David Van Nuys: Welcome to Wise Counsel, a podcast interview series sponsored by CenterSite, LLC, covering topics in mental health, wellness, and psychotherapy. My name is Dr. David Van Nuys. I'm a clinical psychologist and your host.
On today's show we'll be talking about the vexing problem of self-injury with Dr. Barent Walsh. Barent Walsh, Ph.D. has written extensively and presented internationally on the topic of self-destructive behavior. He's the author of the book Treating Self-Injury: A Practical Guide, and he's also co-author of the book Self-Mutilation: Theory, Research and Treatment. Both of these volumes have been translated into Japanese. Dr. Walsh recently completed a self-injury prevention DVD and program for high schools in collaboration with Screening for Mental Health of Wellesley, Massachusetts. Dr. Walsh is the executive director of The Bridge of Central Massachusetts in Worcester, Massachusetts. He oversees 35 programs including special education services and residential treatment for children, adolescents and adults with mental illness, developmental disabilities and/or complex family problems. The Bridge also provides services for homeless individuals and operates two drop-in centers for gay, lesbian, bisexual and transgender youth.
Now, here's the interview.
David: Dr. Barry Walsh, welcome to Wise Counsel.
Barent Walsh: Thank you very much for having me.
David: I recently discovered your work as a result of a flier I received in the mail announcing the upcoming 42nd Annual Conference of the American Association of Suicidology, in which you'll be giving a workshop on self-injury.
Barent Walsh: That's right; I've been doing that for quite a few years now.
David: Oh, really. Well, in case anyone listening would like to attend, it's a three day conference in San Francisco and will be held April 15-18, 2009. We'll put a link on our website. At any rate, as I read the blurb about you and your self-injury workshop, and also found other information about you on the Internet, I quickly saw that you're an expert on this topic and was eager to interview you.
Barent Walsh: Well, great.
David: So perhaps we could start with a bit of your background and what drew you to working with self-injury.
Barent Walsh: Well, in the late '70s and early '80s, early in my career, I was running a variety of adolescent programs and they were presenting with self-injury. These were pretty seriously compromised adolescents and I was perplexed by the problem of why people would keep hurting themselves over and over again. And at the time I was also in graduate school and needed a dissertation topic.
David: Oh, I remember that phase very well.
Barent Walsh: Yeah, so it was a promising topic and, oddly enough, it's one that I've lived with ever since.
David: Okay, well, what are the forms that self-injury takes?
Barent Walsh: Well, there are many forms of self-injury. In the large number of empirical studies about self-injury the most common forms are generally self-cutting, burning, picking at wounds, self-hitting; but there's really a myriad of forms. People are always inventing new forms, such as I read a case study recently of a fellow who expelled his asthma inhaler on his arm -- all 200 doses -- and created a lesion in his arm. But the thing that's distinctive about self-injury is it's a behavior that causes bodily harm but generally is not about suicide.
David: Okay, and talking about the variety, I seem to recall seeing a special on TV, if I recall correctly, that was about people who have a compulsion to get amputations, to actually have parts of their bodies amputated. I don't know if that would be considered along the same continuum, or if that's something different.
Barent Walsh: Well, that generally wouldn't be considered self-injury because it involves another party; not many people amputate their own limbs. Now there are some extreme cases in the literature where people do self-amputations, but they're extremely rare. Other people who seek out surgeons for various types of body modification really generally wouldn't be considered self-injury, but another kind of problem that perhaps is linked in terms of self destructive thoughts and feelings, but not technically self-injury.
David: Okay, now do you have any statistics at hand about the frequency of these sorts of behaviors?
Barent Walsh: Well, we do. Self-injury currently seems to be an epidemic in our country, and the statistics in various studies nationally and actually beyond -- in the U.K., Japan and Europe -- is many samples of youth are coming in the 10-20% range, even in community samples, samples from high schools, universities and the general population. And in clinical samples the rates are even higher; you can get 15-30% in certain in-patient samples.
David: Wow, that is very frequent. Now, what about age distribution? I have the impression that it's more common among young people. Is that right?
