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Summer 2005, Volume 4, Issue 3
Understanding Self-Injurious Behavior in Eating Disorders
Treating Self-Injurious Behavior in Eating Disorders
Case Study: Anorexia and Self-Injurious Behavior
With the current issue of The Remuda Review, we begin a new series of articles on common co-occurring problems faced by eating disorder patients. Throughout this new series, we plan to consider the assessment, conceptualization, and treatment of self-injurious behavior, anxiety disorders, mood disorders, substance use, trauma, and personality disorders within Remuda’s bio-psycho-social-spiritual model. In each article, we will consider how these co-occurring problems relate to eating disorder development, symptoms, and maintenance, and, where relevant, variable manifestations based on age, development, and culture.
The present issue focuses in depth on our first topic: self-injurious behavior. We have chosen to begin with this exploration because, unlike the other co-occurring problems we intend to explore, self-injurious behavior is a real-time burgeoning phenomenon among eating disorder patients. We are in the midst of an epidemic of self-harm, and the need is evident to assist health professionals in dealing practically and effectively with this emerging problem.
We hope the articles and case study in this issue will help to raise awareness of self-injurious behavior among eating disorder patients and offer professionals practical tools for understanding and aiding those who repetitively mutilate their bodies in extreme efforts to meet their needs and soothe emotional turmoil. Above all, we hope to communicate to the professional community that self-injurious behavior is not often done with manipulative intentions, but is most often used by patients as a method of coping with emotional distress. To automatically label those with self-injurious behavior as manipulative does a great disservice to patients: it prevents our understanding their true needs and aiding them in the acquisition of healthier coping skills. As healthcare professionals, we need to recognize that it is a new day: effective methods now exist to assist self-injuring patients in living healthier lives free of this destructive behavior.
Understanding Self-Injurious Behavior in Eating Disorders
Marian C. Eberly, RN, MSW, LCSW, DAPA
Division of Patient Care Services
Remuda Ranch Programs for Anorexia and Bulimia
Although the psychiatric community first recognized self-injurious behavior (SIB) in the 19th Century, SIB has warranted treatment professionals’ attention most significantly in the last decade. In recent years, eating disorder professionals are talking about SIB as a common co-occurring condition with both anorexia and bulimia. We do not see this phenomenon mitigating in the near future. Thus, there is a need to increase awareness of SIB’s many functions and effective treatment strategies for eating disorder patients who engage in SIB.
To respond to the growing incidence of SIB among eating disorder patients, in fall 2003 Remuda established a multidisciplinary task force to explore SIB in depth. Our objectives were:
1) To come to greater understanding of the conceptual framework of SIB and the functions it serves, i.e., “what is the meaning behind the behavior?”
2) To evaluate areas of risk in our patient care practices.
3) To evaluate current treatments of SIB.
4) To develop a comprehensive bio-psycho-social-spiritual treatment approach for use with Remuda’s SIB patients.
The current article describes the work that Remuda has completed in recent years to better understand SIB in eating disorders. The comprehensive treatment program developed for eating disorder patients with SIB is discussed in greater detail in a companion article in the current issue of The Remuda Review, Treating Self-Injurious Behavior in Eating Disorders.
SIB has been analyzed in many publications. It is evident that diversity exists in the terminology used, including self-harm, self-injurious behavior, and self-mutilation, as well as in how these terms are defined. We prefer the term SIB, but will use these several terms interchangeably to reflect authors’ preferred usage when citing their works.
Within this article and in The Remuda Review, SIB—and the related terms—are defined as: Any socially unacceptable behavior, involving immediate, deliberate, direct, and usually repetitive physical injury to one’s own body, resulting in mild to moderate harm, usually without suicidal intent, and not due to psychiatric organicity.
As such, SIB describes individuals’ mild to moderate wound infliction on their body surface, encompassing the range of parasuicidal gestures that are generally not truly suicidal in nature but which may mimic suicide attempts. SIB typically includes behaviors such as scratching, cutting, carving, burning, rubbing, abrading, punching, pinching, biting, head banging, and hair pulling. In cutting, the tool most often used is a razor blade and the most common body parts cut are the wrists and forearms, followed by the legs.
