Self-Injury and the Role of the Human Service Professional

Laurie M. Craigen, Ph.D., LPC
Rebekah F. Cole
Tammi Milliken
Old Dominion University
Norfolk, Virginia, USA

 

Abstract
Given the broad field of human services, human service professionals are likely to encounter self-injur. Thus it is critical that they become knowledgeable about self-injury and understand how to best intervene with clients who self-injure. Through case studies the readers will learn about helpful ways to respond to a client who harms him/her self through the use of a non-judgmental and supportive stance.  This manuscript has direct implications for direct human service providers, human service educators, human service students, and supervisors by demonstrating the wide continuum of services humans service professionals can provide to clients who self-injure including: utilizing basic helping skills, educating oneself, issues of confidentiality, how to make referrals, and the importance of creating self-injury protocols. 

Introduction
Self-injury is a socially unacceptable act aimed to self-soothe (Craigen, Healey, Walley, Byrd, and Schuster, 2010). It can be described by the self-destructive actions of the client which may include cutting, burning, wound interference, bone breaking, limb amputation, eye enucleation, hair pulling, and eating disorders (Favazza & Conterio, 1989; Levenkron, 1998; McAllister, 2003; Trepal & Wester, 2005; Zila & Kiselica, 2001).  Individuals who self-injure may also exhibit noticeable characteristics that may suggest that he or she is harming oneself. These characteristics include blood stains on the clothes, loose fitting clothes, and becoming defensive when approached about self-injury. Other behaviors may include a predilection towards sharp, accessible objects such as knives, needles, scissors, razors, and paper clips (Favazza & Conterio, 1989; Levenkron, 1998; Zila & Kiselica, 2001). 

Youth and adolescents as well as women make up a high percentage of self-injuring clients that human service professionals may encounter. Thirteen percent of adolescents, for example, engage in self-injury (McAllister, 2003). In addition, 40-60% of adolescents in an inpatient setting engage in self-injury (Ross & Heath, 2002). Furthermore, the typical age range for clients who self-injure is 13-23 years old (Favazza & Conterio, 1989). These statistics ultimately may be unreliable or underestimated based on the number of self-injurious clients who are reported or go unreported (McAllister, 2003). Further, many of these statistics are drawn from data in both emergency room and inpatient settings.  The reality is that many individuals who self-injure never receive these kinds of services. In addition to the high numbers of youth and adolescents who self-injure, women are three to four times more likely to self-injure than men (McAllister, 2003). One common explanation is that the high percentage may result from negative or pressure-filled messages from society that women receive throughout their lives (Parker, Bermudez, & Neustifter, 2007).

Relevance to Human Service Professionals
Working with clients who self-injure is relevant to the defined roles of the human service professional, especially as he or she acts as a broker, advocate, teacher, behavior changer, mobilize, and caregiver (Neukrug, 2008). Further, the basic characteristics of an effective human service professional such as relationship building, genuineness, acceptance, and empathy (Neukrug, 2008) are found to be compatible with the needs of a client who self-injures (Craigen & Foster, 2009). Given the diverse roles and characteristics of the human service professional, it is likely that human service professionals will encounter a client who harms him/herself. Human service professionals additionally may be the first point of contact for the client as a caseworker, residential staff member, intake interviewer, child advocate, or as another front-line position (Craigen, 2008).

While human service professionals seem to be in an ideal position to work with clients who self-injure, many professionals may feel unprepared, unable, or ineffective in working with individuals who harm themselves (Zila & Kiselica, 2001).  This is not surprising given that pre-service education on self-injury in human service programs is not common (CSHSE, 2010). Also, there are no universal guidelines for treating clients who self-injure, which may serve as an additional challenge for human service professionals faced with clients who cause harm to themselves (Muehkenkamp, 2006; Trepal &Wester, 2007).

Thus far, the authors of this manuscript have introduced the topic of self-injury, provided a definition of self-injury, revealed demographics of clients who self-injure, and stressed the importance of knowledge and awareness for human service professionals. The following case vignettes were developed by the authors and informed by the research and literature on self-injury best practices. Further, they are provided so that human service professionals in a variety of different settings can consider how to respond and intervene with clients who self-injure. At the conclusion of each case vignette, the authors will highlight a variety of best practices for working with clients who self-injure.    Thus, the purpose of this paper is to provide human service professionals with case vignettes that are readily adaptable to their real-world experiences in the field of human services.

Case Vignettes
Jill: Intake Coordinator
Jill is an intake coordinator at a community services board in the Southeastern United States.  She recently graduated with a Bachelor of Science in Human Services degree.  Her main duty is to conduct face-to-face intake interviews.  Then, she assigns each case to the appropriate helping professional. 

