ___________________________________________________________
Frequency_____________________________________________________________

Types of self-injury (cutting, picking, burning, self-hitting . . .) _____________

119

Type(s) of self-injury most frequently used _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Duration of a self-injuring episode _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Time of day when SI usually occurs _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ __

Places where self-injury occurs _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ __

Number of wounds per episode _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Area(s) of body _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Extent of i n j u r y - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Medical care required _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Tool(s) used to self-injure _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ __

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Triggers/antecedents _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ __ __

Reducers of client's self-injury (being with friends, going for a walk, writing . . .) _ _ __

Friends who self-injure/Describe _ __ _ __ __ _ __ _ __ _ _ __ _ _ __

Self-injure alone or with others/Who _ _ _ _ _ __ _ _ _ _ __ _ _ _ _ _ _ __

Access to self-injury websites/Which ones/How often

- -- - - - - -- - - -----

Consequences of self-injury _ _ _ _ _ _ _ __ _ _ _ _ _ _ __ __ _ _ _ __

121

Others aware of self-injury _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Recent changes in self-injury/What _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Functions (purposes) of self-injury/How SI helps the client _ _ _ _ _ _ _ _ _ _ __

Other information:

----------------------------

122
Notes:

Date

Approximate
Time Spent
Self-In.iurin2
Location

Name: ---------------------------Triggers

Journal

Feelings

Appendix D

Extent of
Injury

Consequences

Week: -------------------------

123

124
Notes:

125
Appendix E
Selected and Annotated SI Resources
Professional Reference Books
Bowman, S., & Randall, K. (2006). See my pain!: Creative strategies and activities for
helping young people who self-injure (2nd ed.). Chapin, SC: YouthLight.

• A reference for practitioners working with children/adolescents who self-injure.
• Includes background information, assessment questions, and activities to use with
individuals or small groups.
• Includes a spiritual component with references to God and the value of prayer, an
approach that some adolescent clients may not find helpful.
Favazza, A. ( 1996). Bodies under siege: Self-mutilation and body modification in
culture and psychiatry. Baltimore: Johns Hopkins University Press.

• Author is considered one of the pioneers in the study and treatment of SI.
• Provides historical, cultural, and sociological perspectives of SI.
• Includes information on the treatment and diagnosis of SI.
Nixon, M., & Heath, N. (Eds.). (2009). Self-injury in youth: The essential guide to
assessment and intervention. New York: Routledge.

• A comprehensive resource for the clinician edited by two Canadian SI researchers
with clinical experience.
• Contains a great deal of in-depth information, all focusing on youth.
• In addition to the two editors/authors, the book also contains the writings of many
prominent researchers and clinicians (e.g., Lloyd-Richardson, Nock, Prinstein,
Klonsky, Muehlenkamp, and Toste).

126
• Edited resource is of value to those requiring information beyond that presented in
this manual.
• Information presented is based on empirical evidence.
• Can be viewed as one of the most current and defmitive references available for
practitioners working with self-injuring adolescents.
Walsh, B. (2006). Treating self-injury: A practical guide. New York: Guilford.
• A reference book for clinicians.
• Does not focus specifically on adolescents, however a great deal of information is
relevant to adolescent SI issues (e.g. a chapter on dealing with self-injurers within
the school system).
• Walsh's book indicates that he has vast experience and sound SI background.
• Thorough, well-presented, and informative.

Professional journal articles
A detailed list of journal articles can be found in this manual's reference list. The following
articles provide valuable SI information that, once read, would provide the reader with sound
background regarding SI and its treatment.
Best, R. (2006). Deliberate self-harm in adolescence: A challenge for schools. British

Journal of Guidance and Counselling, 34, 161-175.
• Presents the results of a research study that accessed SI knowledge and attitude of
high school teachers and school-related professionals.
Froeschle, J., & Moyer, M. (2004). Just cut it out: Legal and ethical challenges in
counseling students who self-mutilate. Professional School Counselling, 7, 231-235.
• Provides background information on SI.

