Treating Self-Destructive Behaviors in Trauma Survivors

A Clinician’s Guide

Lisa Ferentz

• Publisher: Routledge
• Year: 2014
• eBook ISBN: 9781317626671
• Edition: 2
• Topic: Psicologia
• Subtopic: Salute mentale in psicologia

Treating Self-Destructive Behaviors in Trauma Survivors, 2nd ed, is a book for clinicians who specialize in helping trauma survivors and, during the course of treatment, find themselves unexpectedly confronted with client disclosures of self-destructive behaviors, including self-mutilation and other manifestations of deliberately "hurting the body" such as bingeing, purging, starving, substance abuse and other addictive behaviors. Arguing that standard safety contracts are not effective, renowned clinician Lisa Ferentz introduces viable treatment alternatives, assessment tools, and new ways of understanding self-destructive behavior using a strengths-based approach that distinguishes between the "experimental" non-suicidal self-injury (NSSI) that some teenagers occasionally engage in and the self-destructive behaviors that are repetitive and chronic. In the new edition, many of the treatment strategies are cross referenced to a useful workbook, giving therapists and clients concrete ways to integrate theory into practice. In addition, Ferentz emphasizes the importance of assessing for and strengthening clients' self-compassion, and explains how nurturing this idea cognitively, emotionally, and somatically can become the catalyst for motivation and change. The book also explores a cycle of behavior that clinicians can personalize and use as a template for treatment. In its final sections, the book focuses on counter-transferential responses and the different ways in which therapists can work with self-destructive behaviors and avoid vicarious traumatization by adopting tools and strategies for self-care.

Treating Self-Destructive Behaviors in Trauma Survivors, 2nd ed, can be used on its own or in conjunction with the accompanying client-focused workbook, Letting Go of Self-Destructive Behaviors: A Workbook of Hope and Healing.

PART I IT MAKES SENSE GIVEN WHERE THEY’VE COME FROM

DOI: 10.4324/9781315755298-1

1 TOWARD A NEW UNDERSTANDING OF SELF-DESTRUCTIVE BEHAVIORS

DOI: 10.4324/9781315755298-2

See if you can relate to the following clinical scenario: There are 5 minutes to go at the end of a seemingly calm and productive therapy session with a trauma survivor. Suddenly, the client rolls up her sleeve, exposes her wrist and forearm, and reveals five deep, angry-looking scratches and a cigarette burn. Her affect is a combination of intense shame and pride. She says she spent the whole session internally debating about whether to show you what she had done the night before. She discloses that she has been hurting her body off and on for years. She is worried that you will be angry, disgusted, or afraid. She is even more terrified about the possibility of you wanting to put her in the hospital. You are trying to maintain an outwardly calm facade, yet your heart is racing, and you are unsure of how to proceed. Although you have been working competently and comfortably with trauma survivors and their issues, when faced with client disclosures of chronic self-destructive behaviors, you are on less confident ground.

Those of us who work with trauma have many tools in our toolbox. We understand the importance of building a therapeutic alliance, incorporating mind–body approaches, addressing cognitive distortions, creating safety, assessing for attachment, focusing on affect regulation, and offering clients reparative experiences. However, much of this sound clinical knowledge can be overshadowed by anxiety and other countertransferential responses that get activated when challenging and tenacious self-destructive behaviors such as eating disorders, addictions, and acts of self-mutilation (cutting, burning, inserting objects into the body, etc.) are brought into the therapy room. As a result, we are put into a state of emotional disequilibrium, trying to balance genuine compassion and concern for the client with our own fears and hyperarousal. Walking this tightrope can deplete our energy and focus and potentially compromise our clinical efficacy.

Much of the time, self-destructive acts are not articulated as the presenting problem or revealed to us in the early stages of treatment. In fact, many clients who have experienced significant traumatic events do not initially identify themselves as trauma survivors. When these issues surface in treatment, they can catch well-meaning and well-qualified clinicians off guard. This book offers guidance to therapists who may feel blindsided or understandably overwhelmed by disclosures of childhood abuse and subsequent behaviors that harm the body.

It would be inaccurate to state that all clients who engage in self-destructive behaviors have prior histories of trauma, abuse, or neglect. However, this book is designed to specifically explore the connections between trauma and self-destructive behaviors, offering creative ways to work with the large cohort of people who chronically harm or injure their bodies and who do come from significantly dysfunctional and abusive backgrounds. The correlation between abuse, neglect, and self-destructive behaviors has been well documented in the literature and is worthy of our attention (Briere & Jordan, 2009; Cozolino, 2006; Gladstone et al., 2004; Glassman, Weierich, Hooley, Deliberto, & Nock, 2007; Goulding & Schwartz, 2002; Gratz, 2003; Hollander, 2008; Miller, 1994; Najavits, 2001; Nock & Prinstein, 2005; Sansone, Gaither, & Songer, 2001; van der Kolk, McFarlane, & Weisaeth, 2006; van der Kolk, Perry, & Herman, 1991; Yates, 2004).