After a long day of work, Jill’s last appointment arrives.  Amy walks in to the building with her mother.  She appears frustrated and unhappy to be at the appointment as evidenced by her closed-off posture.  Her mother speaks first, stating “Amy is here because she is cutting herself and we need to get her help right away.”  Amy reacts strongly to her mother’s comments yelling, “Mom, please leave, I don’t want you in my business.”  Shaking her head, her mother stands up and leaves the room. Jill begins her intake with Amy.  Jill starts by welcoming Amy and introduces herself to Amy in an attempt to make her feel more comfortable.  She then asks Amy to share some information about herself.  Amy talks about her love for music, her involvement in the acting program, and her desire to be a music producer.  After actively listening to Amy share, Jill leans in and asks, “Can you tell me in your own words what brings you here today?”  Amy responds, “I cut myself when I get angry and my mother found out.  She thinks I am crazy.  I guess I am just a crazy and weird kid.”  Jill shakes her head and responds, “You don’t seem weird to me.  You sound like a very passionate young woman and it seems like cutting may be your outlet for expressing your anger.  In counseling here, you and your counselor will work on finding other ways of expressing your anger.”  Amy remarks, “Well, you may be the only person on the face of this earth that doesn’t think I am crazy.” [The interview continues as Jill asks more questions on the intake interview].       

Analysis of Jill
In this vignette, Jill responded to her client, Amy, in a non-judgmental manner.  Her words were void of blame and judgment and demonstrated an understanding of self-injury.  Oftentimes, human service professionals pathologize self-injury due to their lack of understanding and knowledge about the behavior (Craigen, 2008).  These approaches have long-lasting effects upon individuals resulting in both negative views of the self and helping professionals (Favazza & Conterio, 1989; Shaw, 2002; Craigen & Foster, 2009).   Jill also validated Amy’s feelings and took the time to learn about her and listen to her.  Craigen & Foster (2009) indicate that women who self-injure value a helper who takes the time to listen to their story and gets to know them beyond their self-injury.  In this vignette, Jill asked Amy to share information about herself without interrupting or interjecting her own thoughts.  In summary, Jill demonstrated two skills that are critical to utilize when working with self-injury: responding without judgment and listening.  It would behoove human service professionals in a variety of different contexts to adopt these tools in their own work with clients who self-injure.

Kenneth: Residential Treatment Provider
Kenneth is a senior undergraduate student at a large university in the northeastern United States.  He is halfway through his required internship and plans to graduate with his bachelor’s degree in Human Services next semester.  His internship site is a residential treatment home for at-risk young men ages 12-17.  There are seven men living at the home. Kenneth is responsible for overseeing their activities and providing support, among several other duties.  Late one night, David, a 14 year-old boy walked down the stairs with what appeared to be a bloodstain on his shirt.  Kenneth asked David what happened and David lifted up his sleeve revealing a series of cuts on his forearm.  Kenneth sat with David for a while as they discussed David’s feelings and his reasons for harming himself. 

Kenneth immediately reported the case to his supervisor, as he remembered that the two main reasons for breaking confidentiality are potential harm to oneself and others.  Kenneth then made a referral to a local counseling agency so David could receive in-depth counseling services.  Finally, because it was the first time that Kenneth had ever encountered the behavior, he left work that night and immediately started researching and learning about the topic of self-injury. In his reading, he learned about the importance for agencies to have their own self-injury protocol. The next day, Kenneth advocated for a protocol to be developed to one of his supervisors. As a result, by the end of his internship, a protocol was in place.

Analysis of Kenneth
In this vignette, we will highlight four actions that Kenneth took with David.  Each action reflects best practices when working with a client who self-injures: making referrals, reporting incidences of self-injury, educating oneself, and creating a self-injury protocol. After responding in an understanding and nonjudgmental manner, Kenneth referred David to a local counseling agency.  Kenneth realized that he did not have the knowledge or skills to provide in-depth counseling related to self-injury. Making referrals based on one’s level of expertise is an ethical obligation for human service professionals (Craigen, 2008).   The National Organization of Human Services’ Ethical Standard 26 states the following:  “Human service professionals know the limit and scope of their professional knowledge and offer services only within their knowledge and skill base” (NOHS, 2010). 

In addition to making a referral, Kenneth also reported the incidence of self-injury to his direct supervisor as he remembered what he learned in his coursework related to confidentiality. The National Organization of Human Services (NOHS) Ethical Standard 4, states the following:

If it is suspected that danger or harm may occur to the client or to others as a result of a client's behavior, the human service professional acts in an appropriate and professional manner to protect the safety of those individuals. This may involve seeking consultation, supervision, and/or breaking the confidentiality of the relationship (NOHS, 2010).  

