Cognitive-behavioural therapy for deliberate self-harm Slee, N.

Citation

Slee, N. (2008, April 24). Cognitive-behavioural therapy for deliberate self-harm. Retrieved from https://hdl.handle.net/1887/12835

Version: Not Applicable (or Unknown)

License: Leiden University Non-exclusive license Downloaded from: https://hdl.handle.net/1887/12835

Note: To cite this publication please use the final published version (if applicable).

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Therapist: If you harm yourself it is important to get help, because it is very difficult to get better on your own. In order to get an idea of how the treatment works, we can look at the example which you just talked about of a difficult situation last weekend. What exactly happened?

Christy (17): When I went to my parents¸

home last weekend, my father, mother and sister

(*

were washing the car. Total chaos entered my head and I didn't know anymore what to do.

I cut myself with a kitchen knife to stop the chaos. I don't understand myself, because there really wasn't anything going on that was a problem.

Therapist: In order to gain an insight into the chaos it can be very helpful to look closely at what was happening, what you were thinking, what you were feeling, what you were doing and how your parents and sister reacted. Do you remember what you were thinking when you arrived and saw your parents and sister washing the car?

Christy: My sister still lives at home and I just came by and then I wound up hanging around.

Therapist: What did you feel then?

Christy: Lonely, sad, and also tense; it just started to get worse. Thoughts raced through my head - total chaos.

Therapist: Do you remember what you were thinking?

Christy: My parents don't care about me. Nobody cares about me…Nobody cares…I felt so sad and lonely…

Therapist: Yes, the more negative thoughts you have, the lonelier, sadder and more tense you will start to feel. See how your thoughts and feelings amplify one another?

Christy: It feels good to talk about this, because I find it really strange and scary, as if cutting just happens for no reason at all.

Therapist: The feeling of chaos does not just appear from nowhere. Nor does the cutting. When you start to become aware of your thoughts, feelings and behaviour in difficult situations, you can gradually learn how to stop the cutting behaviour. This is the main objective of the treatment. During the treatment you will learn to recognize negative thoughts and how to challenge them. You will learn to bear and accept negative feelings. You will also learn how to deal with problems and gain self confidence.

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5.1 Early phase of the treatment (sessions 1 and 2)

5.1.1 The significance of DSH

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id]Zg#‘I am usually busy with work and sports. When I am not busy, I start to think about things that happened in the past. I can't stop these thoughts. They only stop when I start to cut myself. That brings relief. The cutting hurts, but the tension before the cutting is worse.

Just like long ago when my mother would hit me; the moments before the hitting were the worst. I would be relieved once it was over…¸

5.1.2 Explanation of administering treatment and making practical agreements

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5.1.3 Formulating goals

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Amy (24), discussed previously, appears to avoid experiencing emotions by cutting herself or staying busy. The therapist is of the opinion that Amy can benefit from expanding her emotion regulation skills. During the sessions she can learn to experience her feelings of tension in a safe manner, and outside the sessions she can in the first instance benefit from activities which offer her solace. Processing the earlier traumatic life events does not fit within the short term treatment, but could be a subject for follow up treatment. Amy, together with her therapist, formulates the following goals: She wants to reduce stress and learn alternatives to take the place of cutting herself.

(-

5.1.4 Making a help chart

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5.1.5 Filling in the agreement card

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5.2 Middle phase of the treatment: sessions 3 and 4

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5.2.1 Evaluating the current mood and DSH during the past week

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5.2.2 Introducing the diary for problem situations

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5.2.3 Skills, talent and resilience

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When Jade (19) is asked about her strengths, she reveals that she can dance well and that she is rather social.

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Initially, Helen (23) is not able to name any activities which she enjoys. As therapy progresses, it appears that she enjoys watching old movies. She will reward her self by watching a movie after coming home from a long day at work.

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5.3 Middle phase of treatment (continued): sessions 5 through 10

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5.3.1 Possible interventions for cognitive problems

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™ Recognizing, challenging and distancing from negative thoughts

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Grace (17): I have been depressed for a year and it is just getting worse. It is really hard on my parents. Sometimes I think that it would be better for everyone if I were dead.

Therapist: What would you think if your parents were depressed and needed care?

Grace: Well, if they were depressed, I would also want to take care of them.

Therapist: Also?

Grace (smiles): Yes, when I think of it, my parents want to take care of me because they love me.

Therapist: How do you feel when you think like that?

Grace: This thought makes me feel better.

™ Identifying dysfunctional schemas

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Emily (22) refers to herself as ‘bad ‚ .

Therapist: I was wondering if you know of anyone who is a good example of ‘bad ‚

; someone you know personally or someone you have read about in the newspaper or know about from TV.

Emily: Well murderers, psychopaths, parents who abuse their children, people who abuse animals.

))

Therapist: If you compare yourself with them, how much badness do you show?

Emily: …Well, not that much.

Therapist: Is it then correct when you say that you are bad?

Emily: No, not really, I think.

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Jasmine (23) lives in student housing with six others. There is always someone who would like to do something with one or more of the group.

