Self-Harm Behavior and Eating Disorders

Dynamics, Assessment, and Treatment

John L. Levitt, Ph.D., Randy A. Sansone, M.D., Leigh Cohn, M.A.T., John L. Levitt, Ph.D., Randy A. Sansone, M.D., Leigh Cohn, M.A.T.

• Publisher: Routledge
• Year: 2005
• ISBN:
  9781135938857
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

The number of eating disorders patients presenting with symptoms of self-harm is growing quickly, and yet there is surprisingly little known about this unique population.

Self-Harm Behavior and Eating Disorders explores the prevalent but largely uncharted relationship between self-injury behaviors and eating disorders symptoms. In the first major book to focus on this area, a renowned group of international scholars and practitioners addresses the subject from a variety of theoretical and practical perspectives. The book is categorized into sections covering epidemiology, psychodynamics, assessment, and a final section covering potential treatment options, including dialectical behavioral therapy, cognitive therapy, interventions strategies, group therapy, and pharmacological approaches.

This unrivaled collection of case studies, theoretical exploration, and practical application forms a benchmark for the field, and offers a stepping-stone for new research and innovative treatment strategies. In an area with little available information, previously spread out among diffuse sources, this volume represents the state-of-the-field resource for anyone working with complex eating disorders patients.

Treatment

CHAPTER 9
An Overview of Psychotherapy Strategies for the Management of Self-Harm Behavior

RANDY A. SANSONE, JOHN L. LEVITT, AND LORI A. SANSONE

Introduction

The psychotherapy approaches to the management of self-harm behavior (SHB) among individuals with eating disorders are quite varied. Empirical data are scant, and most of the techniques for SHB described in the literature evolve from two populations—individuals with borderline personality and those with mental retardation. In this chapter, we summarize these various psychotherapy techniques. As with all treatment interventions, the integration of these techniques is highly individualized and the patient’s motivation for recovery is critical. Because SHB is semi-chronic in many cases, these interventions should be conceived as part of an ongoing treatment structure that may also include other interventions such as medications (this material is covered in another chapter) and/or brief psychiatric hospitalization.

SHB among those with eating disorders is a common comorbid phe-nomenon. However, the explicit relationship between eating disorders and SHB is unclear. At times, SHB may manifest as overt behavior (e.g., self-cutting); in other instances, the eating disorder symptoms, themselves, may function as self-injury equivalents. From our clinical experience, individuals with longstanding SHB appear to require a longitudinal treatment approach. For many clinicians, this approach consists of a combination of techniques designed to reduce the frequency of such behaviors, explore their possible deeper meaning(s), and assist the patient to psychologically reframe the behaviors as ego-dystonic. In this chapter, we review the various general psychotherapy strategies for the management of these behaviors. Like any therapeutic intervention, psychotherapy treatment must be individualized and, regardless of strategy, efficacious treatment requires a motivated patient. Most importantly, we emphasize those strategies that are relevant in working with patients with both eating disorder and self-harm symptoms. As a caveat, there is little empirical evidence regarding the efficacy of these treatments, although many authors, including our-selves, have found these approaches clinically useful.

Cognitive Restructuring

In our work with patients with eating disorders, we have found that many harbor faulty cognitive beliefs that subtly promote SHB. These illogical beliefs may have developed from dysfunctional family backgrounds (i.e., learned behavior) and/or have been constructed by the patient through a variety of negative, or difficult, life experiences (i.e., early abuse, develop-mental transitions). Regardless, the resulting cognitive structure, which is often beyond the patient’s immediate awareness, establishes a conducive backdrop for SHB.

An example of a common cognitive distortion is, “Self-harm behavior is acceptable.” This belief may parallel a family environment in which other members routinely participate in various self-harm, self-defeating, or high-risk behaviors. “What I do isn’t any worse than the rest of my family—my mother abuses prescription drugs, my father is an alcoholic, and my sister has had multiple suicide attempts.”

Another example of a common faulty cognition is, “I deserve to be pun-ished.” This conclusion is frequently entangled with the patient’s exceed-ingly low self-esteem, lack of personal value, and very negative self-image. As a final example of common cognitive distortions, some patients believe that SHB is a necessary and legitimate means of communicating needs or resolving intolerable feelings—“Cutting myself is necessary to convince others that I really hurt or to bring me relief from emotional pain.”

