An Interview with Barent Walsh, Ph.D. on the Nature and Treatment of Self-Injury
In this edition of the Wise Counsel Podcast, Dr. Van Nuys interviews Barent Walsh, Ph.D., a Massachusetts-based Clinical Social Worker and executive director for The Bridge of Central Massachusetts, an organization providing community-based mental health and developmental disability services in Worcester, MA. Dr. Walsh has been interested in understanding and treating self-injurious behaviors since he was a graduate student working with troubled adolescents many years ago. His dissertation was focused on the subject of self-injury, and the topic has remained highly relevant for him as he has continued to work with self-injurious populations across many years of clinical service.
Dr. Walsh starts out by providing basic information on self-injury which he defines as behaviors which are designed to create bodily harm without suicidal intent. The most common forms of self-injurious behavior are cutting and burning one's self (with a blade, with fire). Other forms include picking at wounds and self-hitting (e.g., punching one's self with sufficient force to create a bruise). New forms of self-injury are constantly being created as well. By definition, self-injury involves a person damaging themselves. If a third-party is involved (as is the case when someone convinces a doctor to do unnecessary surgery), the phenomena is not properly labeled self-injury (although the two forms of injury are linked in terms of motivation).
The intent of the self-injury is to create tissue damage; there is generally no intent to commit suicide. Nevertheless, self-injury does appear to raises the probability that any future actual suicide attempts that may occur will succeed. Dr. Walsh suggests that the act of self-injury increases a person's general fearlessness, which noted Suicide researcher Thomas Joiner suggests needs to be present before someone with suicidal intent will actually try to kill themselves. But in general the motivation to kill one's self is not there in the self-injuring population and most self-injurers do not go on to kill themselves.
Dr. Walsh notes that there appear to be two distinct groups that self-injury with frequency. The first are psychiatric patients, generally experiencing the after-effects of significant abuse. The other group are typically students who are otherwise fairly functional. The average age of onset for self-injury is 13-15 years old. The abused clinical population may continue to self-injury well into adulthood. The student population tends to age out of the behavior as they enter adulthood. Overall, self-injury is extremely common, with youth samples reporting rates between 10 and 20%, and clinical samples reporting rates between 15 and 30%. The overall rate of self-injury is rising across the world, a finding Dr. Walsh suggests is due to "social contagion" - the spread of the idea of self-injury as the fashionable expression of adolescent distress. As such, self-injury has become the "anorexia nervosa of the 2000s". Teens become attracted to self-injury during times of significant emotional distress and use it as a means of mood regulation.
Dr. Van Nuys asks why people are drawn to self-injure. Dr. Walsh responds that self-injury is primarily attractive to people who are experiencing strong and painful emotions such as anxiety, depression, shame or anger as a means of regulating and controlling these negative emotions. In fact, self-injury is a form of coping (if not healthy coping). It does help people to manage their painful emotions. People who self-injury repeatedly will typically not have available to them better, more functional ways of coping with painful moods.
Dr. Van Nuys asks if people sometimes self-injure as a way of manipulating others to gain their sympathy and attention. Dr. Walsh suggests that this may occur sometimes, but that in the vast majority of cases where self-injury is chronically present, there is no manipulative intent, but instead only the use of self-injury as a means of emotion regulation.
There is a subset of self-injurers, primarily those who were abused, who dissociate and who use self-injury as a means of regulating their tendency to dissociate. However, the younger student population of self-injurers does not typically dissociate and uses self-injury primarily as a means of mood regulation.
Research does suggest that there are some brain and biological differences between people who self-injure and those who do not. The meaning of these findings is not clear, however. Self-injurers have been documented to have a higher pain threshold than people who do not self-injure. Some brain studies suggest that there may be impaired limbic system functioning in populations of people who self-injure. The limbic system is the "emotional portion" of the brain, and such impairment would result in the brain having more difficulty reigning in the emotions produced by the limbic system.