127
• Offers best practice for schools.
• Investigates legal and ethical considerations pertaining to SI and the school system.
Lloyd-Richardson, E., Perrine, N., Dierker, L. , & Kelley, M. (2007). Characteristics and
functions of non-suicidal self-injury in a community sample of adolescents.

Psychological Medicine, 3 7, 1183-1192.
• A study (n=633) that results in a vast amount of adolescent SI information.
• One of the few studies conducted using adolescent participants that are not
hospitalized or in outpatient treatment.
• Results indicate why adolescents self-injure.
• Makes intervention recommendations.
Klonsky, E. (2007). The functions of deliberate self-injury: A review of the evidence.

Clinical Psychology Review, 27, 226-239.
• Review of empirical research related to the functions of SI.
• Concludes that affect-regulation is a significant function of SI but also recognizes
support for other functions.
• Includes the review of research using adolescent participants.
Klonsky, E., & Muehlenkamp, J. (2007). Self-Injury: A research review for the practitioner.

Journal of Clinical Psychology: In Session, 63, 1045-1056.
• Provides accurate and useful background information regarding SI.
• Includes the functions of SI and treatment approaches.
• Published in a journal volume entirely allocated to the topic of SI.
Muehlenkamp, J. (2006). Empirically supported treatments and general therapy guidelines
for non-suicidal self-injury. Journal of Mental Health Counseling, 28, 166-185.

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• Muehlenkamp has been a major contributor to the understanding of adolescent SI.
• Although not focused specifically on adolescent SI, the author offers treatment
approaches and strategies that are useful for adolescents.
• Suggests cognitive behavioral approaches as she reports they have the most
empirical support.
Nock, M., Teper, R., & Hollander, M. (2007). Psychological treatment of self-injury among
adolescents. Journal of Clinical Psychology: In Session, 63, 1081-1089.
• Focuses on the use of dialectical behavioral therapy.
• Provides an in-depth counselling case study.
• Published in a journal issue that is devoted to SI.
Roberts-Dobie, S., & Donatelle, R. (2007). School counselors and student self-injury.
Journal of School Health, 77, 257-264.

• Research regarding the issue of SI from a school counsellor's perspective.
• Authors conclude that the school counsellor's role is that of a liaison, and
encourage counsellors to refer students to appropriate community resources.
Ross, S., & Heath, N. (2002). A study of the frequency of self-mutilation in a community
sample of adolescents. Journal of Youth and Adolescence, 31, 67-77.
• A research article that is referenced by many authors in SI literature and research.
• Canadian study conducted by two knowledgeable and well-qualified researchers
and clinicians.
Walsh, B. (2007). Clinical assessment of self-injury: A practical guide Journal of Clinical
Psychology: In Session, 63, 1057-1068.

• Presents factors that require assessment.

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• A case study is presented to illustrate how assessment can be conducted.
• One of several articles presented in a journal issue focusing on SI.
Whitlock, J., Lader, W., & Conterio, K. (2007). The Internet and self-injury: What
psychotherapists should know. Journal of Clinical Psychology: In Session, 64, 11351143.
• Summarizes the possible impact oflnternet sites on self-injuring behavior.
• Review of research.
• Provides recommendations for clinicians.
• Published in a journal issue that is devoted to SI.
Zila, L., & Kiselica, M. (2001). Understanding and counseling self-mutilation in female
adolescents and young adults. Journal of Counseling and Development, 79(1 ), 46-52.
• Provides female adolescent SI information.
• Article is often sited in other SI references.
• Offers treatment alternatives and suggests treatments to avoid.
Reference Books for Parents

Hollander, M. (2008). Helping teens who cut. New York: Guilford Press.
• Written in a less technical way than the professional books highlighted in this
appendix.
• Hollander is a psychotherapist with vast experience working with self-injuring
adolescents.
• This book lacks citations, an aspect of the publication that parents may find
desirable because it may be perceived as "readable".
• The resource helps parents understand SI and assists them in accessing appropriate