The basic therapeutic strategy in this approach is to be aware that these cognitions exist, to actively elicit them, to explore how they legitimize SHB, and to have the patient challenge and restructure them. For example, in response to, “I deserve to be punished,” the therapist might respond, “I think that this is a misguided thought—you don’t deserve this kind of maltreatment, nor does anyone else.” From this juncture, the therapist might explore the rationales for this conclusion, challenge those rationales in a logical and intellectualized manner, and encourage the patient to reexamine the conclusions. This technique is very similar in style to the cognitive approaches that are utilized to confront faulty thinking around food, body, and weight issues, and is empirically reported as effective with both suicidal behavior and eating disorder symptoms (Perris & Herlofson, 1993).

Dynamic Intervention

According to Gunderson (1984; 2001), there are a number of strategic intrapsychic and interpersonal functions that are achieved by SHB. For example, SHB may be used to regulate, or distract oneself from, intoler-able affects (e.g., overwhelming feelings of anger, anxiety, emptiness) that cannot be psychologically managed by the patient. In addition, SHB may function as a means of atonement (i.e., to punish oneself for a perceived failing or negative outcome—“He didn’t show up for our date, so I cut myself ”). For some psychosis-prone patients with the borderline personality symptomatology, SHB may alleviate impending psychotic fragmentation.

At times, SHB may function as a means of reinforcing an identity for those individuals without a solid sense of self. In this regard, the identity is organized around themes of self-destruction (i.e., “rebel without a cause”). This function is readily apparent in the group treatment setting, wherein some patients with eating disorders actively compete with each other regarding who has exhibited the worst behavior (e.g., “How many times have you been in the intensive care unit for low potassium?” “How many times have you had a hyperalimentation line put in?”). For these individuals, being the worst is at least perceived as being something, rather than the intense distress of perhaps being nothing.

Finally, Gunderson (1984) emphasizes that SHB may function to elicit caring responses from others. In this way, SHB enables one to bypass the normal processes of interpersonal communication and vulnerability that accompany the negotiation of needs with others. Given its dramatic nature, SHB acutely elicits powerful emotional and caretaking responses from others (e.g., “You cut yourself—we need to get that taken care of immediately!”).

Given that any or all of the preceding dynamics may be present, the therapist must scrutinize each self-harming patient for the presence of these functions. It is critically important to appreciate that in patients with-out psychosis, pathological behavior has some adaptive value, and that this value must be acknowledged and validated by the therapist. When a specific adaptive function is encountered, the therapist might say, “I believe that you cut yourself because you genuinely struggle with your own anger, and this seems to be one way to control it.” To further validate the function of the behavior, the therapist might continue, “I can really see how this would contain your anger.” The therapist can then challenge this method of prob-lem- solving. “But, we need to examine less costly ways for you to defuse your anger.” In summary, this technique involves being alert for and explor-ing dynamics, identifying them with the patient, validating and interpreting the function of the dynamics, challenging the patient around the excessive emotional cost of this behavior, and guiding the patient to contemplate less costly alternatives.

Interpersonal Restructuring

In our opinion, one of the most important contributions by Gunderson (1984) to the field of borderline personality is his description of the technique of interpersonal restructuring. This intervention is based upon the assumption that one significant role of SHB among patients is the elicitation of caring responses from others. Intervention is designed to restructure the meaning and function of SHB in the therapy relationship—a challenging task—with the expectation that this will generalize to other social relationships.

The Gunderson approach to interpersonal restructuring is engaged at the outset of every self-harm threat or crisis. The basic principles during the acute crisis phase are: (a) explore what the patient is really asking for or needing in the therapeutic relationship; (b) clarify that SHB has an effect on the treatment relationship by heightening the anxiety of the ther-apist, thereby impeding his/her effectiveness in the treatment process; and (c) regardless of what intervention is decided upon, the therapist’s response to the patient is governed by legal and ethical concerns—that therapists choose to show caring to patients in healthier ways than rescuing them.

