Treating Self-Injurious Behavior in Eating Disorders
Summer 2005, Vol 4, Issue 3
Marian C. Eberly, RN, MSW, LCSW, DAPA
Division of Patient Care Services
Remuda Ranch Programs for Anorexia and Bulimia, Inc
Remuda’s program to treat self-injurious behavior (SIB) is extensive and broad. It conceptualizes and addresses SIB within Remuda’s bio-psycho-social-spiritual model; see the companion article in the current issue of The Remuda Review, Understanding Self-Injurious Behavior in Eating Disorders (Eberly, 2005). Remuda’s treatment teams utilize an extensive battery of multidisciplinary assessments to understand patients’ needs and history of self-harm. Using these assessments, a plan is designed to prevent patients from self-harming. If SIB occurs, it is addressed immediately. Psychotherapeutic interventions are premised on cognitive behavioral therapy, emphasizing assisting patients to make connections between their thoughts, feelings, and behaviors. Patients are actively engaged in the process from beginning to end, with self-assessments and participation in Remuda’s Skills Program (Eberly, Wall, & Cabrera, 2003).
Remuda’s self-harm task force began in fall 2003 and completed its first phase in fall 2004. The program has progressed further in 2005. It was determined early on that Remuda’s adult and adolescent programs would each develop their own self-harm committees, with the committee chairs remaining part of the central self-harm task force. Using structured performance improvement methodologies, each program developed a plan to address its patients’ specific needs with an awareness of their unique developmental issues. The central self-harm task force continues to meet regularly to evaluate processes and communicate change throughout the Remuda system.
Staff are trained throughout the year in the SIB protocols used at Remuda. All disciplines work conjointly to establish a safe environment for the patient. It is important that interdisciplinary treatment teams work closely to achieve cohesion and consistency in practice as they carry out these protocols. Milieu-wide behavioral programs of this kind cannot succeed without shared vision and training among patient contact staff (Linehan, 1993).
Assessment and Treatment Protocols
Assessment is the key to preventing and teaching patients to live successfully without SIB. Safety is the guiding principle behind thorough assessment. All gears turn toward safety when a patient is struggling with SIB. We start the assessment process prior to admission with a comprehensive pre-screen. When self-harm is acknowledged on this pre-screen, patients are asked to sign a Safety Commitment upon admission and are placed on a proactive high risk precaution status, which alerts the treatment team of their SIB history and the need to continue evaluating for self-harm and suicidal risk. This precautionary status is slowly reduced to lesser precautions as patients adjust to treatment.
A thorough psychosocial self-assessment tool is utilized following admission to gain information about self-injury from the patients’ perspective. The self-assessment tool asks patients about their history, frequency, urges, methods, severity, subjective experiences, triggers, and consequences of self-harm, as well as their motivation to change the behavior and perceived level of control over the behavior. The results are evaluated by a Licensed Psychologist and the patients’ primary therapist. A self-harm re-assessment is performed halfway through treatment and again at discharge.
Patients also complete an objective spiritual assessment at admission and discharge, and spiritual issues related to self-harm are integrated into treatment planning. Comprehensive, holistic assessment is critical to healing. Someone once said: “If we fail to plan, we plan to fail.” At Remuda, we hear this mantra over and over again because we know from research and experience that assessment is critical to good outcomes. Spiritual assessment is thus as important a part of the assessment process as clinical information gleaned from patients, their families, and other treating professionals. Spiritual assessment allows us to identify what matters to each patient spiritually at this point in her life. Has she been wounded spiritually? Does she perceive God to be a part of her healing and recovery? What does she think and feel about spiritual matters in general? What is her experience of God in the midst of her pain and suffering? A recent article in The Remuda Review details the content of a spiritual assessment (Darden, 2005).
Patients are also seen by a psychiatric provider on admission and repeatedly thereafter to evaluate the need for medications to proactively manage psychiatric conditions that predispose to impulsive and destructive behaviors such as SIB. Body checks to assess for self-harm may be initiated by doctor’s orders as needed. These are carried out by nursing staff and documented on a self-harm flow sheet.
In keeping with the proactive approach upon admission, nursing staff explains the Safety Commitment and the patient signs this. The patient then reviews the Safety Commitment again with her primary therapist during their first meeting. The message given to the patient is deliberately repetitive. We want her to understand early on that she will be taking an active, participatory role in her treatment, working together with staff to remain safe as she processes through difficult issues.