Jasmine: Sometimes I long to be alone for just a little while. I could just scream. I then go to my room to cut myself in order to feel some peace. I know I can ‚

t go on like this, but I am afraid to say no if they ask me for something. I am afraid that they will then start to ignore me.

Therapist: How do you know that they will ignore you if you choose to say no for a change?

Jasmine: Well, that ‚

s just what I think.

Therapist: How could you find out if this is really true?

Jasmine: I could ask my best friends what they would think if I said ‘no ‚ .

Therapist: Wonderful. In order for it to be a real test, it is important that you write down what you think they will say, so that we can compare it with that what your friends are going to say.

5.3.2 Possible interventions with emotional problems

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™ :c]VcX^c\bddYidaZgVcXZAZVgc^c\iddWhZgkZZbdi^dch

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WdY^Zh#

Julia (16) experiences flat affect to the point that she is unable to indicate what she felt in various situations during the past week. ‘Nothing ‚

, she says, ‘but when I burn myself, I at least feel something ‚

.

Audrey (25) relates in a monotonous tone how one of her neighbours humiliated her. When questioned, she said she did not feel anything when talking about it.

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ll never stop ‚ , says Audrey. 6hhjb^c\Vc^cY^[[ZgZciVii^ijYZXVcVahdWZV[dgbd[hZa[egdiZXi^dc!Vh^hi]ZXVhZ

l^i]?ja^V# ‘If I keep people at a distance, they can ‚

t touch me. ‚

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Therapist: The tension that you just spoke of, where is it located?

Amy (24): In my stomach, it feels tight because of the tension.

Therapist: Okay. Can you place your attention on that area of your stomach, right there where the tension is?

Amy: Yes… it is getting worse. I now also feel pressure on my chest.Therapist: Okay, the tension in your stomach, the pressure on your chest, just let it be. 6bn^hVWaZidZmeZg^ZcXZ

^i[dghZkZgVab^cjiZh#

Therapist: Well done. What did you notice when you observed the tension?

Amy: Well, that it first got worse and then it became less intense. I didn t think I would be able to keep it up.

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Y^hhdX^Vi^dc#

Lilian (28) puts her cat on her lap and pays attention to all sensory perceptions while she pets the cat; the soft fur, the warmth of the cat ‚

s body, the purring, how the cat slowly opens and closes its eyes, the patterns of the brown and black stripes of the fur. She discovers that this calms her and that it prevents her from dissociating.  

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Rachel (15) is not aware of her feelings of fear and dissociates when she watches TV programs that remind her of sexual abuse. She describes how she takes all the medication she can find, as if she were ‘in a daze ‚

. During the session Rachel becomes aware of light feelings of fear and she is able to apply techniques to calm herself (for example, drawing, colouring, reading a book in a rocking chair).

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Kevin (19) divides emotions into two categories: ‘chillÉ and ‘not-chillÉ.

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Rachel (15) discovers that lounging around in a rocking chair with a cup of tea and a children s book, can be more effective than each one of these activities alone. Dci]Z]ZaeX]VgieVi^Zcih

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Jessica (26) notices that taking a walk has a positive impact on her mood if she is mindful of her surroundings.

5.3.3 Possible interventions with behavioural problems

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Mariah (27): The girls I work with are just straight up rude. They are always talking about the way I dress. They are also saying I am fat and other ignorant stuff like if we were in high school. I am really getting frustrated with them and my patience is running low…

Therapist: I am very sorry to hear about your situation...it seems like little bits and pieces of high school will follow us for the rest of our lives.

Mariah: Yes, I had rude people too when I was in high school but just ignored them because if they see that you are not getting upset then they will get bored with bugging you.

Therapist: Could that be helpful in this situation too?

Mariah: Yes, now that I think of it, ignoring them seems the best thing to do.

Therapist: What else did you find helpful back then?

Mariah: Well, I could try to focus on the girls I like to hang out with and not so much on the others. I could also respond playfully, with a joke…that might surprise them!

Therapist: Wonderful how you use your imagination to deal with this situation.

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Zoe (20) tells that she has a knife hidden beneath her bed. The therapist reminds her of the goals she has set.

Therapist: you want to stop cutting yourself, yet you have a knife within reach. When things become hard for you, you can just reach for it. How do you see this?

Zoe: The knife makes me feel safe; when I feel awful I can do something about it.

Therapist: Exactly, you are used to reverting to cutting yourself when you feel bad. You have just started to deal in a different manner with your feeling of pain, such as using the help chart. I wonder if you get the chance to practice this new skill when the knife is in reach…

Zoe: Hmm…, yes, the knife beneath the bed does make it more difficult, and it doesn ‚ t really fit with what I want to change…

).

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Michael (18): I regret that I started using drugs. I lost a lot of friends because of it.

Olivia (28): My grandfather molested me when I was seven. Nothing can change that.

Ethan (20): It is so hard to be depressed for so long and not knowing when I ‚

ll feel better.

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5.3.4 Possible relational interventions

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