Because self-injury spreads through social contagion (e.g., by word of mouth, from peer to peer), it is important that clinicians who are trying to treat self-injury take care when providing group therapy. Primarily, it is important to limit the telling of details about self-injury and "war stories", and to focus the group's efforts on the learning of healthy methods of coping with strong painful emotions that can become a real alternative to self-injury. It is important that clinicians, parents and caregivers respond to self-injury with a "low-key, dispassionate demeanor", meaning that such authority figures not freak out or make a big deal out of the self-injury, or panic and lock someone up for suicidal tendencies, or become too solicitous and in so doing, reinforce the relationship between self-injury and attention. Dr. Walsh encourages clinicians to present a "respectful curiosity" about the function of the self-injury for each patient, meaning that it is useful to ask each patient why they are self-injuring - what self-injury does for them. Asking about the function of the self-injury helps both parties to understand the self-injury as a (dysfunctional) coping strategy, and helps encourage rapport.
Dr. Van Nuys asks Dr. Walsh about various ways clinicians should respond to particular types of self-injury. Dr. Walsh suggests that a crisis response, including hospitalization is appropriate for self-injuries that are significant enough as to require medical attention (such as sutures), and those self-injuries which are inflicted upon the face, eyes, breasts or genitals. These later self-injuries to facial and genital areas are frequently associated with psychosis, or with post-traumatic stress secondary to significant abuse or torture. For lessor forms of self-injury a crisis response would be counter-productive.
The primary form of treatment that is useful for clinicians to offer self-injurers involves replacement skills training, e.g., the teaching of healthy coping skills for managing emotions. Dr. Walsh suggests that the cognitive behavioral approach is frequently useful. It is not useful that authority figures demand that patients stop self-injuring or forbid it from occurring. Instead, it is useful to teach alternatives to self-injury and let patients stop self-injuring at their own pace. Patients have become very dependent on self-injury as a means of managing their moods and it is hard for them to give it up.
The clinical population of self-injurers frequently express self-hatred and body alienation, often secondary to abuse, and this must be dealt with in addition to providing healthy coping skills training. Dr. Walsh recommends exposure treatment for this purpose (e.g., helping people to confront painful memories memories and associations in the manner recommended for treatment of PTSD).
Dr. Walsh suggests that school programs which teach healthy methods of emotion regulation can have a prophylactic effect on the spread of self-injury. Self-injury is not as compelling to young people who already know ways to handle it when they feel awful. Specific interventions which can be taught include simple breathing exercises to help students calm down before tests, and the teaching of stress management skills.
Dr. Van Nuys and Dr. Walsh conclude the interview by discussing how concerned family and friends can locate help for someone who is self-injuring. Dr. Walsh suggests that in the absence of other referral, it is useful to contact the state psychological association. He recommends Dialectical Behavioral Therapy for very severe cases of self-injury, and notes that the main DBT website provides referral to trained DBT therapists. What is most important is that any therapist who is going to provide treatment for self-injury have prior experience working with this population, demonstrate an understanding that self-injury is not suicide, and be capable of offering a skills-training based intervention designed to teach healthy coping alternatives to self-injury.
Links Relevant To This Podcast:
About Barent Walsh, Ph.D.
Barent Walsh, Ph.D. has written extensively and presented internationally on the topic of self-destructive behavior. He is the author of the book, Treating Self-Injury: A Practical Guide published by Guilford Press (2006) and co-author of the book, Self-Mutilation: Theory, Research and Treatment (Guilford Press, New York, 1988). Both of these volumes have been translated into Japanese. Dr. Walsh recently completed a Self-Injury Prevention DVD and program for High Schools in collaboration with Screening for Mental Health of Wellesley, MA.
Dr. Walsh is the Executive Director of The Bridge of Central Massachusetts in Worcester, MA. He oversees 35 programs including special education services and residential treatment for children, adolescents, and adults with mental illness, developmental disabilities, and/or complex family problems. The Bridge also provides services for homeless individuals and operates two drop in centers for gay, lesbian, bisexual, and transgender youth. He can be reached at 'barryw at thebridgecm dot org'
Very Helpful - Byron Scheider LCSW - May 4th 2009
I am a clinical social worker practicing at an inner city middle school. I have wondered about this population of people and I found this article very helpful. The suggestion to teach stress management and replacement strategies for emotional relief is very good. Mental Health resources are limited and sometimes it is difficult to refer these kids to other practitioners due to problematic care giving practices by the guardian. It is good to know a course of action to follow during the time it takes me to get the client to a more experienced practitioner in this clinical area.Byron Scheider LCSW
Thank You - Just Trying - Mar 30th 2009
thank you for this article. I hope to share it with those that are "concerned".