A case is made by some (Claes, Vandereycken, & Vertommen, 2004; Favaro & Santanastaso,1996; Favaro & Santanastaso, 2000) to define SIB to include a broader spectrum of self-defeating and damaging behaviors, such as binging and purging, drinking and smoking, substance misuse, and laxative, diuretic, and diet pill abuse. The use of medications to self-injure would also be placed in this category, including diabetics’ inappropriate use of insulin to maintain or prolong an eating disorder. For the purposes of this paper and companion articles in this issue of The Remuda Review, we do not endorse this broader definition. In addition, we do not include piercing and tattooing in our definition, since most persons in the US who engage in these behaviors do so for cultural and aesthetic reasons, not as a form of SIB.
Favazza (1996) believes there is enough research and knowledge about SIB to argue for the diagnosis of a new disorder, “deliberate self-harm disorder”. Favazza’s (1996) argument is particularly compelling in that self-injury is not always associated with personality disorders. Those who self-injure simply do not always meet the strict criteria for a personality disorder, and thus, their SIB may not be captured in a diagnosis in spite of its clinical significance. In particular, Favazza (1996) argues that self-mutilation is an impulse disorder, occurring frequently with other impulse disorders such as kleptomania and, in his opinion, eating disorders. In support of this perspective, research suggests that among patients who self-injure, those without personality disorders often have more extensive treatment histories than those with personality disorders or even those who commit suicide (Suyemoto, 1998).
Favazza (1996) divides superficial, moderate self-harm into two categories: compulsive and impulsive. Impulsive SIB includes both episodic and repetitive forms.
Compulsive SIB. Compulsive self-harm differs in character from the impulsive forms and is more closely associated with obsessive-compulsive disorder (OCD). It is a pattern of skin-picking and excoriation that is prompted by anxiety. As such, Favazza (1996) suggests that compulsive self-harm has a different intention and root than do the impulsive forms.
Impulsive/Episodic SIB. Both episodic and repetitive self-harm are impulsive acts. The difference between them may be only a matter of degree. Episodic self-injury is defined as SIB that is not premeditated and occurs in response to an emotional trigger event. Individuals who engage in episodic self-harm do not typically see themselves as “self-injurers”. However, what begins in this manner can escalate under certain stressors into a pattern of repetitive or habitual self-injury.
Impulsive/Repetitive SIB. Distinguishing features of repetitive self-injury are rumination about the self-injury, even when not actually carrying out the behavior, and the self-identification as a self-injurer. Repetitive self-harm becomes an impulsive, reactive response to positive and negative stressors. In a manner similar to how some use tobacco in response to stress, the repetitive self-harmer reaches for a sharp instrument. Several researchers have suggested that repetitive self-harm should be characterized as a separate DSM diagnosis. Short of having its own diagnosis, Favazza (1996) suggests that practitioners diagnose repetitive self-injury as impulse control disorder not otherwise specified.
Functions of SIB
It is incredibly important to understand the functions of SIB—to view the behavior as a message. The practitioner has the opportunity to receive the message and help the patient decode it. The patient may or may not have full insight into why s/he self-injures.
The literature describes various functions at work in SIB (Osuch, Noll, Putnam, 1999; Suyemoto, 1998). The most common functions have been well explained by authors Vanderlinden and Vandereyken (1997) as follows:
Stimulation. Escaping dissociative experiences through an intentional gesture to feel one’s body, thereby utilizing SIB as a self-grounding technique.
Punishment. Imposed when feeling guilt, intense shame, weakness, and anger at oneself for demonstrating behaviorally a lack of discipline.
Relaxation. A pleasure response to the warmth of the blood and the physical sensation of pain, a form of tension reduction through direct abreaction and endorphin release.
Diversion. Inducing dissociation or a trance-like state to avoid attending to an emotional trigger, issue, subject, or suicidal thoughts.
Social Motives/Attention. Obtaining self-affirmation by showing oneself and others one’s strength, and achieving nurturance and protection through others’ responses.
Alteration. To become unattractive to self and others through scarring.
An interesting feature of SIB is that it is often performed with a sense of deliberate control, even when impulsive. In those who repeat the action, there seems to be a sense of empowerment and craft—a definite ownership of the behavior.
