Working With Clients Who Self‐Injure: A Grounded Theory Approach

Self-injury is an act of physical self-harm that is done purposefully and without explicit intent to die (Weierich & Nock, 2008). Researchers estimate that approximately 4% to 39% of adolescents self-injure, and this number is expected to increase (Craigen, Healey, Walley, Byrd, & Schuster, 2010). Although not all people who self-injure seek professional assistance (Craigen et al., 2010), the frequency with which counselors work with clients who self-injure is increasing. Researchers who investigate self-injury continue to increase awareness of this issue within the professional community (Trepal & Wester, 2007), but little attention has been paid to the counselor's experience. Accordingly, and in consideration of previous research indicating the effect of various counselor personal qualities on counseling outcome (e.g., Greason & Cashwell, 2009; Urbani et al., 2002; White, Trepal-Wollenzier, & Nolan, 2002), examination of the counselor's response and approach to working with clients who self-injure is warranted. Therefore, the purpose of this study was to develop a theory of the process of working with clients who self-injure on the basis of the clinical work of licensed professional counselors (LPCs). We addressed the following research questions: "What are counselors' experiences working with clients who self-injure?" and "How do LPCs approach working with clients who self-injure?" Noteworthy to any exploration of self-injury is consideration of the relationship between self-injury and suicide. Although a clear understanding of this relationship is not evident, individuals who self-injure are at an increased risk for suicide (Toprak, Cetin, Guven, Can, & Demircan, 2011). Suicide and self-injury share similarities, but significant differences also exist (Chapman & Dixon-Gordon, 2007; Muehlenkamp & Gutierrez, 2004; Wester & Trepal, 2005). Self-injury is sometimes conceptualized as part of the suicidal continuum (e.g., Hawton, Harriss, & Rodham, 2010; Howson, Yates, & Hatcher, 2008). However, the notion of self-injury as a coping skill is also supported. Kakhnovets, Young, Purnell, Huebner, and Bishop (2010) found in their study of college students that self-injury serves as a means of coping with the negative emotions of depression, anger, stress, and loss of control. Nock (2009) echoed this conceptualization, stating that self-injury "functions as a means both of regulating one's emotional/cognitive experiences and of communicating with or influencing others" (p. 79). In this sense, self-injury can be nonsuicidal and serve potentially life-preserving functions. These functions include emotion regulation, emotion expression, and distraction (Chapman & Dixon-Gordon, 2007). Additional research on the relationship between suicide and self-injury is needed. The most effective treatment method for use with this population has yet to be identified (Wester & Trepal, 2005). Empirical evidence suggests the potential efficacy of dialectical behavior therapy (DBT; Hamed, Korslund, Foa, & Linehan, 2011; Pistorello, Fruzzetti, MacLane, Gallop, & Iverson, 2012; Shearin & Linehan, 1994), problem-solving therapy (Hatcher, Sharon, Parag, & Collins, 2011; McLeavey, Daly, Ludgate, & Murray 1994; Raj, Kumaraiah, & Bhide, 2001), and cognitive therapy (Slee, Spinhoven, Gamefski, & Arensman, 2008). However, research examining the efficacy of treatment methods for self-injury is still emerging, and the majority of treatment interventions are based primarily on clinical experience (Trepal & Wester, 2007). Zila and Kiselica (2001) found that the limited scholarly resources available on understanding and treating self-injury can leave counselors feeling frustrated and apprehensive in their work with these clients, ultimately resulting in a lower quality of care. Many counselors have insufficient training to manage the myriad issues that arise when treating clients who self-injure (Hoffinan & Kress, 2010). …