Treating Self-Injury

Michelle Seliner LCSW, Chief Operating Officer for S.A.F.E. Alternatives, discusses the treatment of self-injury, self-harm, including:

• how to determine whether one needs professional help or not when it comes to self-abuse.
• the difficulty in stopping repetitive self-injurious behavior.
• the recognized standard for treating self-injury.
• the S.A.F.E Alternatives (Self-Abuse Finally Ends) method of treatment.
• can self-injury really be stopped altogether or just really managed?

Self-Injury Chat Transcript

Natalie: is the HealthyPlace.com moderator.

The people in blue are audience members.

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Natalie: Good evening. I'm Natalie, your moderator for tonight's "Treating Self-Injury chat conference. I want to welcome everyone to HealthyPlace.com.

Tonight's conference topic is "Treating Self-Injury."

We receive a dozen or more emails every month from people inquiring about self-injury/self-mutilation and when you get to the bottom line, they all have one question in common:

How do I quit hurting myself?

Our guest tonight is Michelle Seliner LCSW, Chief Operating Officer for S.A.F.E. Alternatives, the nationally recognized treatment approach for self-injurious behavior.

S.A.F.E. Alternatives' (Self-Abuse Finally Ends) approach is designed to help people end self-injurious behavior. The website for S.A.F.E is www.selfinjury.com. The phone number 1-800-DONTCUT (1-800-366-8288).

To be clear, self-injury is not a psychiatric disorder, but rather it's a symptom of a more serious psychiatric problem; a personality disorder, a mood disorder like bipolar or depression, or possibly OCD (obsessive-compulsive disorder).

Good evening, Michelle, and thank you for joining us tonight. How does one determine whether they need professional help or not when it comes to self-abuse?

Michelle Seliner: Thank you for inviting me.

It is our opinion at S.A.F.E. that anyone who is injuring could benefit from a professional evaluation. Research shows that even those who have injured only once have a higher level of emotional distress. A professional can help the client to identify the source of that stress and learn to cope in healthier ways. It is our belief that self-injury doesn't "work" for healthy people: That is, rather than providing a sense of relief, it merely hurts.

Natalie: How difficult is it for someone to stop repetitive self-injurious behavior? And why?

Michelle Seliner: Although people can and do get better on their own, many find it incredibly difficult to stop the behavior as it provides an immediate sense of relief. In addition, self-injury is not the actual problem, but rather an attempt to soothe uncomfortable emotional states that underlie the behavior.

Natalie: What is the recognized standard for treating self-injury?

Michelle Seliner: The standard treatment for self-injury involves focusing on emotional regulation through skills training. Clients are taught to pay attention to the irrational thoughts that might serve to fuel intensive feeling states. They are also taught to focus on the present rather than the past.

Natalie: So there's therapy. Are there medications that can help?

Michelle Seliner: Yes, there are medications used to treat the psychiatric diagnosis that accompany the symptoms of self injury.

Natalie: So for instance, if you suffer from bipolar or depression, you might be on an antipsychotic or antidepressant. Do these medications also relieve self-injury behaviors or the urge to commit self-harm?

Michelle Seliner: No, there is no medication used to treat self-injury.

Natalie: Besides the recognized standard, are there any other alternative methods of treatment?

Michelle Seliner: Yes, for example, while the S.A.F.E. Alternatives model also focuses on irrational thinking, we do look at early childhood experiences as well as family systems and relational difficulties.

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Natalie: Michelle, when you speak of "treating" self-harm, are you talking about "curing" it, ending it forever? Or is it more like an addiction or many of the psychiatric illnesses, where the patient "manages" the behavior over the long-term?

Michelle Seliner: While some of our clients have been diagnosed with psychiatric disorders which may need to be managed over their lifetime, we do not view the behavior of self-injury as an addiction. It is our belief that once a client resolves underlying issues and learns to tolerate uncomfortable feelings rather than attempting to "stuff" them, self-injury becomes unnecessary. It is also our experience that when a client gets healthier, self-injury becomes painful rather than helpful.

Natalie: Is self-help, alone, a realistically effective tool in recovering from self-injury?

Michelle Seliner: Some people have gotten better with self-help. This means that they stopped injuring on their own and it doesn't necessarily mean that they have resolved the issues that underlie the behavior. Sometimes, these people are at risk for switching to another coping strategy such as drugs, alcohol or eating disorder.

Natalie: S.A.F.E. Alternatives opened its doors in 1985. That's over 20 years ago. Yet there are still relatively few therapists in the U.S. who know how to treat it. Why is that?