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treatment for their self-injuring child.
• Resource is focused on Dialectical behavior therapy (DBT).
McVey-Noble, M., Khemlani-Patel, S. , & Neziroglu. F. (2006). When y our child is cutting: A

parent 's guide to helping children overcome self-injury. Oakland, CA: New
Harbinger Publications.
• Written by three practicing psychologists and all have a great deal of counselling
experience.
• Provides accurate SI information, presents treatment options, and suggests ways for
parents to support a self-injuring child.
• Readable and not lengthy, both advantages for many parents who want accurate
information that is succinctly presented.

Self-Help References
Haswell, D., & Graham, M. (2008). Overcoming self-abuse: Step by step to success (5 1h ed.).
Hamilton, Ontario, Canada: S.A.F.E BC.
• S.A.F.E.is an acronym for Self-Abuse Finally Ends.
• A manual-assisted cognitive behavioral workbook.
• Designed as a 10-module program. Could be used with therapy.
• Recommended for group meetings, but the concerns about group therapy in this
manual should be referred to prior to the establishment of group sessions.
Shapiro, L. (2008). Stopping the pain: A workbook for teens who cut and self-injure.
Oakland, CA: New Harbinger.
• A manual-assisted cognitive behavioral workbook for adolescent self-injurers.
• Could be used on its own or in conjunction with therapy.

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• Has a useful section on faulty thinking (cognitive distortions) and how to change
them.
Winkler, K. (2003). Cutting and self-mutilation: When teens injure themselves. Berkeley
Heights, NJ: Enslow.
• A reference book for adolescents written by a journalist.
• Would be of value in a school library as it is written specifically for teens.
• Not a large volume, an aspect of the book that is likely to appeal to adolescents.
Internet Resources
Warning: Some Internet sites can promote SI by acting as triggers for the behavior. Extreme

caution must be used to ensure that the site accessed is appropriate and encourages the
healthful cessation of SI. Stress, guilt, and more SI could be outcomes if a website "pushes"
cessation without encouraging healthful alternatives.
Note: Websites are constantly changing. Although access to these websites was available at

the time of writing (Feb. 13, 2009), some sites may be discontinued.
Self-injury: You are not the only one-

.

.

~

.

• Offers accurate SI information.
• Does not appear to have any contagion factors.
• Appears not to have been updated since 2002.
• Authored by Deb Martinson, a person who claims to have worked extensively with
self-injurers.
• Includes some interesting aspects such as quotes, self-assessment and a
questionnaire.
Focus Adolescent Services: What is Self-injury?- www.focusas.com

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• An online information referral service provided by Focus Adolescent Services, an
organization located in Salisbury, Maryland.
• Established for teens and their families.
• Self-injury is one of the topics highlighted on the site.
• Information is accurate.
Self-injury: A struggle- http://self-injury.net
• Appears to be moderated by a 24 years old female university student.
• This is an example of a site that could have a triggering (contagion) effect as it has
quotes from self-injurers and provides an extensive list of self-injury song lyrics.
• This site should be accessed with reservations. There is value in visiting the site to
see what youth can be accessing online, however this site should not be
recommended to adolescent self-injurers, as it could be a trigger.
S.A.F.E. in BC- http://ca.geocities.com/safebc
• A Canadian site with reliable and accurate information.
• Provides accurate information for the self-injurer and loved ones.
• Not likely to have a triggering (contagion) effect, although the site warns of this
possible outcome.
• Provides resources available in Canada, in particular Ontario and British Columbia.
• S.A.F.E. is an acronym for Self-Abuse Finally Ends and was originally coined by
the founders of S.A.F.E. Alternatives in Illinois, U.S.A.