Barent Walsh: Yes, on average the age of onset is about 13-15, but we are finding it in middle school ages too, sixth, seventh, and eighth grade, 12-13-14. But on average its 13-15 for an age of onset in quite a few of the studies that have emerged in decade 2000.
David: Well, those are ages of onset; is it a behavior that people tend to grow out of on their own as time goes by? Or can it continue actually on through life?
Barent Walsh: It depends. You can really think about self-injury in a sense as being bimodaly distributed. There are clinical populations of people who have experienced pretty aversive experiences, such as abuse, and they're compromised and they carry with them pretty serious psychiatric diagnoses; and for those folks self-injury can persist well into their 20s and even 30s. But there's a new emerging generation of healthier self-injurers, such as people who are functioning quite adequately in college samples, who are self-injuring. And those folks it would appear that the length of their self-injury is much briefer, particularly if they get some help early in the game.
David: Earlier you used the word epidemic proportions, and it seems like we hear a lot more about these sorts of self-injurious behaviors today. Is that because they are actually on the rise or because of better reporting?
Barent Walsh: It's pretty clear they're on the rise. Self-injury these days is sometimes described as the anorexia nervosa of the 2000s, and by that I mean it's sometimes viewed as the current, most popular expression of adolescent angst. Many kids who self-injure are experiencing pretty intense emotion disregulation, and one of the main functions of self-injury is that it's oddly effective in regulating emotional distress. It helps people feel less anxious or angry or sad or ashamed, and for whatever reason, self-injury is resonating in the general population with youth these days. There's also some evidence that there is a social contagion influence on the Internet and beyond.
David: Yeah, I wanted to ask you about that. Maybe I'll come back to that. You're presenting at a conference on suicide. What's the relationship between self-injury and suicide, if any, apart from the obvious fact that suicide might be considered the extreme case? Do they have similar or different underlying dynamics?
Barent Walsh: Well, that's a complicated question to answer. The first is that self-injury, in and of itself, is separate and distinct from suicide; but because it involves bodily harm, it generally entails little or no suicidal intent. So, for example, cutting the forearms, punching yourself, burning yourself in a way that does tissue damage but poses little or no risk to life, that's not really about suicide. But as Thomas Joiner and others have pointed to, people who habitually hurt themselves may develop an ability to commit suicide down the line. So self-injury can be a powerful risk factor for suicide eventually, although the large majority of self-injurers do not go on to kill themselves.
David: Okay, you mentioned Thomas Joiner; by the way, he is my previous interviewee, prior to this interview.
Barent Walsh: Yes, well, I'm actually having Dr. Joiner to my agency next week. He's doing a training for us on why people die by suicide, so I certainly have high regard for his work.
David: Yes, well, that's wonderful. What do we know about the causes of self-injurious behavior?
Barent Walsh: I think the most direct cause is that someone is in intense emotional distress and they lack healthy coping or self-soothing skills to regulate that distress. And that's a somewhat simplistic answer, but it's the most direct answer.
David: Okay, well, I know that there's some genetic and neurological findings in relation to suicide. Are there similar studies or findings in relation to self-injury?
Barent Walsh: There are. There's a host of biological research going on related to self-injury, and some of them point to people having impaired limbic system dysfunction, that they just don't regulate their emotions very well; perhaps the limbic system is impaired or underdeveloped. One area of biological research that you've probably encountered has to do with the endogenous opioid system, and the notion that self-injury may release chemicals within the body such as endorphins that produce a sense of high or exhilaration. And one of the hypotheses is that people self-injure in order to retrieve that exhilaration or high. And there are other biological studies that have found that recurrent, even chronic, self-injurers in the laboratory seem to have much higher pain thresholds than normal controls. So there's quite a lot going on in the area of biological research and self-injury.
David: Well, that's fascinating, what you were just saying about the opiod system. I don't know whether it's from television series or somewhere I've gotten the impression that, at least in some cases, people are engaging in cutting or other kinds of self-injurious behavior to overcome a sense of numbness; that they just feel numb and that they're willing to go to that extreme just to feel something. Is that accurate?
