Family Enrichment Center of Seattle

Professional Programs

Clinical Approaches to Chronic Self-Harm Syndromes

An estimated three million Americans engage in some form of self injury. Incidence rates are increasing, especially among adolescent and young women. Without benefit of specific training, clinicians’ countertransferences, misconceptions, and lack of information about chronic self-injury can misinform clinical judgment leading to exacerbation of self-injurious behaviors. 

For adolescent and adult survivors of abuse and neglect, while suicidal ideation and frank suicidal behavior may coexist with patterns of chronic self-injury, clinicians often misconstrue these acts as expressions of suicidal versus self-regulatory intent. Such a failure of empathy can lead to iatrogenic exacerbation of the client’s self-injurious behavior.

Chronic self-injury in such patients is better understood as an attempt to adapt to and manage a difficult existence, than to end one.  Survivors of childhood abuse and neglect most often use self-injury as a way to manage emotional states, body states, cognition, and psychological function. The motivation for self injury often is complex and variable.  Personal rationales for self-injury often are “trance logical” (e.g., “hurting will relieve the pain,” “pain is pleasure,” “I can keep you from hurting me by hurting me first/worst”). Self-injurious behaviors are trance-based (i.e., dissociated from their rightful sensations, affects or knowledge).

Client expressions of severe or chronic self harm can trigger primitive countertransference and counterresistance in even seasoned clinicians. Unexplored countertransference reactions, misconceptions, and lack of information about chronic self-injury can misinform clinical judgment and lead to iatrogenic exacerbation of self-injurious behaviors.

Through lecture, discussion, clinical examples, and practical exercises, the presenter will explore the origins, motivations, logical properties, and clinical management of self-injury.  The presenter will describe typical motivational frameworks for self-injury among adolescent and adult survivors of abuse and neglect, along with guidelines and strategies for intervention illustrated with ample case material.  Building on this theoretical basis, participants then will engage in powerful supervised exercises and feedback sessions designed to: 1. clarify their experience of client self-harm, 2. explore idiosyncratic reactions, and 3. identify and perhaps work through countertransference vulnerabilities in current practice.

The program will assist participants to become intervention-generative in their own cases.

Working with the Shattered Self

Especially for clinicians unfamiliar with the autohypnotic basis of dissociative symptomology, the treatment of dissociative disorders can be bewildering, frustrating, and taxing to client and clinician alike. Multiple transferences, frequent crises, entrenched patterns of self- (and other) harming behaviors, highly conflicted interpersonal fields, gross cognitive distortions and trenchant dysfunctional beliefs can overwhelm and disorient even the experienced clinician   Working with issues of severe and extreme abuse may challenge or shatter the therapist’s basic beliefs about safety, goodness, and meaning, leaving one anxious, vulnerable, and uncertain.

These factors often conspire to promote common clinical errors such as:
- Failure to create or hold the therapeutic framework
- Fascination/reification of the disorder
- Errors in pacing/timing sequencing
- Safety and containment failures
- Role/boundary confusion/diffusion, multiple roles
- Over-functioning, over-involvement
- Countertransference counterresistant avoidance of difficult affects, themes
- Countertransference Compensation of Client (codependency)
- Making “memory work” the purpose or goal of treatment to the detriment of personality integration and functionality.

The presenter will discuss effective clinical management, common treatment errors and other issues in the treatment of disorders along the dissociative spectrum.

The session will conclude with a videotaped clinical demonstration showing the presenter’s emergency consultation with an acutely and chronically suicidal, chronically self-injuring, dissociative identity disordered client with imminent plans to kill herself. The therapist is seen making rapport with a group of highly oppositional, emotionally charged, self-destructive ego-states and, using techniques drawn from hypnotherapy, along with other direct and indirect techniques, helping the client to metabolize painful affects, shift cognitive frameworks, build expectancy for positive change, and incorporate safety measures.  The therapist draws upon a variety of formal hypnotic techniques and phenomena (i.e., hallucination, eidetic imagery, age progression, amnesia, and so on) but also utilizes and directs the client’s dissociative capacities as an extension of the hypno-dissociative working medium.  The presenter will share some of his own thoughts and feelings that occurred at critical points in the session as well as field questions and discussion between tape segments.  Finally, he will present a four year follow-up on the case.

Countertransference, Creativity, Play, and Renewal

Working with trauma and abuse victims can evoke powerful countertransference, counterresistance, and parallel process in clinicians. At times, these unconscious reactions can signal the clinician’s own unresolved woundedness or trauma. At other times they are a “normal” occupational hazard. Left unchecked and unexamined, though, either type can scuttle therapy and endanger both client and clinician.  Clinicians caught in the grips of unexamined countertransference, secondary traumatization, or burnout may retaliate, become disabled, or collude with the client to extrude valuable expressions from the therapeutic crucible, thus potentiating client acting-in or -out.

Beyond the intensity and demands of trauma therapy itself, clinicians today must operate in an increasingly turbulent climate of practice. Contradictory pressures buffet them from all sides (e.g., the strictures of managed care and the death knell for long term, depth psychotherapy; the blurring of traditional distinctions between forensic and psychotherapeutic domains; the adversarial climate surrounding the trauma recovery field, coupled with claims that assertions of widespread traumatic abuse in the culture evince a new type of “witch hunt” of innocents by abuse and trauma professionals; the degradation of the therapist-client confidentiality privilege; major reductions in social and health services; the movement against entitlements; and so on). Clinicians may find it increasingly difficult to protect the boundaries of the therapy frame from forceful incursions of the system.

Caught in this matrix of demands, clinicians are at greater risk than ever for issues of the self. Yet, rarely can therapists escape the maelstrom to come together safely to honestly assess their current countertransference and counterresistances as well as other issues of the self of the therapist in a non-adversarial, supportive, confidential and well-boundaried, psychoeducational community.

In this experiential supervision clinic, participants first will create a well-boundaried psychoeducational learning community.  In the second session, participants will engage in large and small group exercises that emphasize the qualities of spontaneity, play, reflection, experimentation, choice, and esprit de corps.  In the second session, participants will use these heightened sensibilities and skills to examine current countertransferences and counterresistances, in light of personal woundedness, trauma, and childhood internalizations.

The leader will endeavor to create an enjoyable, playful climate of mutual respect, trust, confidentiality and containment throughout the clinic, with a strong emphasis on the voluntary nature of all activities during the clinic.