While this statement is clear, self-injury falls within a grey area -- the behavior is certainly causing damage but the level of damage is debatable. Self-injury is not necessarily synonymous with suicide. Oftentimes, the intent behind each behavior is radically different.  At the same time, parallels do exist between the two behaviors (Vicekandanda, 2000).  Research indicates that approximately 55%-85% of individuals who self-injure have made at least one suicide attempt (Favazza & Conterio, 1989; Stanley, Gameroff, Michalsen, & Mann, 2001).  Yet, a newer conceptualization argues that both self-injury and suicide are forms of self-injurious behavior that fall at extreme ends of the same continuum (Craigen, et. al, 2010).   While this grey area clearly exists, Kenneth made a decision that would best protect David from harm -- reporting the behavior to his supervisor.

Kenneth was equally impressive as he sought to learn more about self-injury.  As soon as he left work, he delved into the research and literature on self-injury in order to best help David.  As human service professionals, it is impossible to know about every behavior and every type of individual.  However, it is critical that we have an open-mind and are willing to seek knowledge when we are lacking in a particular area.  Some would say that it is our ethical obligation to not only read about self-injury, but also to attain adequate training on the topic of self-injury (Trepal & Wester, 2007).  So, in addition to reading the literature, Kenneth could also attend workshops on self-injury and advocate for pre-service training on self-injury at his university.

Finally, it was most impressive that Kenneth advocated for his agency to create a self-injury protocol. Many agencies have suicide protocols or formal guidelines when working with a client who is suicidal, yet very few agencies have self-injury protocols.  A self-injury protocol would ensure that all employees respond to self-injury in a uniform manner. A comprehensive self-injury protocol may further include information on how staff can distinguish between self-injury and suicide, information on reporting self-injury, making appropriate referrals, and how to respond to acts of self-injury that need immediate attention (Walsh, 2006).

Case Vignette Summaries
The two case vignettes of Jill and Kenneth highlight critical ways of working with clients who self-injure. They demonstrate a variety of different interventions including basic helping skills, educating oneself on the topic of self-injury, issues of confidentiality, making referrals, and creating self-injury protocols. 

Discussion
Given the broad field of human services, human service professionals are likely to encounter self-injury and it is critical that they become knowledgeable about self-injury and understand how to best intervene with clients who self-injure. This manuscript has direct implications for direct human service providers, human service educators, human service students, and supervisors. It demonstrates the wide continuum of services human service professionals can provide to clients who self-injure including: utilizing basic helping skills, educating oneself, issues of confidentiality, how to make referrals, and the importance of creating self-injury protocols. 

While a number of interventions are offered, the authors of this study are not arguing that all human service professionals are prepared to effectively work with clients who self-injure. In fact, it is necessary to adhere to the NOHS Ethical Standards which state that human service professionals are not to practice in areas beyond their expertise or training (NOHS, 2010). Thus, prior to working with self-injury human service professionals must have adequate and extensive training on the topic of self-injury. Nonetheless, many of the skills utilized when working with self-injury are indirectly addressed in the context of the human service curriculum.  For example, basic helping skills such as listening and encouraging are critical when working with self-injury.  Thus, it may prove beneficial for human service educators to focus on developing these skills through their coursework and through their internship.

Additionally, while the topic of self-injury may not be specifically covered within their human service curriculum, it would benefit students to take initiative, become resourceful, and seek information that will help them to better understand self-injury.  For example, it may be helpful for a student or human service professional to search for and attend conferences on self-injury, to examine literature on the Internet, to find articles on self-injury within professional journals, or to discover books on self-injury. 

Research supports the need for human service educators to teach their students about the limits of confidentiality and empower their students to engage in advocacy on behalf of clients with mental health problems, including self-injury.  Thus, human service educators could engage their students in the study of ethical dilemmas related to confidentiality through case studies.  For example, with minors who self-injure, does one always break confidentiality?  Further, it could be beneficial for educators to encourage discussions or to have mock debates on different issues on the aforementioned question.

In addition to confidentiality, this manuscript addresses the topic of making referrals with clients who self-injure.  It is important that professionals have a strong understanding of the referral process.  Self-injury is a behavior often accompanied with shame and secrecy (Levenkron, 1998).  Thus, when making referrals it is important that human service professionals communicate clearly and openly with the client about why they are making the referral, to whom the referral will be made, and what the referral process will look like.