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Appendix F
Agency/Counsellor/Medical Care Contact and Release of Information
Consent Form
PLACE ON BUSINESS LETTERHEAD
(This is the minimum information required on a consent form and
agencies may need to add details to meet their mandate.)
Agency and/or counsellor requesting contact _ _ __ _ _ _ _ _ _ _ __ _ __ _

Client - - - - - - -- - - - - - - - - - Date of birth - - - - - -- - -- - -

I (We) hereby give my (our) consent for-----------------------------------to contact and share - - - - - - - - -- - - - - - - - - - - - - with
- - - - - - -- - -- - - - - - - - -- - -- -· The information provided
will be held in confidence, shared with the client and/or guardian(s), and used only for
treatment purposes.

Client Signature _ __ _ _ __ _ __ _ _ _ _ _ __ Date

----------------

Guardian( s) Signature( s) _ _________________________ Date _______________

- - - -- - -- - - - - - - - - Date-

--------------

Witness - - -- - - - - -- - - - - - - - - - - - - Date---------------

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Appendix G
Frequently Asked Questions -Self-Injury
When someone you care about is intentionally injuring himself/herself, it can be confusing
and scary. These answers to frequently asked questions will provide you with some accurate
information regarding self-injury (SI).
1. What is self-injury (SI)?
SI is a behavior individuals may turn to when experiencing emotional difficulty. A person
will intentionally harm an area(s) of the body. Some methods of SI are cutting, burning, hair
pulling, self-hitting, scratching, and bone breaking. Cutting is the most common form of SI.

2. Where on the body do individuals self-injure?
Typically, injury can be done on arms, thighs, breasts, genitals, abdomen, or ankles. Injury is
not restricted to these areas. The area of SI is often a place that is easily covered by clothing
so that the injury site is not obvious to others.

3. Why do individuals self-injure?
There is no one reason to explain why people self-injure. A common aspect of the behavior is
that the individual is experiencing overwhelming emotional difficulties. When SI occurs, the
individual experiences intense emotional relief. Individuals who practice SI sometimes have
trauma in their backgrounds. Examples of trauma could be child abuse, the death of a loved
one, separation from a caregiver, a caregiver who misuses substances, family dysfunction, or
isolation from others. SI can also occur with no history of trauma.

4. Does a self-injuring person require hospitalization?
Usually not. If a person's safety is in jeopardy, hospitalization is sometimes considered to
ensure the self-injurer's safety. If SI is severe or if there is evidence of other psychological

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conditions (examples are borderline personality disorder, obsessive-compulsive disorder,
depression, or anxiety), a physician may recommend hospitalization to stabilize the selfinjurer and to conduct a thorough psychological assessment over several days or weeks.
Otherwise, a person can usually be treated in the community without hospitalization.

5. Is SI a way to get attention?
Usually not. SI is often a secretive and private act rather than an attention getting act.
Evidence of SI is usually hidden. It is helpful to view SI as a way to cope, not as a way to get
attention.

6. How common is self-injury?
Among adolescents, research indicates that 4% to 14% of adolescents use SI as a coping
mechanism. The variance in this reported prevalence is due to how SI is defined and the
participants in the research study. For example, SI is more prevalent among adolescents
hospitalized due to mental health issues than in adolescent community populations.

7. Is SI the same as suicide?
No, SI and suicide are very different. Suicidal individuals want to remove the emotional pain
permanently. SI is a way to generate emotional relief so that the person can continue living. It
is important that a skilled professional assesses the risk of suicide because some self-injuring
individuals do attempt suicide. Safety considerations should be of the utmost concern and
need to be evaluated prior to the onset of treatment.

8. Is SI an addictive behavior?
Yes, research indicates that it is. It is addictive from both a psychological and physiological
perspective. Because SI provides instant emotional relief, an individual can become addicted
to the relief the behavior offers. When an individual self- injures, research indicates that the

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behavior releases naturally produced neurotransmitters (serotonin, dopamine, and opiods).
These natural compounds are similar to those released with other addictive behaviors such as
alcohol or drug misuse and can be equally addictive.