There is a great deal of agreement among patient self-reports about SIB. The events that often precipitate SIB are: 1) the perception of loss and abandonment—e.g., canceling an appointment, breaking a date; and 2) the experience of shame—e.g., failure on the job, feedback perceived as judgment or criticism. Isolation almost always occurs before an act of self-injury (Suyemoto, 1998). In one study of 101 eating disorder patients (Claes, Vandereycken, & Vertommen, 2004), the most frequently mentioned motive for SIB was to diminish negative feelings, followed by self-punishment and, to somewhat lesser degrees, to avoid painful memories and place oneself in a trancelike state. For all types of SIB, anger at oneself and sadness were most often mentioned as feelings both preceding and consequent to SIB. 70% of SIB patients report a release of tension and anxiety and a sense of satisfaction following SIB, since they experience the behavior as ending their anger, dissociation, or painful memory intrusion. The vast majority of patients speak of this emotional release as a key reinforcing factor for the behavior (Brown, Comtois, & Linehan, 2002).
One researcher’s definition gives a glimpse into the world of those suffering with self-injury, viewing it not as a self-destructive act but one of self-preservation. This applies particularly to those who have trauma history. Favazza (1996) describes habitual self-mutilation as “a purposeful act of self-help which enables the subject to re-establish contact with the world.” Self-medication or self-soothing and protection are often evident in the transcendent and sometimes dissociative experience of self-injury. Though the pain of SIB may be horrifically unbearable physically, it is preferred over the mental and emotional anguish and is believed by the injurer to effectively assuage their anguish and deep inner suffering. Imperative to theories surrounding SIB behavior is the understanding that many authorities have today: SIB sometimes, if not most of the time, has the ring of self-saving, not self-rejection and self-annihilation, and should be distinguished from pathologies with clear suicidal and self-destructive intent.
SIB and Eating Disorders
Estimates of SIB in the general US population range from 14 to 600 per 100,000 annually, or less than 1% (.014 % to 0.6%). Given the current US population of approximately 280 million, this indicates that between 39,200 and 1,680,000 people engage in SIB each year. Rates seem higher in adolescents and young adults: 1.8% in those aged 15-35, and 12% in college populations (Suyemoto & Kountz, 2000). Research suggests that most persons who self-injure are unmarried and female.
Western culture has long been known for its influence on the rest of the world, and this influence has continued with eating disorders. Recent cross-cultural research has found that eating disorders are emerging in societies, cultures, and ethnic groups that had earlier been presumed immune to these disorders (Becker et al, 2002; Nasser, 1997). Likewise with SIB. When rates of SIB were compared among indigenous populations in Australia, New Zealand, Canada, and the United States, researchers concluded that youth were quite vulnerable to breakdowns in traditional culture and roles spawned by Western influences, and attributed SIB predominantly to this factor (Hunter & Harvey, 2002).
Among patients with mental health disorders, the prevalence of SIB ranges from 4.3% to 13%, higher than in the general population but low in comparison to that found in eating disorders. In eating disorders, prevalence ranges from 25% to 45% (Claes, Vandereycken, & Vertommen, 2003; Herpertz, 1995; Paul et al, 2002). Correspondingly, Walsh and Rosen (1988) found that self-mutilating teens were significantly more likely to have an eating disorder, and Favazza (1996) concluded that as many as 50% of those who self-injure have a documented history of an eating disorder. Evidently, then, there is a high rate of co-occurrence between eating disorders and SIB. Quite interestingly, in one study with 35 patients (Solano et al, 2005), SIB had simultaneous onset with the eating disorder in 48.5% of patients, later onset in 40%, and previous onset in only 11.5%. The authors suggest that perhaps SIB serves differential functions in the three groups.
Differences in SIB rates between patients with anorexia and bulimia have not reached statistical significance (Favaro & Santonastaso, 1998; Fichter, Quadflieg, & Reif, 1994; Matsunaga et al, 2000). Furthermore, although patients with purging symptoms showed a higher frequency of SIB than non-purgers, the difference again did not reach statistical significance (Solano et al, 2005). This suggests that all eating disorder patients, regardless of diagnosis or subtype, have an equal risk of engaging in SIB. What differentiates one eating disorder patient from another in terms of SIB appears to lie beyond the diagnostic categories.