We will focus on male and female adolescent and adult clients who engage in self-destructive acts that are repetitive, chronic, and diversified and who, on closer inspection, come from backgrounds where abuse, neglect, and traumatic experiences were the norm. In these cases, acts that compromise the body can be attributed to severe affect dysregulation, loss of attachment, feelings of worthlessness, distorted self-blame that evokes the need to self-punish, and the profoundly debilitating effects of a breach of caretaker trust and protection. In later chapters we will explore these issues in greater detail. Their identification and resolution become an important part of the treatment process.

Regarding acts of self-mutilation (cutting, burning, etc.), some well-respected researchers and clinicians emphasize the importance of focusing on and treating the function of the behavior (Hollander, 2008; Mikolajczak, Petrides, & Hurry, 2009; Nock and Prinstein, 2005). Yates (2004) also supported a more in-depth understanding of the functionality and treatment needs of this population when he said, “[A] negative response to self-injurious behavior has fueled a multitude of treatment paradigms that endeavor to eliminate the behavior, but place comparatively little emphasis on understanding its developmental origins and adaptational functions.” (p. 63). Klonsky (2007) echoed this concept as well when he said, “Understanding the function of self-injury, or in other words, the variables that motivate and reinforce the behavior, could greatly improve prevention and treatment.” (p. 228).

I feel it is equally essential to process the meaning of the behavior, particularly as it relates to unresolved trauma. Yates (2004) echoed this sentiment, suggesting that the treatment of self-injurious behavior (SIB) should integrate behavioral methods with “psychodynamic techniques to foster a greater understanding within the individual of the meaning of SIB” (p. 64). Swales (2008) also acknowledged that “some therapists advocate addressing the underlying problems in the past (and also in the present) that lead to the behavior, rather than focusing on the behavior itself. They argue that when these problems are resolved the behavior will cease” (p. 6). Glassman et al. (2007) theorized that if treatment focused on family interventions designed to eliminate the maltreatment of children, this would translate into a reduction of nonsuicidal self-injury in that population.

The treatment debate between addressing the function of the behavior versus addressing the meaning of the behavior can be confusing. I suggest it is equally valid to work on both pieces of this puzzle: What do clients “get” from their actions, and what is the underlying communication that is nonverbally articulated through the behavior? This invites an understanding and discussion of the “metacommunication” of these behaviors as they serve to either reenact or restory prior pain narratives. We will explore how to psychoeducationally present these issues to clients and then how to weave them into treatment strategies. In this way, we help clients gain the most insight and decrease the likelihood that they will sublimate the behavior into other self-destructive behaviors.

Despite the fact that self-destructive behaviors are often seen in adolescents, and it seems to be the population most often studied and written about by researchers and clinicians, if you are a therapist working in the trauma field, you know from firsthand experience that these behaviors continue well into adulthood. Many of my clients carved into their skin and were sexually promiscuous as teenagers, and in adulthood they grapple with bingeing and a sexual addiction that has left them with an STD or HIV.

Consider the possibility that many clients who began hurting their bodies as teenagers are still doing versions of self-destructive behaviors in their 40s, 50s, and 60s because their treatment remained solidly planted in present-tense cognitive behavioral work that simply attempted to extinguish the behavior. I believe one of the critical missing pieces for these clients is assessing for and healing their unresolved trauma. Symptomatic adults often carry “pain narratives” that have not been identified or decoded. Present-day parenting, relationships, and workplace challenges can rekindle anxiety, grief, fear, and rage that have their roots in unmetabolized past traumas. Clients regress back to the self-destructive behaviors of their adolescence when these unresolved emotions reemerge. If we don’t address underlying causes and meaning, we may be trying to put a Band-Aid on something that actually requires surgery to extinguish the behavior and promote true healing.

In the past, attempts have been made by researchers such as Ross and McKay (1979) to compartmentalize self-destructive behaviors by classifying acts of self-mutilation such as cutting and burning as “direct” and other behaviors such as substance abuse and eating disorders as “indirect.” Some current authors in the field focus predominately on acts of self-mutilation, suggesting that when those behaviors are thwarted, clients then develop other diagnoses including eating disorders and substance abuse.

I invite you to view all self-imposed, self-directed behaviors as self-destructive. Starving or purging; getting drunk or high; shopping or gambling compulsively; engaging in unsafe, unprotected sex; or taking a razor blade or lighter fluid to one’s body can all serve the same purpose. For this reason, throughout the book the term self-destructive behavior represents this full range of addictive, destructive acts that are punitive, are harmful, hurt the body, or compromise physical safety.