9. How can self-injurious behaviors be stopped?
An individual cannot be forced to stop SI. If this is attempted, the individual usually

continues the behavior, but the individual becomes more secretive when self-injuring to
avoid detection. It is recommended that a self-injurer not be forced to terminate SI without
first developing other more healthful coping strategies. Trying to take away SI without
treatment can be dangerous because the individual is losing a way of coping with stress
without it being replaced with a better coping method. The longer the behavior has been used
as a coping mechanism, the more difficult it is to terminate. Treating SI usually requires
professional help (for example: physician, counsellor, therapist, mental health professionals).

10. Does a self-injuring person require medication?
There is no medication identified to treat SI; however, medication may be prescribed for
other conditions that can occur at the same time. Some of these conditions are depression,
anxiety, obsessive-compulsive disorder, and borderline personality disorder.

11. How long does treatment take?
The length of treatment depends on many variables. One ofthe most significant is the length
of time for which an adolescent has self-injured. Although it is not always the case, the
longer a person has been self-injuring, the longer the treatment required. Some other
variables are the frequency of SI, and the presence of other mental health issues (such as
disordered eating, borderline personality disorder, depression, and post traumatic distress).

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12. How can I (we) get help for SI?
Safety must be the first consideration. If a self-injurer's safety is at risk (for example, the
person requires wound care, has suicidal thoughts), the individual needs immediate medical
care. This can be accessed in a hospital emergency room or doctor's office. Once safety is
addressed, seeking mental health support should be considered. If the adolescent self-injurer
is attending school, one place to start is with the school counsellor. Although school
counsellors often do not have the time required for long-term treatment, they can refer a
client to appropriate community resources. A school counsellor will offer support to the
client and family and advocate for the youth ' s health and learning in the school system. A
physician is also another starting point. If. the adolescent has a social worker, this person can
link an adolescent with an appropriate counsellor.
13. What should I (we) look for in a counsellor?
A counsellor/therapist working with adolescents who self-injure should have:
a) A great deal of experience working with adolescents,
b) An understanding of SI (for example: what SI is, the functions of SI, risk factors,
assessment, and treatment approaches), and
c) Practical experience working with self-injuring clients.
14. What SI resources are available?
Ask the counsellor, medical professional, or agency providing support for recommended
resources. There are self-help manuals, books for self-injurers, books for parents, and
websites that can provide sound information. There is also inappropriate information
available that can actually trigger SI, so it is important to assess reliable resources, especially
when using the computer.

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The following is a limited list of printed resources you can consider accessing. These
books can be obtained from a bookstore or an on-line book supplier. If a book is not available
in a bookstore, it can be ordered by the store. A list of on-line book suppliers can be
generated by conducting a "Google" search using the book's title.
Alderman, T. ( 1997). The scarred soul: Understanding and ending self-inflicted violence.
Oakland, CA: New Harbinger. ISBN:l-57224-079-2
Conterio, K., & Lader, W. ( 1998). Bodily Harm: The break through healing program for

self-injurers. New York: Hyperion. No ISBN provided.
Haswell, D., & Graham, M. (2008). Overcoming self-abuse: Step by step to success (5 1h
ed.). Hamilton, Ontario, Canada: S.A.F.E. BC. No ISBN provided.
To access this resource, phone Mary Graham at 289-389-2337.
Hollander, M. (2008). Helping teens who cut: Understanding and ending self-injury. New
York: Guilford Press. ISBN: 978-1-59358-426-3
McVey-Nobel, M., Khemlani-Patel, S., & Neziroglu, F. (2006). When your child is cutting:

A parent's guide to helping children overcome self-injury. Oakland, CA: New
Harbinger. ISBN-13: 978-1-57224-437-5
Shapiro, L. (2008). Stopping the pain: A workbook for teens who cut and self-injure.
Oakland, CA: New Harbinger. ISBN-13: 978-1-57224-602-7