Overall, SIB research leaves us with some lack of clarity. Despite many studies on impulsivity and its relationship to eating disorders, few studies address self-harm specifically, and those that do have unclear clinical implications. Some of the contradictory results in the literature are due to imprecise and divergent definitions of SIB—heterogeneous criteria. Some definitions are very broad. Others include suicidal attempts and other forms of self-harm such as poisoning, which leads to overestimates of SIB. Still others choose to deal with only very mild forms of self-harm, leading to underestimates. Additional problems include limited sample sizes and mixing levels of care such as inpatients and outpatients. Future studies must explore the prevalence of SIB in greater depth and detail. There remains the unanswered question of the role that culture plays in the dynamic of self-injury. What roles do one’s geographic, ethnic, socioeconomic, religious, and/or racial backgrounds play in the development of SIB? This requires further study and may affect the prevalence estimates of SIB.
Trauma. A relationship between childhood sexual abuse and SIB has often been raised. The assumption is often made by practitioners that patients who self-injure are likely to have a history of childhood sexual abuse. Among Remuda’s eating disorder patients (N=6033), 49% report a sexual abuse history prior to age 18. Of those with sexual abuse histories, 37% report engaging in SIB, while only 21% of those without a sexual abuse history report SIB. Sexual abuse thus appears to increase the likelihood of SIB in eating disorder patients. Consistent with Remuda’s data, Paul and colleagues (2002) reported a significantly higher rate of trauma in eating disorder patients who engage in self-harm versus those who do not. Researchers and practitioners agree that trauma does appear to play a significant role in the propensity to self-harm.
There is also a substantial body of empirical work demonstrating an association between sexual abuse and eating disorders themselves (e.g., Palmer et al, 1990; Schmidt, Humphries, & Treasure, 1997). In the context of the eating disorder, self-harm has been said to represent a language of its own that crosses cultural, racial, and ethnic barriers. Even as the eating disorder has been called the patient’s “voice”, SIB is said to express past trauma experiences, repeatedly. In the words of one patient who engaged in self-harm: “When I could not find the words, cutting had become the language to describe the pain, communicating everything I felt” (Pembroke’s study, as cited in Takemoto, 2001).
To summarize, findings in the literature suggest that childhood sexual abuse appears to be a nonspecific risk factor for a range of psychiatric issues, including both eating disorders and SIB (Anderson & Bulik 2002). Among eating disorders, childhood sexual abuse has been found to be most closely correlated with bulimia nervosa (Kendler et al, 2000; Wonderlich et al, 1997), although there are no demonstrated differences in rates of SIB between anorexia and bulimia.
Other Psychopathology. In the general population, SIB is positively correlated with impulsiveness and antisocial behaviors (Simeon et al, 1992; Stephens, 2003), sexual promiscuity and high risk for HIV (Diclemente, Ponton, & Hartley, 1991), and suicide attempts (Dulit et al, 1994). Among psychiatric patients, those with SIB demonstrate significantly more anxiety, depression, hostility, feelings of anger, traumatic experiences, dissociation, and cluster B personality disorders than those without SIB (Claes, Vandereycken, & Vertommen, 2003; Newton, Freeman, & Munro, 1993).
The prevalence of personality disorder is one of several contributory factors to SIB in eating disorder patients. The inability to self-regulate emotions and tolerate distress have been identified as key underlying problems in many Axis II disorders as well as in SIB (Linehan, 1993). Other common features in the backgrounds of those with personality disorders—early abuse histories, high levels of dissociative defenses, highly chaotic family environments, lack of sufficient parental support, extensive psychosocial stressors, and severe mood disorders—are also risk factors for SIB (Levitt, Sansone, & Cohn, 2004).
In the eating disorder population specifically, SIB has been positively linked to neuroticism and conscientiousness, and negatively with extraversion and openness (Claes, Vandereycken, & Vertommen, 2004). There is a very high correlation between substance/alcohol abuse and SIB in all types of eating disorders (Claes, Vandereycken, & Vertommen, 2004). SIB in eating disorders is further associated with purging behaviors, generalized impulsiveness, suicide attempts, mood disorder, sexual abuse history, dissociation, co-morbidity, severity of illness, higher treatment dropout rates, and poor treatment outcome (Favaro & Santonastaso, 2000; Pierloot, Wellens, & Houben, 1975; Solano et al, 2005).