So why do our clients engage in these behaviors? They manage affect through distraction, numbing, or endorphin release; short-circuit bad thoughts and feelings; punish or reclaim control over the body; evoke dissociative or regrounding responses; reenact pain; and communicate or restory prior abuse. All self-destructive acts are, ultimately, creative attempts to cope with untenable thoughts, feelings, and memories. They are cries for help, and ones that should be heeded, not ignored. Ironically, provocative behaviors that scare or disgust us are actually attempts to engage us and connect with significant others. They tell us that our clients are in pain; they need something that they are not getting.

Clients who engage in these behaviors often get the pathological label of being “manipulative,” yet self-destructive acts represent the only language trauma survivors know how to speak. Taking amorphous, invisible, internal pain and making it visible through a cut, burn, drunken state, or obese or dramatically underweight body gives us something to bear witness to, and this, in turn, validates experiences that were never acknowledged before. In addition to punishing their own bodies, clients sometimes engage in destructive behaviors to punish others, evoking fear, helplessness, anger, and anxiety. For clients with no self-worth and no sense of self, being floridly symptomatic can be a way to reclaim a sense of identity.

When we put all of these behaviors on a level playing field rather than hierarchically categorize cutting as “self-harm” and eating disorders and addictions as “something else,” it allows us to define self-harm in a more inclusive way. With this broader mind-set, the metadialogues and deeper meanings we uncover, as well as the treatment modalities we use, can be applied to a much wider range of presenting problems. The fact that so many clients give up one manifestation of self-destructive behavior (cutting) and move on to another (anorexia, substance abuse, gambling addiction) suggests they all serve the same purpose and are rooted in the same unmet needs and unresolved pain narratives.

Hollander (2008) supported the notion that teens tend to not engage in self-injury under the influence of drugs or alcohol because they all serve similar functions. Therefore, I believe we can look at the functionality, metacommunication, and reinforcing components of these different behaviors somewhat interchangeably. Briere and Jordan (2009) corroborated this idea, defining trauma-related behaviors as “external activities that are used in an attempt to reduce negative internal states, typically through distraction, self-soothing, or induction of a distress-incompatible positive state. Examples of such behaviors are compulsive sexual behaviors, binge/purge eating, impulsive aggression, suicidality, and self-mutilation” (p. 378). Najavits (2001) also recognized the universal dynamics of the aforementioned impulsive behaviors and suggested that a treatment paradigm can successfully address more than one kind of self-destructive behavior.

In recent years, issues including cutting, burning, eating disordered behaviors, substance abuse, and sexual addiction have been paraded out in the open. Made-for-TV movies, talk shows, Web sites, chat rooms, and books (for both professionals and the general public) disseminate information, universalize the dynamics, and attach real people—even celebrities—to the behaviors. In some ways this has been positive: our clients no longer have to suffer in silence as their struggles are identified and validated. It is hoped that clients are inspired by the courage of others who talk openly about these behaviors and feel encouraged to seek out help for themselves. Unfortunately, there can be a downside to this public processing. The issues can be minimized, even romanticized, on a talk show or in a movie. Vulnerable viewers who are in pain and feel bereft of resources can be lured into trying self-destructive behaviors after viewing glamorized versions of it depicted by popular actors. Seventeen-year-old Tiffany, struggling in a toxic family rife with domestic violence and poverty, turned to cutting after learning about it on TV.

I guess I was sad and angry all the time, but I couldn’t show it ’cause it would hurt my parents or make things get worse at home. When I saw this girl cutting her arms on a TV movie, it seemed to make everything better, so I found a box cutter and tried it.

The pain and struggles associated with self-destructive behaviors can be significantly exploited on television and in film. This exploitation is usually followed by the intimation that these behaviors can be resolved within the quick fix of a half-hour talk show or 2-hour movie. This is dangerous and insulting to those who have grappled with these behaviors for many years.

The challenge for us as helping professionals is to accept that until the behavior is translated, understood, and put into the context of a chronic cycle, and until our clients have successfully integrated alternative coping strategies and self-soothing techniques, the behavior will continue (Alderman, 1997; Hollander, 2008). To expect anything else is unreasonable. I explain to clients that they understandably cling to self-destructive behaviors as if they were clinging to tiny life jackets in the middle of the ocean (Ferentz, 2002). It’s all they have, and it’s all they know. As far as they are concerned, it keeps them afloat. The instinct to have and hold on to a life jacket is actually appropriate and necessary. It is a primitive survival response that is a part of our hardwiring. No one could manage being out in the ocean without one. It doesn’t matter to them that this seemingly helpful resource is too small, has lots of holes in it, and may get them into trouble later on. When they are out there struggling, that tiny jacket is the only thing that feels accessible to them. And they hold on to it for dear life.

Many well-meaning helping professionals demand that clients relinquish their destructive behaviors either thro...

Table of contents

• Cover Page
• Half Title Page
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Preface
• Acknowledgment
• Part I It makes sense given where they’ve come from
• Part II Understanding and working with self-destructive behaviors
• Part III Helping others while taking care of ourselves
• Bibliography
• Index