The topic of self-injury protocols was also addressed within this manuscript.  First, while many students and professionals are aware that suicide protocols may exist within the work environment, it is less likely that they are aware of the development and implementation of self-injury protocols.  Thus, educators could teach students about the importance of creating self-injury protocols and teach students how to advocate for self-injury protocols in a professional and effective manner.

While this manuscript discusses the importance of learning about self-injury for the human service field, research is lacking on the specific roles that human service professionals can play with self-injury.  Future research on the topic of self-injury and how it relates to the human service professional would be beneficial to the field.  Researchers could also examine the relationship between training and treatment effectiveness.  In other words, does education and knowledge on the topic of self-injury improve treatment outcomes for clients who self-injure?  Finally, a study that examines human service professionals’ knowledge, awareness, or skills related to self-injury could be help professionals to determine a baseline of where many human service professionals are at in working with clients who self-injure.  

References

Craigen, L. (2008). Working with self-injury: Ten guidelines for human service professionals. Human Service Education, 27(1), 132-142.  

Craigen, L., & Foster, V. (2009). A qualitative investigation of the counseling experiences of adolescent women with a history of self-injury. Journal of Mental Health Counseling, 31(1), 76-94.

Craigen, L., Healey, A., Walley, C., Byrd, R., & Schuster, J. (2010). Assessment and self-injury: Implications for mental health professionals. Measurement and Evaluation in Counseling and Development, 43(15), 3-15.

CSHSE (2010). Council For Standards in Human Service Educators. Retrieved from http://www.cshse.org/

Favazza, A. R., & Conterio, K. (1989). The plight of chronic self-mutilators. Journal of Community Mental Health, 24, 22-30.

Levenkron, S. (1998). Understanding and overcoming self-mutilation. New York: W.W. Norton and Company.

McAllister, M. (2003). Multiple meanings of self-harm: A critical review. International Journal of Mental Health Nursing, 12, 175-185.

Muehlenkamp, J. J. (2006). Empirically supported treatments and general therapy guidelines for non-suicidal self-injury. Journal of Mental Health Counseling, 28(2), 166-185.

NOHS (National Organization of Human Services). (2010). Retrieved from www.natinonalhumanservices.org

Neukrug, E. (2008). Theory, practice, and trends in human services: An introduction. Belmont, CA: Brooks/Cole.

Parker, M. L., Bermudez, J. M., & Neustifter, R. (2007). Kite in flight: Girls’ identity and empowerment in dating relationships. Journal of Feminist Family Therapy, 19, 1-20.

Ross, S., & Heath, N. L. (2002). A study of the frequency of self-mutilation in a community sample of adolescents. Journal of Youth and Adolescence, 31, 67-77.

Shaw, N. (2002). Shifting conversations on girls’ and women’s self-injury: An analysis of the clinical literature in historical context. Feminism and Psychology, 12(2), 191-219.

Stanley, B., Gameroff, M., Michalsen, V., & Mann, J. (2001). Are suicide attempters who self-mutilate a unique population? American Journal of Psychiatry, 158, 427-432.

Trepal, H. C., & Wester, K. L. (2005). School counselors and self-injurious behaviors: Assessing perceptions, prevalence, and training issues. Journal of School Counseling, 4(18). Retrieved from http://www.jsc.montana.edu/articles/v4n18.pdf

Trepal, H. C., & Wester, K. L. (2007). Self-injurious behaviors, diagnoses, and treatment methods: What mental health professionals are reporting. Journal of Mental Health Counseling, 29(4), 363-375.

Vicekandanda, K. (2000). Integrating models for understanding self-injury. Psychotherapy in Australia, 7, 18-25.

Walsh, B. W. (2006). Treating self-injury. New York: NY: Guilford Press.

Zila, L. M., & Kiselica, M.S. (2001). Understanding and counseling self-mutilation in female adolescents and young adults. Journal of Counseling & Development, 79, 46-52.


Author  Information
Drs.  Craigen, Cole and Milliken are faculty members in the Department of Counseling and Human Services at Old Dominion Univerisity. Dr. Craigen is also a practicing counselor at Southside Counseling Center in Suffolk, Virginia. They may be reached at lcraigen@odu.edu, rfariss@odu.edu, and tmillike@odu.edu.
 

 


This article was published in Human Services Today, Fall 2010, Volume 7, Issue 1 .
http://hst.coehs.uwosh.edu This article may be freely distributed for educational purposes provided above copyright information is included.


Human Services Today is a free, online publication of the College of Education and Human Services, University of Wisconsin Oshkosh. To subscribe, send an email to hst@uwosh.edu. Include the word Subscribe in the subject line. In the body of the email please provide your name, organization, mailing address, email address, telephone number, and job title or position.