It has also been noted that eating disorder SIB patients are considerably body-focused, demonstrating a love/hate relationship with their bodies. As such, they demonstrate greater body dissatisfaction than those who do not self-injure (Claes, Vandereycken, & Vertommen, 2003). Remuda’s data accord with this perspective, in that Remuda’s patients who self-harm evidence higher scores on measures of somatization (Minnesota Multiphasic Personality Inventory-2; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) and body dissatisfaction (Eating Disorder Inventory-2; Garner, 1991), with both differences being highly statistically significant using analysis of variance. The notion of using one’s body as an expressive outlet for emotional tension would seem worthy of continued reflection among eating disorder professionals (Claes, Vandereycken, & Vertommen, 2004).
The Spiritual and Sacred in SIB
The suffering we speak of in SIB is of a profound, almost sacred, type. Most practitioners are no longer shocked or dumbfounded by the behavior itself. That is not to say that one ever becomes immune to hearing about or seeing SIB, but it has indeed become an epidemic among young people across the world (Nasser, 1997; Nasser, Katzman, & Gordon, 2001). SIB tests the limits of normality and rationality from a psychological perspective. And from a spiritual perspective it still causes us to pause, in a quiet, sorrowful grief when we hear the stories told. The notion that one would need to go to the depths of physically carving, cutting, or burning one’s own body to be released from the burden of interior anguish, even for a single moment, is deeply troubling. And so it should be.
In the Hebrew Scriptures, we read of the prophets of Baal who felt the need to mutilate their bodies through acts of carving and cutting their skin. They became agitated and “shouted louder and, as was their custom, cut themselves with knives and swords until the blood gushed out. They raved all afternoon until the time of the evening sacrifice, but there was no reply, no voice, no answer” (1 Kings 18:28-29; TLB).
These men did many of the things we hear about self-injurers doing today. But one thing was quite different: their motivation was not to avoid a painful memory or to reject themselves in some way. Their self-injurious acts were done as a ritual sacrifice to a god named Baal. They believed that if they could show this god devotion by imposing severe physical suffering upon themselves they would be seen as worthy. They believed their actions would render a response from Baal, a figure of power in their lives. In return they believed they had the power to convince this god to be moved by their actions: he would respond to their cries and show himself to be real and true, validating their identity as belonging to him, and delivering them from their difficulties. But he did not validate their beliefs or reinforce the identity they had in relation to him. As the story goes, Baal did not show up for dinner. They had a whole bull ready to be barbecued in his honor, but he never came. He abandoned them in their hour of need. But Jehovah did show up that day. “Then, suddenly, fire flashed down from heaven and burned up the young bull, the wood, the stones, the dust, and even evaporated all the water in the ditch! And when the people saw it, they fell to their faces upon the ground shouting, ‘Jehovah is God! Jehovah is God!’” (1 Kings 18:38-39; TLB).
It is imperative to know to whom one belongs and in whom one can trust. Adolescents and young adults often experience a loss of trust in significant others. There is a constant theme of being left, abandoned, and betrayed that pours forth from those who self-injure. It is a repetitive theme, and their response to this repetitive injury is to repeat the injury on themselves. They are searching for meaning and identity. When their world is shaken and they are left or abandoned in one form or another by those they trust, they punish themselves, then search for something or someone else to believe in, someone to believe in them, and someone or something to help them control their inner chaos. As Suyemoto and Kountz (2000) reflect:
“Youth who self-mutilate may choose this behavior because it meets a multitude of needs at one time. The most common functions of self-mutilation reported by clients and practitioners are expressing and controlling overwhelming emotions, and maintaining a coherent sense of self when threatened with the loss of identity” (emphasis added).
