Abstract
Self-injury is increasing in prevalence and needs to be addressed in counseling and therapy. Walsh provides a timely, compassionate, readable, scholarly book that is intended to be a practical resource that will inform clinicians' understanding, assessment, and treatment of self-injury. The writing is enhanced with the inclusion of numerous brief case examples. He balances attention to traditional groups of individuals who self-injure, such as those persons with high levels of psychological distress who often have a traumatic history and those who practice self-injury but are generally psychologically healthy individuals who come from intact families, do well academically, and have strong social support networks. He does not address self-injury in developmentally delayed or brain-injured populations.
The author approaches self-injury with an individual intrapsychic distress focus that is examined from a biopsychosocial model. Although he recognizes the sociological and feminist understandings of self-injury, he discusses these only briefly. Readers interested in a feminist perspective are referred to Shaw (2002). Walsh emphasizes the importance of language and recommends the use of terms such as self-injury or self-harm rather than more pejorative and sensationalistic references such as self-mutilation or suicide gesture, terms that inaccurately associate self-injury with suicidality or imply a manipulative element. Generally the writing is respectful and compassionate, but includes some disconcerting descriptions of people as “emotionally deregulated people” or “self-injurers.”
The book is divided into three sections: definition and contexts, assessment and treatment, and special topics. The first section provides the reader with a good understanding of self-injury and its differences from suicide and body piercing/tattooing. The core of the book, assessment and treatment, provides cognitive-behavioral strategies that are useful for both new and seasoned therapists. The special topics cover contagion self-injury, self-injury in the school setting, and major forms of self-injury that are more accurately described as self-mutilation. Throughout the book, Walsh provides a number of forms useful for enhancing assessment and treatment as well as a breathing manual that can be photocopied by book purchasers for use with their clients.
The distinctions between self-injury and suicide aid the assessment process and can be reassuring to clinicians new to the area of self-injury. Walsh addresses therapeutic responses to disclosure of self-injury and clearly articulates the distinction between caring supportive reactions that might reinforce the behavior and compassionate inquiry, which neither reinforces nor minimizes the behavior. The assessment of self-injury is directly and logically linked to intervention.
Interventions described in detail include safety contracts, replacement skills training, cognitive interventions, bodywork, exposure treatment for trauma, and family therapy. Walsh discusses limitations and risks of safety or self-protection contracts but also offers when and how they might be useful with particular clients. He provides detailed information on replacement skills and notes which of these skills are of lower quality and less valuable in the long run but may provide a good beginning for some clients. The discussion of cognitive treatment provides clear explanations of a standard, respectful approach to automatic thoughts and cognitive distortions. Walsh recognizes the limitations of cognitive therapy in modifying core beliefs and talks about important “gifts” based on strong therapeutic alliances that are interpersonal in nature.
Walsh recognizes the importance of body image work and devotes a chapter to this topic as well as an appendix with the Body Attitudes Scale. Although Walsh is to be applauded for recognizing the importance of addressing body image, he does not discuss the relevance of social or media issues. Also of concern is his valuing of traditional “attractiveness,” which includes recommending homework that can contribute to difficulty with body image, such as charting weight loss, obtaining intrusive interventions such as derma-abrasion, and going to a “skin salon” rather than working on valuing of self. Other dimensions of body image are more balanced.
The discussion of family therapy is confusing in that Walsh talks about the limited empirical investigations in this area, yet recommends dialectical behavior therapy as the “treatment of choice for self-injurers and their families” (p. 202). He goes on to describe his own cognitive behavioral family approach. The dialogue of therapist/caregiver reactions to individuals who self-injure is compassionate and practical in terms of (a) self-monitoring and (b) strategies to manage affective and cognitive responses prior to responding in ways not helpful for the client. The explicit listing of responses that can interfere with a helpful stance can assist in self-monitoring.
Counselors working in the school system will find the chapter on public school self-injury protocol helpful. However, a major oversight is the lack of discussion of challenges related to informing guardians/parents when there is a high potential for the child being further subjected to highly punitive behaviors or system breakdown. The chapter on major self-injury (true self-mutilation) provides a certain amount of comfort for therapists working with these individuals, offering both hope and acknowledgement of the difficult journey. In addition, the annotated bibliography of both professionally and peer-developed Web sites will be useful to both professionals and individuals who self-injure.
In sum, Treating Self-Injury is a practical guide to understanding self-injury and includes clear descriptions of intervention strategies. A variety of both new and seasoned professionals, working in either clinical or academic settings, will find this to be a useful resource. Researchers will appreciate the extensive coverage of the empirical base along with the discussion of noted gaps in the literature. Clinical students in psychology, counseling, and social work will likely feel more confident facing their first client who self-injures if they have read this book.