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Appendix H
What's Going On?- A Cognitive Behavioral Strategy
This is a cognitive behavioral strategy, which addresses faulty thinking and develops
awareness of the link between behaviors, emotions, and thinking.
Purpose/Goals:
a) To bring attention to faulty thoughts and beliefs that lead to the adolescent client using SI
as a coping strategy.
b) To establish a starting point for the confrontation of the client's faulty beliefs so these
beliefs can be minimized.
c) To challenge the adolescent to change unrealistic, rigid, and automatic thoughts and
beliefs by developing and reinforcing more healthful ones.
Materials:
"What's Going On?" worksheet, "Difficult/Unpleasant Feeling Words" reference sheet,
Thoughts/Emotions/Behaviors sheet
Method:
1. Review the two-page document "What's Going On?" with the client so that he/she
understands how to complete the "assignment". Encourage the client to expand on the
feelings section to get a broader array of emotions than adolescents will typically report;
encourage "richness" (more than one word answers) in their responses. You may want to
provide a copy of the "Difficult/Unpleasant Feeling Words" reference sheet to help the client
identify feelings. Giving this as a homework assignment works well if the client agrees and if
you are certain the client is not likely to self-injure because of completing the form outside
the counselling office. It is suggested, however, that you avoid using the word "assignment"

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with the client because many adolescents have academic and school issues and automatic
negative thoughts can be generated when school-oriented words are used.
2. When the client returns to the next session, review the information recorded by the client.
3. Refer to the Thoughts/Emotions/Behaviors triangle with the client. Summarize the
recorded information by clustering the information the appropriate aspects of the triangle. It
is now possible to view the interconnections between the trigger, thoughts, emotions and
behaviors. The arrows used to build the triangle graphically illustrate this point. If one aspect
of the triangle is impacted, the other aspects will also change.
4. Explain to the client that in future counselling sessions ways to change faulty thoughts
and beliefs will be explored in order to help change other parts of the triangle.
5. Typically, at this point faulty thoughts and beliefs begin to surface. The insight generated
by this activity can provide direction so that the client and therapist can work collaboratively
to replace distorted thoughts with ones that are healthful so that emotions and behaviors
become more healthful as well.

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What is going on? -A Cognitive Behavior SI Strategy
Choose a time when you turned to SI as a way to get through a challenging situation.
What was the "trigger"? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Behavior- Provide detail of the event: where were you, who was with you, what time was it,
how did you self-injure, how long did the self-injuring episode last, what were the positive
and negative consequences of the behavior?

Thoughts- What were you thinking just prior to the behavior? What were the thoughts that
led you to SI? It might help to start with "I was thinking that ... "

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Feelings- What negative feelings were you experiencing just prior to injuring yourself? Use
feeling words and describe your feelings as much as possible. How strong were the feelings
you had? You may want to refer to the attached feelings word list. There are many more
feelings than those listed, but they might help you get started. Try to identify your feelings
with words other than afraid, angry or sad.

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Difficult/Unpleasant Feeling Words:
Terrified

Anxious

Hateful

Frustrated

Scared

Sore

Disappointed

Nervous

Enraged

Depressed

Worried

Resentful

Embarrassed

Threatened

Unsure

Numb

Tortured

Disillusioned

Tense

Desperate

Dominated

Alone

Victimized

Incapable

Rejected

Heartbroken

Vulnerable

Ignored

Humiliated

Hopeless

Betrayed

Alienated

Terrified

Overwhelmed

Unhappy

Alienated

Ashamed

Offended

Grief

Guilty

Panic

Pessimistic

Disgusting

Frightened

Hateful

Powerless

Worried

Shy

Lost

Pained

Pathetic

Inadequate

Distant

Edgy

Tired

Uncertain

Unsupported

Inferior

Lost

Wronged

Bored

Useless

Injured

Lifeless

Empty

Tormented

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Trigger:

Thoughts

Behaviors 4 - - - - - - - - - - - - - - - - . Emotions