Michelle Seliner: Self-injury used to be an obscure psychiatric symptom. Most therapists didn't ever think they would be treating clients who engaged in these behaviors. The escalation of these behaviors has been so rapid that school, hospital, criminal justice, and mental health professionals have been caught off-guard.

Natalie: So are you saying that self-injury is no longer "out of the norm" when it comes to psychiatric symptoms? That a lot of people are engaging in that kind of behavior?

Michelle Seliner: Yes, the most current research shows that 1 in 5 college students engage in the behavior. This study came from Cornell. Similar studies have found similar statistics for middle and high school age students.

Natalie: So how does one go about finding a therapist who specializes in treating self-injury? And what credentials should a prospective patient be asking about?

Michelle Seliner: We have a list of therapists from a variety of states who have expressed an interest in working with self-injurers. In general, they have also received some training in working with this population. While we cannot endorse each of these therapists, it is a place for some clients to start their recovery or evaluation. We welcome any feedback regarding client experiences with the therapists listed on the website.

Natalie: Tell us a bit more about the S.A.F.E. Alternatives program. How does a patient get admitted? How long do they stay? And what should they expect?

Michelle Seliner: We would suggest finding a psychiatric professional who is at least masters prepared as either a psychologist, social worker, or counselor and is licensed in your state. Psychiatrists can help with medication evaluations. Some psychiatrists also do therapy.

The SAFE Alternatives philosophy is based upon the book, Bodily Harm: The Breakthrough Healing Program for Self Injurers. We believe that self-injury is a choice; that there is only pain, not relief in self-injury.

Self-injury negatively affects all portions of a person's life-physical, mental and social. The goal is complete abstinence. The S.A.F.E. program offers a continuum of care for the self-injuring client.

We have an intensive 30-day program, early intervention partial hospitalization program and weekly group psychotherapy. In addition, for professionals, we offer clinical consultation, program development, and training. We have several educational materials available. For more information please visit our website, www.selfinjury.com or call 1-800-DONTCUT.

Natalie: What is the average cost of the program? Does insurance partially or fully cover it?

Michelle Seliner: Yes, insurance typically covers the cost of the program. We have financial counselors available to discuss individual plans.

Natalie: What is the rate of relapse; recurrence of self-injury behaviors after going through the S.A.F.E. Alternatives program?

Michelle Seliner: We find that relapse upon leaving the program is not that unusual. However, the majority of clients find that SI no longer works for them as a soothing strategy as it did in the past. It is our experience that most clients stop the behavior after "testing" it upon leaving the program. In one study, we found that 75% were injury-free two years post-discharge.

Natalie: We have a lot of audience members with questions. Let's get to a few Michelle and then we'll continue on with the interview. Here's the first question:

Andrea484: What type of alternatives does your program suggest to those who come in?

Michelle Seliner: One of the first exercises our clients do is come up with a list of alternatives. When developing your list of alternatives, be sure to choose things that are healthy. For example, you would not want to have an alternative be something that could develop into another issue, like over-exercising. Some good alternatives may be journaling, calling a supportive person, nurturing yourself, going for a walk, reading, etc.

blackswan: What is the one thing you would recommend most to someone who's trying to overcome self-injury?

Michelle Seliner: First, I would recommend that they consider an evaluation from a professional so that together an appropriate plan of treatment can be developed. From there, I would develop a list of alternatives. It is important that you and your therapist agree on a plan of treatment.

aynaelynne: What should a therapist do to stop this behavior? I've heard of contracting, but if the client is unwilling what else and how pressing should the therapist be?

Michelle Seliner: First of all, the only person who can stop the behavior is the client. Contracting will only work if the client is motivated to stop injuring. If the client is unwilling, then alternative treatment should be pursued.

Natalie: So the audience understands, by contracting, I believe the term refers to where the patient signs an agreement not to self-harm.

Michelle Seliner: Yes, SAFE refers to this as the SAFETY Contract.

Natalie: Where is SAFE Alternatives based out of? And is the program open to people from across the U.S.?

Michelle Seliner: SAFE is based out of the Chicagoland area. We take clients from all over the world.

Natalie: Here's an audience comment and more questions:

saab32d: I am a recovering cutter. I did it for 9 years haven't done it for 16.

Michelle Seliner: Congratulations. Best wishes on your road in recovery.

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motochik78: How can those with dissociative disorders work on ending self-injury that is done while in a dissociative state, especially when the "alter" that is "out" enjoys the self-injury so much that they purposefully hurt the person, that they can't overcome it?