From a Biblical viewpoint, we can teach patients that God already believes in them and that they belong to him. He sent his son, Jesus Christ, to die for them. Jesus gave his life for theirs, sacrificing all he was and all he had. “Once for all time he took blood into that most holy place, but not the blood of sacrificial goats and calves, he took his own blood and with it he secured our salvation forever” (Hebrews 9:11-12; NLT). He did this so that we might have peace, identity, and a secure future through eternal life. This is a powerful relationship based on unconditional love, not simply a metaphor of exchange.
There is much to explore in the spiritual life, but chasing after false gods, whatever they may be, is not going to bring the acceptance, identity, and inner security one desires. Many who self-injure are searching not only for a cure from the pain inflicted upon them, but also for meaning and purpose in their lives. What they find in Jesus Christ is one who loves them unconditionally, has a purpose for their lives, and delivers on his promises. They are searching for God, an authentic relationship of love, and when they find it, we see lives restored.
Those who are suffering with self-injury need to have a new tool put in their hands to replace the razor blades and matches. The word of God is meant to be that tool which renews our minds, restores our emotions, establishes our identity, and guides our decisions for life. The author of Hebrews uses this telling analogy: “For the word of God is full of living power. It is sharper than the sharpest knife, cutting deep into our innermost thoughts and desires. It exposes us for what we really are. Nothing in all creation can hide from him. Everything is naked and exposed before his eyes” (Hebrews 4:12,13; NLT).
God knows our thoughts before we think them, and understands our suffering to the deepest extent possible. He is the source of healing. As patients expose their deepest sorrow to him, God restores them, bringing comfort and true healing (e.g., Psalm 71).
The research reviewed in the earlier part of this article is helpful in aiding us to come to greater awareness of … what to call it? … more than a malady, more than a disorder, from the depths of hell pain? Clearly, by additionally reflecting on the spiritual dimension of self-injury, we recognize that comprehensive understanding and treatment must be derived from a holistic perspective. If we fail to do that, we have failed the patient because there is an undeniable aspect of her person that is spiritual (Wall & Eberly, 2002). As such, in addition to a careful scientific understanding of SIB drawn from the latest research and theoretical endeavors, the spiritual dimension must be recognized. Within the comprehensive bio-psycho-social-spiritual model of treatment, we can best offer patients tools and understandings that can guide them into healthier lives free of self-mutilating behavior.
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Treating Self-Injurious Behavior in Eating Disorders
Marian C. Eberly, RN, MSW, LCSW, DAPA
Division of Patient Care Services
Remuda Ranch Programs for Anorexia and Bulimia
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.
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).
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.
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.
Case Study: Anorexia and Self-Injurious Behavior
Kari B. Anderson, MS, LPC
Division of Patient Care Services
Remuda Ranch Programs for Anorexia and Bulimia
A preliminary assessment prior to admission identified this college-age adult as having anorexia, binge-eating/purging type. The patient weighed 90 pounds, which was 80% of her ideal body weight. The patient had a history of depressive symptoms and reported suicidal thoughts and fantasies within the past six months. The patient denied self-injurious behaviors (SIB). Given the history provided for the treatment team, the patient was admitted to Remuda on proactive high risk precaution status, which alerted the team to maintain the patient within eyesight of staff for 72 hours and to further assess her suicide risk. After initial psychiatric assessment at admission and 72 hours of close observation, precautions were reduced and the patient was required to check in every nursing shift, reporting her suicidal thoughts on a 1-10 scale. This continued for one week until the staff deemed the patient safe to discontinue this final precaution.
Although preliminary assessments did not disclose a history of SIB, Remuda’s online screening procedure performed soon after admission, called the Self-Harm Assessment, identified a pattern that the patient had been too ashamed to reveal during her initial interviews. The patient indicated that within the last three months she had engaged in SIB that had caused mild tissue damage. Hitting herself on her upper legs, buttocks, and upper arms helped her inner pain to be externalized. The primary function of her SIB was self-punishment. When her eating disorder behaviors did not suffice in this regard, she progressed to SIB to punish herself. Triggers to this punitive form of SIB were feelings of guilt or hatred toward her body. Self-harm in this situation is not an act of attention seeking. In fact, it was very important to the patient that others not find out about her SIB.