Nurses practice neutral nursing, a non-emotionally charged response to patient self-harm episodes. Neutral responses assist patients with the immediate medical care they need without offering unneeded nurturance that could inadvertently reinforce the self-harm behavior.
Primary therapists have the range of assessment information available as they begin counseling sessions early in the course of treatment. In light of the assessments, sessions with patients who have a history of SIB are planned to accomplish several objectives:
• Building initial trust and rapport.
• Reviewing opportunities to assist patients in recovery from self-harm.
• Interventions and supports, as follows:
Basic Skills Group. Patients attend a basic skills group weekly, where they are introduced to the pragmatics of skills. The skills are taught comprehensively in a six week curriculum. They are reinforced in application-based process groups throughout treatment, as well as in all aspects of program and activities. Upon admission, those with an active self-injury history receive one-to-one coaching in skills to help understand and use the skills effectively, which they then apply to a personalized safety plan.
One-to-One Sessions. Attending one-to-one appointments with the primary therapist, since some patients may require additional support and encouragement as they continue to practice their new behavioral skills.
Safety Plan. Collaboration between patient and primary therapist to develop a personalized safety plan based on discussions about what has and has not been helpful in self-harm reduction. The safety plan is used to support patients with resources to prevent them from engaging in self-harm. The therapist explains how self-harm is handled behaviorally at Remuda. Patients are coached on preventive skills, identification of triggers, and healthier responses to them. These plans are placed on a card and given to patients to keep with them as a reference. A copy is placed in the front of patients’ medical records to educate members of the treatment team about how best to identify signs of distress and the skills each patient has chosen to use when needing support.
As Needed Supportive Tools: Patients with impulsive self-harm are given multiple supports throughout their stay to help them remain focused on what is helpful. For example, diary cards are a tool used by patients to individually track which skills they use for which triggers. This helps patients to identify what is most useful in preventing impulsive acts against themselves, and in gaining strength to combat the obsessive thoughts which often accompany self-injury. Other tools used as needed with patients are beyond the scope of this article.
Behavior Chain Analysis. A behavior chain analysis (BCA) is another supportive tool that is used to gain insight regarding an undesirable behavioral event or maladaptive behavior, such as self-injury. The patient works collaboratively with the treatment team to carefully identify what thoughts and feelings were triggered precipitously and to link the thoughts, feelings, and behaviors to the resulting event. As each small link in the chain is identified and discussed, the therapist questions the patient about the details of her responses: “what the patient was doing, feeling (emotions and sensations), thinking (both implicitly and explicitly, as in expectations and assumptions), including imagining” (Linehan, 1993, p. 259). Insight gleaned from the BCA aids in identifying risk factors for future self-harm and establishes or modifies the patient’s preventive Safety Plan. After processing her BCA and safety plan fully with her primary therapist and psychiatrist, the patient resumes full participation in her normal treatment program. Patients use this tool as often as necessary, and may at times become weary of it, but simultaneously they see how they are gaining insight into their thoughts and feelings and become better able to manage their subsequent behavior.
Precautions Protocol. It is critical that treatment teams respond in a consistent manner to patient self-injury. Therefore, Remuda has developed a Precautions Protocol which provides our treatment teams a standardized set of responses to patient self-injury, consistent across all disciplines. This protocol identifies specific supports that are put in place depending on the level of ideation or injury experienced. For example, if a patient self-harms but does not require medical attention for the injury, she must remain within nursing eyesight for 24 hours and complete and process a BCA with her primary therapist, including one-to-one coaching. For adolescents and children who self-injure, Remuda uses a modified version of this protocol, adjusted for developmental needs. For those in lower levels of care, such as the Remuda Extended Care, Day Treatment, or Outpatient Programs, staff also utilizes the same protocol, modified to suit each care level.
Aftercare Planning. Aftercare planning includes the development of a harm prevention plan executed by the patient with support from her treatment team. This information is shared with her outpatient treatment team for accountability and support. Should the patient remain in our care and transfer to the Remuda Life Extended Care Program, the treatment team there will consistently carry out the same philosophy of treatment utilized in the intensive setting, with skills classes continuing and BCAs available to the patient as needed.