Barent Walsh: It is accurate for some self-injurers; that gets back to my distinction between the clinical and the community samples of self-injurers. In clinical samples it's quite common that self-injurers have had a history of abusive experiences; and people who are abused often have learned to dissociate in order to survive abusive experiences. And those are the folks that, when dissociating, may self-injure to terminate those states of dissociation which are often described as feeling numb or dead or zombie-like. So there is a group of self-injurers who will use that behavior to terminate unpleasant experiences of dissociation. But the new healthier group of self-injurers, it appears that a lot of them don't dissociate, and they're not using self-injury to terminate dissociation but rather to bring down emotional intensity, such as anxiety, sadness, rage, shame, guilt and so on.
David: So actually we have two very different dynamics that we're talking about; on the one hand, people who are trying to raise their level of stimulation, and on the other people who are, in a sense, trying to lower it.
Barent Walsh: That's right, and then you have to also include all the social reinforcement influences as well, because some people use self-injury to communicate or to effect change in the behavior of others. And there's a couple of studies that point to the fact that self-injury is reinforced on the Internet; that people who self-injure may spent a lot of time in websites, chat rooms, message boards, devoted to self-injury. So a good understanding of self-injury these days has to look at internal psychological factors but also interpersonal factors.
David: Yes, I was wondering about the role of social contagion as I was thinking about this, and it seemed to me that, in fact -- I didn't know about the Internet -- but I did have a sense, or at least I wondered, if there might be a kind of faddishness and I wonder that about some diagnostic categories; and it seems like that really fits for this one.
Barent Walsh: You're absolutely right, there is something that is fad-like to the current popularity of self-injury, and it's important in working with adolescents that you be careful in how you use groups. For example, I've consulted to many schools around the country about managing social contagion episodes; sometimes they encounter five or six or ten students, all of whom know each other, and they may be actively encouraging each other to self-injure. And in working in groups with people who self-injure, it's important not to allow detailed discussion of self-injury because it actually can trigger the behavior. Groups can be very useful if you teach alternative coping skills within those groups, but self-injury war stories are counterproductive.
David: That's fascinating. So it becomes kind of like a university for techniques to hurt one's self.
Barent Walsh: That's exactly right. I've done a number of empirical studies of social contagion in group homes or special ed schools that my agency [unclear] -- it's called The Bridge, in Worcester, Massachusetts. And we have found that the behavior, if not well managed, can spread among teens; and even those who come in to care never having self-injured can learn it from others and have the iatrogenoc effect of learning self-injury while in care. So we've really learned some much more effective strategies for managing self-injury in milieu in order to avoid those kinds of disadvantages.
David: The epidemic proportion's rise has caused me to wonder about possible environmental causes -- toxic pollutants or heavy metals affecting the brain. Is there any evidence that something like that might be going on?
Barent Walsh: I can't say I've ever heard that particular hypothesis floated in the self-injury professional meetings that I go to, so that's an interesting area of speculation, but not one I've heard about.
David: Okay, well, you heard it here first.
Barent Walsh: I'll give you full credit.
David: And maybe there's some grad student out there looking for that dissertation topic, it might be a good area to investigate. Now in the flier for your workshop, you mentioned five areas of care and treatment. Maybe we can go through those here, though of course not in the same depth as you will in the workshop. You discuss what you call the informal response, which I guess refers to how a parent or a teacher might best respond when they discover cutting or some other self-injurious behavior.
Barent Walsh: That's right, yes. The informal response is important because it sets the stage for anything else. And I have two recommendations around what I call the informal response. The first is that you respond to self-injury with a low-key, dispassionate demeanor; and the reason for that is, that people who self-injure are generally emotionally disregulated, so it doesn't help to add more emotion to the mix. In fact, it's unstrategic; you don't want to run the risk of inadvertently reinforcing the behavior by being too effusively supportive, and certainly you don't want to condemn or put down somebody in distress. So a low key, dispassionate demeanor is strategic and appropriate.