Upon learning of this SIB from the Self-Harm Assessment, the patient’s Psychologist immediately notified her Primary Therapist to meet with the patient regarding the results and to formulate an individualized safety plan as part of a Safety Commitment signed by the patient. The safety plan included events that lead the patient to engage in SIB and other ineffective behaviors, followed by skills that she could use to replace these behaviors.
Further assessment interviews revealed a long history of depressive symptoms dating to the same year of eating disorder onset. The prompting event was the death of the patient’s sister in a car accident. The patient wished it were she herself who had died instead of her sister. Her survivor guilt was reinforced when she overheard her father, in a time of grief, stating the same wish.
Following the accident, the patient’s mother overly attached to the patient in an effort to compensate for the loss of her other child. Meanwhile, her father, who had been very close to the deceased sister, withdrew from the family and devoted himself to work. The patient admitted that from a family systems perspective her eating disorder communicated anger, as a way to “get back at dad” and also, somewhat paradoxically, to seek his approval. Family dynamics were significant, as the family had never completely grieved the sister’s loss, creating a conflict between mother and father. This marital conflict further reinforced the enmeshed attachment of mother and daughter and the distancing of the father, resulting in a dysfunctional pattern of triangulation where the mother and daughter bonded against the father and pushed him out of the picture.
Psychological testing revealed that this patient tended to feel sad and unhappy, pessimistic about her future, and self-critical, with low self-esteem. Disabling feelings of guilt and shame were present along with self-punishing thoughts. She had difficulty expressing her anger directly and was often unaware of her angry feelings. Consequently, her anger manifested itself in indirect and passive-aggressive ways. Defenses included repression, denial, and somatization. The patient’s Eating Disorder Inventory-2 (EDI-2; Garner, 1991) underscored these results, indicating feelings of worthlessness, emptiness, inadequacy, and low self-esteem. The Remuda Spiritual Assessment Questionnaire (RSAQ; Wall, Cumella, & Darden, 2003) reflected significant spiritual distress. In spite of her Christian beliefs, the patient’s responses indicated that she likely viewed God as judgmental and condemning, seeing God as having difficulty forgiving human frailty and weakness.
The patient’s purging behaviors by self-induced vomiting were usually precipitated by feelings of regret, shame, and guilt. Typically, she restricted during times of loneliness and when feeling insignificant. She described this aspect of her eating disorder as a “slow kind of suicide”. Later in treatment she also elaborated on her suicidal ideation and fantasies of killing herself. She had imagined killing herself by driving into oncoming traffic, smothering herself, and hanging herself. She stated that she had never acted on her thoughts and that she did not have plans to carry them out. Upon learning of the extent of her suicidal ideation, the patient was again placed on a preventive precautions program requiring her to check in with nurses every hour, rating her suicidal thoughts on a 1-10 scale, and meet daily with her psychiatrist. Precautions were eventually discontinued when the patient’s skills were demonstrated to be securely in place.
In addition to a nutritional protocol that restored twenty-two pounds during her nine week stay, the patient’s treatment plan focused on transforming her shame-based beliefs and equipping her with more effective tools to manage her life. Her depression was treated with Paxil® and followed by her psychiatrist. Therapeutic interventions focused on emotional identification and expression, recognizing ineffective patterns and creating new responses, exploring family relationships, and promoting healthier communication skills. Individual therapy with her primary therapist concentrated on the underlying issues, mainly shame, which prompted her eating disorder and self-harm behaviors. The therapist facilitated personal and spiritual growth emphasizing grace and forgiveness. The body image specialist addressed the patient’s shame in relation to body dissatisfaction.
Each week in the patient’s weekly self-assessment and diary cards she rated her SIB urges and reinforced her commitment to safety. As a result of these interventions, the patient did not self-harm throughout the first 7 weeks of treatment. Her Safety Plan seemed quite effective. But urges to self-harm became increasingly pronounced as her Intensive Family Week approached. Also, as the patient’s weight restored, her body image distress increased. The patient did not verbalize the extent of her growing anxiety, yet revealed later in treatment that the days approaching Family Week were the most difficult of her treatment.
