Offering that sense of calm and acceptance was integral to Kim Johancen-Walt's
work with "Jennifer," a client Johancen-Walt calls one of her
first met Jennifer, then 15, the teenage client was already cutting several times daily, but that soon ballooned to upward of 50 times a day.
"Although Jennifer's family had overcome many challenges and now offered support, she was still struggling with old patterns of thinking that continued to fuel self-injury," says Johancen-Walt, an ACA member who has 20 years of experience working with clients on issues of self-injury and suicide in a variety of settings.
A third of her
caseload in her
private practice in Durango, Colo., involves clients either currently or formerly engaged in self-injury.
Equipped with that information and knowing that Jennifer felt very disconnected from herself and others, Johancen-Walt
focused on building her relationship with Jennifer.
I accepted her
unconditionally and told her she
deserved love and kindness throughout treatment," Johancen-Walt
"Although the old messages of self-hatred were still there, she
now had a different way of defining herself.
With my help, along with [that of] many others, she
was eventually able to do what I now refer to as 'putting a wedge in the choke hold of self-injury.'"
still has a list that Jennifer found online of 72 strategies to avoid self-mutilating.
reminded me that just as with other types of addictive behavior, we have to help people replace faulty coping skills with more effective ones," Johancen-Walt
"This takes time, but eventually the scale can tip and the costs of self-injury can begin to outweigh the benefits [for clients].
also taught me how quickly habituation can happen and why we have to talk about self-injury from the beginning of treatment."
At the point when Johancen-Walt
and Jennifer stopped working together, Jennifer was still having occasional "slips," Johancen-Walt
says, but she
was also righting herself more quickly and maintaining the progress they had made together.
"We both defined her
treatment as a success and acknowledged that she
was a long way away from where she
was at the beginning of treatment," Johancen-Walt
emphasizes that she
represented only one component of the support Jennifer received.
Her support system also included her family, the caregivers in residential treatment and the school-based outpatient program where Johancen-Walt was then working as a therapist.
"I believe that our work - and relentless support - helped her
explore other possible ways of viewing herself in the world and an awareness that reality is subjective," Johancen-Walt
"Although it took several months, and a break from therapy while in residential treatment, she
was finally able to accept care and validation from others, and [she] improved quickly.
Her lens had effectively changed," says Johancen-Walt
, who contributed a chapter to The Adolescent & Young Adult Self-Harming Treatment Manual by Matthew D. Selekman.
says, although anyone can be at risk for self-injury, unresolved grief and loss appear to be common risk factors.
says that many of her
clients who self-injure are referred by others who care about them, including family members, friends, other counselors, teachers or doctors.
"Out of those self-referred, many have reached a state of desperation where they feel completely out of control because either the self-injury is no longer working for them or because they know they are becoming more at risk," she
"Clients are checking out our comfort level with this topic from the moment they enter our offices," she
"If I fail to address it, then I risk communicating to my client that I am not safe.
If I can't tolerate holding self-injury, then I can't tolerate the reasons they are doing it."
Additionally, if a client relays information about a significant loss, Johancen-Walt
typically asks how the client has been coping with the impact of that loss.
"This question is an invitation to talk about self-injury if it is in the room," she
and Wester point out that clients who engage in self-injury often use more than one method.
Probing the question of why these clients self-injure is also crucial, Johancen-Walt
"People self-mutilate for a variety of reasons, and we have to be careful about making assumptions about a behavior.
Over the years, I have received countless answers to that question.
However, one of the most common responses I have received is that it serves as a form of 'relief' from emotional suffering.
In these instances, it can be both a distraction and expression of emotional pain."
Another common explanation is that clients want to "feel something," Johancen-Walt
says, which is usually indicative of those who feel incredibly disconnected from themselves and from those around them.
Although less common, Johancen-Walt
says some clients use self-injury as a form of self-punishment.
"They have come to believe that they have to be punished, not only for their mistakes, but also for the mistakes of those around them," she
Counselors must be careful not to make assumptions about these clients, especially concerning whether they are "attention seeking" or "manipulative," Johancen-Walt
also tries to help clients externalize the self-injury.
"I will teach clients who are ashamed and not wanting to talk about their behavior or what is fueling it that self-injury wants them to stay silent," she
Externalizing the behavior can also reduce resistance on the part of the client, Johancen-Walt says, helping the counselor and client to form a united front against self-injury.
Buser says researchers have found that individuals who engage in NSSI are more likely to experience suicidal thoughts, and Johancen-Walt
adds that suicide risk increases the longer someone engages in self-injury.
emphasizes that counselors should not assume that clients engaged in self-injury are suicidal because many are not.
says, "if self-injury is not addressed in treatment, a client's risk of suicide may increase over time.
Remember that the end goal may not be to eliminate the self-injurious behavior completely, Johancen-Walt
Instead, it may be to change the client's relationship with the behavior.
"For example," she
says, "when the client is triggered and experiences an urge to 'use,' they can view that event as an opportunity to practice more effective coping skills, to figure out what they need and to validate themselves.
This is a process I refer to as 'shaking hands' with self-injury."
says counselors must also understand that these clients are engaging in self-injury in an attempt to survive; otherwise, they wouldn't be doing it.
encourages counselors to share that sense of understanding with their clients.
"I have had several clients over the years tell me that if they had not been self-mutilating they would have completed suicide," she
Finding the "soft spot" within each client means recognizing that each individual is unique - something Johancen-Walt
says is vital in this work.
One of her
mentors taught her
that counselors get into trouble as soon as they think they have clients figured out.
carries that lesson with her
, especially in her
work with self-injuring clients.
"This is an important reminder for therapists who may think they have 'seen it all,'" she
Kim Johancen-Walt at email@example.com