Michelle Seliner: This is a difficult question. As you may know, there is controversy surrounding the diagnosis of DID. When we encounter someone who comes to us with a DID diagnosis we first work on grounding techniques, in hopes to prevent the "alters" from taking over. We treat dissociation the same way we do self-injury, in that we see it as a coping strategy to avoid uncomfortable feeling states. We ask clients to pay attention to their dissociation and to pair it with feeling states. If someone is DID, and can't sign our No-Harm contract, it may be that they need to do some more individual and integrative work before they would be ready for our program.

mousey!!: If a person enjoys self-injury, like doing it, I don't know, because it feels good, is there any way to get them to agree to get help?

Michelle Seliner: You can offer them support and information. Self-injury does serve a soothing purpose for someone who is struggling. Bodily Harm is a good resource for persons who self-injure, their families and professionals.

KrazyKelz89: What is the relapse rate of someone who self-injures and stops?

Michelle Seliner: We have found that post-treatment in the SAFE program that 75% of clients are self-injury free 2 years post-treatment. I cannot speak for the general population, as many self-injurers, prior to treatment, start and stop injuring. Typically a psychiatrist is used to manage medication for an accompanying diagnosis.

Psychiatrists usually do not do psychotherapy. Some clients have found a support group to be helpful.

Natalie: Michelle, do you think more people are self-injuring because it's glorified on tv or other media?

Michelle Seliner: Certainly that is a contributing factor but there are also others. It is a common coping strategy used by those struggling. We do not subscribe to the contagion effect, as healthy people do not self-injure.

miked123lf: What about the PEM program, the Psycho-Educational Model program where rewards are given for positive behavior? Could that work for cutters and people who self-injure? Or is this used for behavioral problems only?

Michelle Seliner: I am not familiar with this program being used for self-injurers. Applying what I know about self-injury, it is so important to remember that self-injury is a choice. Regardless of the rewards or who is asking you to give up the behavior, ultimately it is only you that can keep yourself safe.

Natalie: What are the characteristics of someone who is likely to be more successful when it comes to achieving a positive outcome from treatment?

Michelle Seliner: We have found it very difficult to predict who will do well. However, clients who seem to do best are those that honestly engage in the treatment process and recognize that treatment is for their own well-being and not for the treatment staff or parents.

Natalie: Is there an age limit to get into the SAFE program?

Michelle Seliner: We accept clients 12 and up. To date, our most senior client was 77 years old.

thelostone: Can the S.A.F.E program also help someone my age (43) recover from years of self-harm and not dealing with my feelings for years?

Michelle Seliner: Yes, often times we are a client's last resort. Some of our clients have been hospitalized hundreds of times. For some, it is their first hospitalization.

Natalie: I'm assuming since there are very few self-injury treatment programs, your program is very busy. How long does it take to get in? Is there a waitlist?

Michelle Seliner: Yes, there is a waiting list. It can take 2 weeks to 1 month.

NobodyKnows: How would somebody go about seeking admission to the program?

Michelle Seliner: To seek admission to the program, please contact us through the website or call 1.800 DONTCUT (1-800-366-8288).

Natalie: Is there a group of people who self-injure who are treatment-resistant; who despite trying various methods of treatment won't be able to control their behavior?

Michelle Seliner: Unless there is significant neurological damage, we don't believe that people can't control learning to stop self-injury. As stated before, some clients will continue to deal with disorders such as depression, anxiety, thought disorders, bipolar, etc. They may still experience intense emotional states, but they can learn to respond in a healthier, more productive way.

Natalie: We also have parents of children who self-injure, along with family members and loved ones, in the audience tonight. For these individuals, discovering and seeing that someone they care about is hurting themselves it can be very scary, alarming, distressing. What would you say to these people? And what can they do to help the self-injurer?

Michelle Seliner: The first thing to recognize is that they are not "crazy." They are instead trying to cope and survive in the best way they know how. The good news is that people can and do get better all the time and go on to live healthy, happy and productive lives. It is important for the family to take the behavior seriously, but anger and hysterics are counter-productive.

It's important to keep the lines of communication open. Parents and friends should not be the therapist, it is helpful for self-injurers to have someone to talk to who can truly help them to identify the problem and learn healthier ways of responding.

Natalie: Our time is up tonight. Thank you, Michelle, for being our guest, for sharing this valuable information on self-injury treatment and for answering audience questions. We appreciate you being here.

Michelle Seliner: Again, thank you for the opportunity to share our approach to the treatment of self-injury.

Natalie: Thank you, everybody, for coming. I hope you found the chat interesting and helpful. Good night everyone.

Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.