On the weekend prior to Family Week, the patient was struggling with a desire to purge. With the intention of finding a time of peaceful reflection and meditative prayer, the patient asked to visit the Remuda chapel during her free time. Since she was not on precautions at this juncture, she was allowed to leave the community for a short time. As she began to pray in the chapel, an intense sense of shame, unworthiness, and personal disgust began to overwhelm her. She was having a difficult time understanding how God could accept her and believed that the concept of grace was impossible to comprehend. She reflected on her past behaviors and felt that she had brought disgrace to her family. She thought, “Why in the world would God want me to be his daughter?” She did not understand the Gospel message that Christ had already forgiven her when He chose to die on the cross for her sins. Instead, she felt that she could not accept forgiveness and entry into God’s family without punishing herself. Historically, this patient would turn first to purging when she felt the urge to punish herself. But she had committed to Remuda staff that this would no longer be an option for her. In a state of despair, the patient picked up a tambourine in the chapel room and began beating her arm with its sharp side. Within minutes, the patient realized that God would not want this and stopped the behavior. She returned to the community with plans to hide the incident. Upon discovery of the bruising on the upper portion of her arm by nursing staff, the patient stated that she had fallen while going downstairs. After receiving comfort and medical attention from the staff, she felt guilty and disclosed the incident. Staff learned that she had indeed tried to utilize cognitive-behavioral skills taught in Remuda’s Skills Program and that they had worked to a certain point prior to the SIB.
Following Remuda’s Self-Harm Protocol, the patient was immediately assigned a support staff person to keep her within eyesight at all times. She was also taken out of regular program so that she could focus on and grow from the SIB incident through a Behavior Chain Analysis (BCA).
The patient’s BCA showed that the events leading to the SIB began the day before. The patient found herself vulnerable from anxiety as Family Week approached. She found herself thinking that she was unworthy of her family’s care and guilty that her father would have to miss work to spend a week with her. She felt shameful. In the past, she had used purging behaviors to temporarily resolve these feelings. Using her skills of radically accepting the reality that purging was no longer an option, she had resolved not to purge. She tried several additional distress tolerance skills, including distracting with activities, pushing away thoughts, self-soothing through self-care activities, and plans to find meaning through time with God and prayer. As such, her plan to visit the chapel was well-intentioned. Yet it ended up being the prompting event or trigger for her self-harm.
In reviewing her BCA, she listed skills that could have prevented her SIB. The patient realized that all of her interventions were isolative and that the key factor necessary was to reach out to others. The patient also understood that the skills of keeping her self-respect and acting opposite to emotion could have been useful. The patient was able to see that the self-harm actually created more guilt and shame, and that the behavior had not been effective in giving her relief. In exploring the spiritual struggle that had occurred in the chapel, she further found that sharing her difficulty through prayer and listening to God’s will through meditation on the Scriptures might have given her the answers she needed during the difficult time. She was encouraged to ask for guidance from staff when spiritual dilemmas would occur. The patient was able to formulate a Safety Plan to prevent further self-harm incidents. The patient’s support precautions were slowly diminished as she earned the trust of staff that she would indeed be able to keep herself from SIB. She did, in fact, remain free of self-harm for the remainder of treatment.
Family Week was effective in that the patient verbalized her current eating disorder patterns and how the events in her life had shaped her ineffective beliefs. Although the family had an understanding of her problem and learned new communication tools, unresolved grief and marital discord diminished the family’s ability to reach full resolution of certain issues. The family was encouraged to seek ongoing individual and family counseling in their home state.
The patient’s discharge planning involved a detailed self-harm prevention plan. Contracting to stay safe, the patient was admitted to a lower level of care to provide a transition prior to outpatient treatment. The patient was vulnerable to purging as she reached her ideal body weight. Continued skill building and practice to reinforce her confidence were necessary for her to continue in recovery. The patient also needed continued support in her spiritual growth to fully accept the grace and forgiveness inherent in her Christian beliefs. Staff communicated verbally and through medical records to the team who would be taking over her care and the patient discharged with optimism about her future.
Garner, D.M. (1991). Eating Disorder Inventory-2: Professional manual. Odessa, FL: Psychological Assessment Resources, Inc.
Wall, A.D., Cumella, E.J., & Darden, R.A. (2003). Remuda Spiritual Assessment Questionnaire Version 1.0. Wickenburg, AZ : Remuda Ranch Center for Anorexia and Bulimia, Inc.
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