Spiritual Care
As appropriate, patients are also helped to understand self-harm from a spiritual perspective. Appropriately selected Scriptures can be used as part of cognitive-behavioral interventions to assist Christian patients in developing an accurate understanding of their faith, and can be used as meditations, prayers, and affirmations during times of distress. The following Scriptures have proved helpful in working therapeutically with patients to overcome SIB. These Scriptures minister to the person’s spirit, helping them to understand—and hopefully to experience—that they belong to a loving God who intends to comfort them during times of suffering and bring meaning to their lives.
“Do not be afraid for I have ransomed you. I have called you by name, you are mine. When you go through deep waters and great trouble I will be with you, when you go through rivers of difficulty you will not drown! When you walk through the fire of oppression you will not be burned up; the flames will not consume you. For I am the Holy one of Israel, your Savior… and I love you” (Isaiah 43:1-3; NLT).
“That is why we have a great high priest who has gone to heaven, Jesus the Son of God, let us cling to Him, and never stop trusting him. This high priest of ours understands our weaknesses, for he faces all the same temptations we do, yet he did not sin. So let us come boldly to the throne of our gracious God. There we will receive his mercy and we will find grace to help us when we need it” (Hebrews 4:14-16; NLT).
“God can be trusted to keep his promises” (Hebrews 10:23; NLT).
“Your words will sustain me. They bring me great joy and are my heart’s delight” (Jeremiah 15:16: NLT).
“By his mighty power at work within us he is able to accomplish infinitely more than we would ever dare to ask or hope” (Ephesians 3:14-21; NLT).
“Yet now God in his gracious kindness, declares us not guilty” (Romans 3:24-25; NLT).
“Nothing in all creation will ever be able to separate us from the love of God that is revealed in Christ Jesus our Lord” (Romans 8:39; NLT).
“’For I know the plans I have for you,’ declares the LORD, ‘plans to prosper you and not to harm you, plans to give you hope and a future… you will call upon me and come and pray to me, and I will listen to you. You will seek me and find me… (Jeremiah 29:11-13).
Outcomes
Remuda’s self-harm intervention plan has been evaluated each quarter to determine its effectiveness. Prior to implementation, we had an average of 29 self-harm incidents per quarter across our treatment centers. After implementation of the plan, this decreased to 10 incidents per quarter. Overall, then, we observed a 66% decrease in self-harm at the inpatient treatment level since our comprehensive approach was instituted. Approximately 50% of Remuda’s adult inpatients admit with a self-harm history. Likely due to our comprehensive self-harm reduction program, only 5% of our patients actually self-harm while at Remuda. Therefore, our program appears to be effective in preventing self-harm in 9 out of 10 patients with self-harm in their histories. Of those who do ultimately self-harm at Remuda, approximately 75% attempt SIB one to three times early in treatment, but the vast majority do not continue to self-harm as treatment progresses. With our interventions, their SIB falls off dramatically as they learn to cope with emotional distress using newly learned skills.
We believe our program for treating self-harm has been successful for several reasons. Patient care leadership had a solid commitment to the establishment of a comprehensive bio-psycho-social-spiritual approach to the treatment of SIB and led the way in developing the program. Staff have been unified in carrying out the protocols in a consistent manner across all disciplines. This was challenging at the beginning, but with continued training and coaching milieu-wide consistency has become a reality. The multidisciplinary team has been trained and is continually re-trained to develop a clear understanding of motivational and cognitive behavioral theories. A spiritual assessment and ongoing counseling for these concerns is thoroughly integrated into the treatment process. Patients are not viewed as manipulative or victims, but as agents of change—people capable of change. Patients have benefited from the evidence-based tools we have incorporated and the structured intervention plans we have developed. They are helped not only to understand what is driving their self-harm behavior, but to acquire healthy skills that effectively replace self-harm by accomplishing the same goals without the compromises SIB entails. They are thus empowered to live without self-harm as they discharge from Remuda’s structured environment and return to everyday life.
References
Eberly, M. (2005). Understanding self-injurious behavior in eating disorders. The Remuda Review: The Christian Journal of Eating Disorders, 4, 26-30.
Eberly, M., Wall, A.D., & Cabrera, D. (2003). Cognitive-behavioral therapy: Applications and skills. The Remuda Review: The Christian Journal of Eating Disorders, 2, 1-8.
Darden, R. (2005). Spiritual assessment and treatment strategies. The Remuda Review: The Christian Journal of Eating Disorders, 4, 14-16.
1996. The Holy Bible (New Living Translation). Wheaton, IL: Tyndale.
Linehan, M. (1993). Skills training manual for treating borderline personality disorder. New York: Guilford Press.