And second of all, another aspect of the informal response is if you're a professional intervening with self-injury, it's important to present with a respectful curiosity. And I got that phrase from Caroline Kettlewell, who wrote a memoir about her experience self-injuring, called Skin Game. And Caroline and I have presented together quite a few times, and what she means by respectful curiosity, is that someone takes the time to understand what the functions of self-injury are for a person. And the way I like to address that is by asking the question, what does self-injury do for you? What does cutting do for you? What does burning do for you? Meaning, rather than leaping on and trying to stomp it out, or leaping into intervention, let's understand its functions first, and that entails a respectful curiosity that isn't judgmental, but is respectfully interested in learning more about why this is a behavior that works for a particular person.
David: Okay, that's very interesting. You know, earlier you mentioned the interpersonal aspect of it, and is it sometimes used to manipulate either parents or boyfriend, girlfriend, spouse?
Barent Walsh: I try to avoid the word manipulation because it has such pejorative, judgmental connotations; but self-injury is sometimes used to coerce people to act in a way that is targeted. But my take on self-injury in general is that interpersonal influences, by and large, are not sufficient to sustain self-injury over time. What's necessary for a really sustained pattern of self-injury would be some sort of internal emotional disregulation.
David: Okay, the second of the five areas of care and treatment that you mentioned refers to crisis intervention. What are you getting at there?
Barent Walsh: What I'm getting at there, is that I spend a lot of time in my workshop differentiating self-injury from suicide; that it's a behavior that is about emotional regulation, not about ending life; that it's a behavior that poses little or no risk to life physically; that its functions are different; that its aftermaths are different from suicide. So there are many ways that self-injury is different from suicide, but sometimes certain types of self-injury are particularly alarming and do require a crisis response. And these are low-frequency forms of self-injury, but they require a crisis response just like a suicide plan or suicide behavior.
And to be more specific, what I mean by that is that if people self-injure in a way that requires medical intervention such as multiple sutures, then that's a crisis response. And, by the way, in empirical studies of self-injury, 90% or more of self-injurers do a level of damage that does not require medical intervention. So when someone does do a level of damage that requires medical intervention, that usually suggests an exaggerated level of distress and that a psychiatric emergency evaluation at your local emergency room would be indicated.
The other time, the other circumstance, when self-injury does require an emergency response is related to particular body areas; and those body areas, in general, are face, eyes, breasts and genitals. I can't go into all the details of that in this format, but those body areas tend to be associated with psychotic decompensation or, in the case of breast and genitals, it can be related to some sort of PTSD response.
David: Oh, that's very interesting.
Barent Walsh: And those are atypical, alarming, unusual forms of self-injury that may require a crisis intervention.
David: Okay, now another aspect of treatment that you refer to is replacement skills training. What are you getting at there?
Barent Walsh: Well, standard cognitive behavioral skills training. The royal road to helping people give up self-injury is not to forbid it or to contract for safety or to condemn it, it is to teach people other ways to regulate their emotions that work as well as the self-injury. So replacement skills are what it's all about, and if someone's going to give up self-injury, it's a tall order, because people often say that it's very difficult to give up, They become very habituated to it, and if they are going to give it up they need other ways to regulate their sadness, anxiety, shame, anger and the like that works as well as cutting or burning.
David: You also talk about exposure treatment for those who've been abused and suffer from body alienation. What can you tell us about that?
Barent Walsh: Now we're back to that distinction between the clinical populations and the community populations. And in the clinical populations quite a few have had these aversive, abusive experiences, and for those folks, just learning skills in and of itself may not solve the problem, they may have to deal with the underlying trauma.
If you've been sexually abused or physically abused, sometimes it's not unusual that people develop a profound sense of body alienation. They come to hate their bodies because of what's been done to their bodies; they associate their bodies with traumatic, horrific experiences; they view their body as not really theirs, as contaminated, as dirty, and the like. And exposure treatment, which develops a hierarchy of traumatic events and guides a person using replacement skills through that hierarchy so that they're not longer plagued and controlled by the flashbacks and memories and intrusive experiences associated with those events; exposure treatment can really liberate them from their histories of trauma and allow them to move beyond that history and also fully give up self-injury.
