The purpose of this article is to present an intervention, the externalization of client problems, which can be used to address non-suicidal-self-injurious behavior. Specific externalization techniques are discussed, including naming the problem, letter writing, and drawing. A case application and implications for practice are presented.
Non-suicidal-self-injury (NSSI) is most concisely described as a volitional act of self-harm with the intent of causing physical tissue damage (Favazza, 1996). Yates (2004) elaborated on the definition of NSSI by describing this act as the direct and socially unacceptable destruction of body tissue, which occurs without conscious, intentional suicidal intent.
Counselors who work with clients engaging in NSSI may struggle to determine the presenting problem, treatment goals, or appropriate level of care for current behaviors. Moreover, treatment paradigms may rely on the assumption that in order to effectively help clients with NSSI, the counselor must help the client to completely ameliorate the self-injurious behaviors. Another common assumption of most theoretical paradigms is the idea that the client must be taught (by the counselor) to apply cognitive and behavioral skills that will, theoretically, preclude further self-injury (Muehlenkamp, 2006). This prescriptive approach may fail to consider the unique strengths and contributions of the client and may serve to alienate the client by providing little opportunity for her or his perceived goals to be expressed and integrated into the counseling process. Given the ostensible value of a collaborative approach in facilitating therapeutic success (Eron & Lund, 1996), we present in this article a strength-based intervention (i.e., the use of externalizing techniques) that can be applied when counseling clients who engage in NSSI.
OVERVIEW OF NSSI
Research estimates have indicated that 21% to 66% of clinical samples and 1% to 4% of the general population engage in NSSI (Darche, 1990; DiClemente, Ponton, & Hartley, 1991). Prevalence rates appear to be equally distributed among men and women in community samples (Briere & Gil, 1998). In one study, 13% of high school students reported that they had engaged in NSSI at least once (Ross & Heath, 2002). One recent study of college students found that the lifetime prevalence rate of college students having at least one NSSI incident was 17% (Whitlock, Eckenrode, & Silverman, 2006), suggesting that a significant number of adolescents and young adults engage in NSSI.
Osuch, Noll, and Putman (1999) suggested that the following six motivational factors underlie NSSI: (a) affect modulation, (b) desolation, (c) punitive duality, (d) influencing others, (e) magical control, and (f) self-stimulation. Affect modulation encompasses the use of NSSI to control (i.e., increase or decease) feelings and emotions. The concept of desolation describes using NSSI to alleviate feelings of emptiness and anhedonia. Punitive duality relates to the concept of self-punishment, or situations in which a person engages in self-inflicted violence because of the need to punish her- or himself. Individuals who use NSSI as a method for influencing others often engage in the behavior with the intention of communicating anger, hurt, or rebellion in a manner that does not involve verbally speaking of these emotions. Magical control involves the client believing that her or his self-injury will prevent something from happening or will control some unacceptable impulse or desire (i.e., preventing the client from hurting someone else). The last motivational category identified by Osuch et al., self-stimulation, involves the client engaging in NSSI with the intention of increasing emotional arousal (e.g., increasing a pleasurable, euphoric sensation).
NSSI is a complex behavior. People who self-injure have a variety of mental health diagnoses (e. …