As a working clinical example, imagine a 1:00 a.m. telephone call. The patient states, “I hope that I am not disturbing you, but I had an aca-demic question. How much Zoloft do I need to take to kill myself?” Using the Gunderson approach, the therapist might respond, “I need to understand what you are really wanting or needing from me right now.” With some prodding, the patient admits that the previous session left her feeling very angry with the therapist. During the telephone conversation, she episodically returns to self-harm threats. The therapist might respond, “You know, when you make threats to harm yourself, it really heightens my anxiety, which makes me less effective as a therapist for you. I don’t know how we will resolve this crisis, tonight—whether we will talk this out next week or send you to the emergency room. But, I need to let you know that whatever we do is based upon my legal and ethical obligations to you—that therapists choose to show caring in healthier ways than rescuing patients.”

During the post-crisis phase, Gunderson recommends that therapists: (a) explore the patient’s reaction to the intervention; (b) reinforce the mutual need to understand the patient’s SHB; and (c) acknowledge satis-faction at having been available for the crisis, but clarify that the therapist is not always available. For the preceding example, these techniques might unfold during the next appointment during the following week. The ther-apist might say, “How did you feel about how I managed the situation last weekend?” The patient might respond, “I can tell you this—if you had called the police, I wouldn’t have been there in my apartment when they arrived.” The therapist might respond, “This incident underscores our need to keep focusing in your treatment on SHB. By the way, I was pleased that I could help you out last weekend, but please realize that I am not always available.”

With regard to interpersonal restructuring, Gunderson emphasizes a consistent and repetitive verbal phraseology by the therapist. By using the same wording, the patient is able to inculcate the principles and internally use them to curb future SHB (this is somewhat akin to utilizing Alcoholics Anonymous clichés like, “one day at a time”). The therapist must anticipate the repeated use of interpersonal restructuring during the early phases of the treatment relationship. Once SHB is stabilized in the treatment relationship, this intervention will be less necessary.

Family Therapy

Family therapy can be an effective tool in the approach to SHB. Indeed, Lock, Le Grange, Agras, and Dare (2001) have developed a family therapy model based on clinical trials developed at Maudsley Hospital for treating adolescents with anorexia. The treatment team views SHB as part of an overall pattern of family communication. This enables the family therapist to examine self-harm patterns within the family, and their intended mes-sage and impact on family members. This model may be particularly effec-tive for younger adolescents with low-level self-injury behaviors. For suicidal patients with anorexia, Achimovich (1985) reviews the literature on family therapy techniques.

Behavior Modification

Behavior modification entails identifying problematic behaviors and their frequency, and developing reinforcers and contingencies to extinguish negative behaviors and increase desired behaviors. In our experience with characterological patients with eating disorders, this approach has not worked particularly well for the treatment of SHB. For these dynamically complex patients, SHB is intimately intertwined with complex intrapsy-chic and interpersonal dynamics. To complicate matters, target behaviors for treatment can be quickly substituted for more covert behaviors (e.g., substituting cutting oneself with biting the inside of one’s mouth), making effective monitoring of progress virtually impossible. We have also found that this behaviorally focused approach lacks the psychological intimacy that many of these patients yearn for. Because of these and other factors, behavior modification has not worked consistently well in our work with patients with eating disorders.

Substitution vs. Sublimation

The process of substitution entails exchanging high-damage behaviors for ones perceived to be less so. For example, instead of cutting oneself, the therapist contracts with the patient that he/she will substitute another behavior, like squeezing rubber balls. However, the strategic risk with the substitutive approach is that patients may use the new “therapeutic” sub-stitute in an unexpected and equally damaging fashion. In one instance, we encountered a patient who was advised to snap rubber bands against her wrist, which resulted in extensive bruising. Another patient, who was burning herself, was advised to substitute the immersion of her face in ice water; she eventually appeared in the emergency room with cold injuries to her face. Because of these potential risks among self-harming patients, we do not encourage explicit substitution of behaviors.

We do, however, recommend sublimation, an approach that entails the redirection of unhealthy behaviors into healthier alternative behaviors. We have found this approach particularly helpful in somewhat higher functioning and/or creative patients. We typically suggest, for example, redirecting aggressive behaviors to expression on paper. Using journals or artwork, the patient learns how to manage as well as start to express overwhelming affects. We have found that many patients readily gravitate toward this type o...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Editors
• Inside My Wounds
• Acknowledgments
• Introduction
• Epidemiology
• Psychodynamics
• Assessment
• Treatment
• Contributors