CBT with Self-mutilation

Self-destructive behavior can be a major problem in psychotherapy, particularly when working with clients who meet DSM criteria for Borderline Personality Disorder. It is problematic not only because self-mutilation can be dangerous to the client and because it often elicits intense responses from the client’s significant others, but also because this behavior often elicits very strong emotional reactions in the therapist.

When a therapist discovers that their client has been cutting herself, burning himself with cigarettes, hitting himself with a hammer, etc. they are likely to have a strong reaction. In fact, it is not unusual for therapy to be seriously disrupted by the therapist’s responses to self-mutilation. Obviously, the first step towards intervening effectively is for the therapist to handle his or her initial reaction so that it does not disrupt the collaborative relationship on which CT is based. It is important to take the client seriously without overreacting.

In intervening with self-destructive behavior, it is important to start by developing a clear understanding of the client's motivation for self-destructive behavior. You will hear many therapists argue that there is one particular motive which is always behind self-mutilation (“It is anger turned inward,” “it is manipulative,” etc.). There is reason to believe that there are many different motives which can lead to self-mutilation. This can be done by examining the thoughts and emotions leading up to the self-destructive impulses or behavior, and then by asking direct questions such as "What did you intend to accomplish through ___________?" , "What was the point to __________?", “How did you expect people to react?”, “What did you expect to happen if you didn’t do it?”.

Suicide attempts, self-mutilation, and other acutely self-destructive acts can be the product of many different motives: a desire to punish others whom the client is angry at, a desire to punish oneself and/or obtain relief from guilt, a desire to distract oneself from even more aversive obsessions, a desire to make it obvious that one is in great distress, a desire to be admitted to the hospital, etc. Once the motivation is understood, it is possible to work with the client to consider whether self-mutilation really is a good way to accomplish what they want and to find other ways to accomplish the same result which are likely to be more adaptive or have fewer bad side effects.

Thus, if it turns out that a client carves words into her arm in the hope that this will result in her family realizing how much pain she is in and being more supportive, the therapist would help her look realistically at whether this strategy turns out to be effective or not, at the drawbacks to using the strategy, and at whether there are other ways to deal with the situation which are likely to work out better. Options could include finding ways to communicate her distress (in words) more effectively, finding ways to cope with her family’s lack of support, finding other sources of support, etc.

It may be necessary to work to improve the client’s impulse control in order for them to be able to control the impulse to self-mutilate long enough to make use of more adaptive alternatives. Often the first step in improving impulse control is to deal with the client's tendency to respond to the idea of controlling impulses with "Why the hell should I!". Many borderline clients have been told by many authority figures over the years that they had better control themselves "Or else!" and, by the time the therapist broaches this topic with them, they may be quite oppositional. It is important for the therapist to make it clear that he or she is not trying to force the client to control his or her impulses and is not trying to enforce society's norms, but is trying to help the client to develop the ability to choose whether to act on an impulse or no. Once this has been established, it is often much easier to get the client to focus on specific problem situations, explore the advantages and disadvantages of controlling the impulse in question, and develop methods for doing so. It may be necessary to work explicitly on very basic steps such as noticing mild impulses before they build to the point where they are difficult to control and identifying adaptive alternatives. Once adaptive alternatives have been identified, self-instructional training can be useful in helping clients implement these new behaviors.

It may be also be important to help the client develop a greater ability to tolerate intense emotions. Often the more adaptive alternatives take a bit more time and effort to implement that the extreme options which the client has been using. They also often involve tolerating distress somewhat longer. A discussion of methods for increasing affect tolerance can be found earlier in this forum.

It can take some time to identify adaptive alternatives and get to the point where the client can use them effectively in real-life situations. Sometimes, as a stop-gap measure, it is sometimes useful to temporarily substitute a minimally self-destructive behavior such as marking oneself with a marking pen, for a more self-destructive act, such as slashing oneself. This less destructive act can then be replaced with a more adaptive alternative when time allows.

Obviously, if the risk of the client's performing seriously self-destructive acts is high and the above interventions do not prove effective in the limited time available, hospitalization may be needed in order to allow sufficient time for effective intervention.

Replies:

Increasing Affect Tolerance, by Jim Pretzer, 03/24/01 Self-mutilation and Suicidality, by Jim Pretzer, 03/27/01

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