David: From a public health standpoint, is there anything that can be done to prevent or lower the incidence of self-injurious behavior?
Barent Walsh: I think there is and, as a matter of fact, I'm launching with an outfit called Screening for Mental Health this month a self-injury prevention DVD and manual for high school students. And Screening for Mental Health is out of Wellesley, Mass.; they've done a number of suicide prevention programs for middle schools and high schools and also the military.
But in a broader sense than just that particular program, schools, for example, can do a better job of teaching kids self-soothing skills in a proactive way. So I'm hearing of some schools, for example, that before they administer exams they may teach their students certain simple breathing techniques to learn how to calm down, to lower their heart rate and respiration rate and be in a calmer state, in a state better able to focus on an examination. So, from a public health perspective, anything that enhances emotion regulation skills, coping skills, self-soothing skills would be something that would help prevent the onset of self-injury as a desperate attempt to manage emotional distress.
David: Well, that sounds like a great program. I'm remembering lots of outreach in the past; people thinking that -- I'm blocking on the word here -- self confidence is what comes to mind, but that's not the right word. But there was a lot of emphasis on trying to have young people have a better self image of themselves. In some ways this is a slightly different focus and seems like, concretely, a very beneficial one.
Barent Walsh: Yeah, well, I think it has the potential to prevent some of this distress and bodily harm if people can learn these skills proactively. I mentioned I do a lot of training in schools, and I've heard of elementary schools where they're teaching belly breathing or simple yoga techniques or other self-soothing skills, so that kids learn these things early in life and can start to use them automatically when they hit adolescence and that level of distress tends to exacerbate.
David: Yes. Do you have any basis for having some sense of how widely distributed among mental health professionals this knowledge is? I mean, what's your sense of the degree to which mental health professionals out there know how to react to and treat self-injurious behavior?
Barent Walsh: It's getting better because there's been just a wave of publications and studies during this decade; but it's still quite spotty. We still routinely have mental health professionals interpreting wrist cuts to be suicide attempts and we get people rushed off to emergency rooms labeled as suicidal who may be doing common low-lethality self-injury designed to regulate some emotional distress. And psychiatric hospitalization in such cases is often ill-advised, a wasted expense, stigmatizing for the person who goes into an in-patient psych unit. So there's still a lot of misunderstanding in emergency rooms and in-patient settings about self-injury, but I do think knowledge in general is being enhanced these days because there's just been a big emphasis on public education around self-injury, such as what we're doing right now.
David: Yes, and so what if one of our listeners has a relative, a child, or a friend who they're concerned about; how would they go about finding a therapist who's trained in this area?
Barent Walsh: A couple of recommendations, I guess, would be to contact the state psychological association. If someone is pretty impaired, a treatment of choice is Dialectical Behavior Therapy and the DBT website, which is behavioraltech.org or .com -- I'm sorry, I don't quite remember which one it is -- but that website for DBT does identify DBT services around the country. I think the thing that people really want to look for is that the mental help professional has experience dealing with self-injury, understands that it's different than suicide, and also uses a skills training approach, so that people can learn new skills that allow them to give up self-injury.
David: Okay, well, Dr. Barry Walsh, you've been very generous with your time and information, and I want to thank you for being my guest today on Wise Counsel.
Barent Walsh: Well, thank you very much for having me.
David: I hope you found this interview with Dr. Barent Walsh to be informative. I know I picked up some valuable tips about not over-reacting to such self-injurious behaviors such as cutting -- taking them seriously, certainly -- but not over-reacting. Toward the end of the interview you heard Dr. Walsh referring to Dialectical Behavior Therapy or DBT for short. Unless you've been listening to Wise Counsel from the beginning, you might not be aware that I interviewed Dr. Marsha Linehan, originator of DBT, back on October 16, 2007.
You've been listening to Wise Counsel, a podcast interview series sponsored by CenterSite, LLC.
If you like Wise Counsel, you might also like ShrinkRapRadio, my other interview podcast series, which is available online at www.shrinkraprado.com. Until next time, this is Dr. David Van Nuys, and you've been listening to Wise Counsel.