In an effort to understand the brain reward system more wholly, the science of addiction medicine is moving away from a focus on specific drugs and including other behaviors defined as the process addictions. Process addictions can include such areas as food, sex, Internet, and gambling addictions (Smith et al., 2012). Addiction fuels the pathological pursuit of substances or addictive behaviors that are directly connected to the brain reward centers. The human brain produces a number of chemicals—serotonin, dopamine, norepinephrine, GABA, and endorphins—all of which work together to produce feelings of well-being. When these chemicals are low or blocked from the brain receptors, it often results in feelings of stress, pain, discomfort, and agitation. This condition is known as the reward deficiency syndrome, or RDS (Blum et al., 2012). Those suffering from RDS are unable to produce adequate feelings of well-being and may self-medicate to help raise the levels of chemicals to feel and function better. Often, self-medication is achieved through the addiction of specific substances, which may include sugar, caffeine, nicotine, or illegal substances (LifeGen, 2010). Similarly, this basic concept of self-soothing, alleviation of pain, and creation of positive feelings is accomplished through engaging in behaviors intended to self-harm (Favazza & Rosenthal, 1993).
In recovery-oriented treatment, the emphasis is abstinence from all substances, including process addictions. The concept of addiction transfer refers to the process by which the client may stop abusing substances and turn to destructive process addictions, including self-harm behaviors, to stimulate a neurochemical reward in the brain.
An abstinence-based addiction treatment model can be appropriate for the treatment of process addictions including self-harm behaviors when associated clinical protocols for related psychosocial dysfunction are implemented.
Though there are varying views as to a common psychological profile, in a residential setting we have found that self-harm is best treated as a primary process addiction within a program of abstinence and recovery rather than as behavior resulting from underlying psychological issues.
As with the early debates over alcoholism and addiction, the pathological behavior needs to be treated while identifying and treating the component psychological issues.
This hypothesis was tested within an adolescent residential treatment program in which the following protocols and cases will present our findings.
Theoretical Models of Self-Harm
It has been agreed upon by the majority of researchers that self-injurious behavior serves a psychological adjustment function by alleviating emotional distress either during, or shortly after the person engages in the behavior (White-Kress, 2003). The anxiety-reduction model and the hostility model have identified the function of self-injurious behavior as a method of regulating the person’s emotional state, thus returning them to a baseline after engaging in the harmful behaviors (Ross & Heath, 2003). Favazza and Rosenthal (1993) found that the motivation underlying self-injurious behaviors “are tension release, termination of depersonalization, euphoria, relief from feelings of depression, alleviation of feelings of loneliness and alienation, decreased troublesome sexual feelings, release of anger, satisfaction from self-punishment, a sense of uniqueness, and manipulation of others” .
Self-injurious behaviors have also been identified to share common characteristics that are seen in other behaviors associated with addiction (Faye, 1995). The American Society of Addiction Medicine redefined addiction with the following characteristics: an inability to abstain, an overall impairment in behavioral control, a craving for drugs or other rewarding experiences, a diminished sense of the problems associated with one’s behavior and interpersonal relationships, and a dysfunctional emotional regulatory response (as cited in Smith, 2012). Buser & Buser (2013) identified that loss of control, compulsivity, the continued participation in the self-injury despite negative consequences, and tolerance were all associated characteristics present in addiction and in many cases of self-injurious behavior. Similar to the function of addictive behaviors, self-injurious behaviors serve the individual by alleviating or altering the person’s experience of unpleasant emotions (Buser & Buser, 2013). The feelings of initial relief followed by intense negative feelings of shame, guilt, and lower self-esteem have been identified in self-injurious and addictive behaviors (Faye, 1995). This shifting from more distressing negative emotions to positive or neutral feelings demonstrates how these unhealthy coping skills are reinforced, despite negative social and emotional consequences (Chapman & Dixon-Gordon, 2007).
The loss of control that is associated with addictive behaviors is also related to the experience of cravings and the motivation to continue to engage in the behavior, self-injury in this case. Self-injurers endorse the urges and cravings to perform acts of self-injury and a perceived lack of control over their behavior. The addictive features of self-injurious behaviors are also evident in the continued participation in self-injury despite the negative consequences and damaging effects of the behavior (Buser & Buser, 2013).
Researchers have found that the development of tolerance among those that self-injure also mirrors the brain activity identified in tolerance of substance-related addictions. Alcoholism has been identified as having a strong relation to the neurotransmitter system, as seen in the endogenous opioid system (EOS). The EOS, which is made up of endorphins, operates to diminish the individual’s experience of pain and for the self-injurer, may even serve to improve mood and emotional regulation. Researchers have suggested that like substance-related addictions, over time the activation of the EOS requires more severe and frequent forms of self-injury, thus modeling the development of tolerance as seen in substance-related addiction (Buser & Buser, 2013).
Smith (2012) posited that the future definitions of addiction and addictive behaviors need to include substance related and non-substance/behavioral addictions, also known as process addictions. Smith (2012) based this definition “on an understanding that both psychoactive drugs and certain behaviors that produce a surge of dopamine in the midbrain are the biological substrate for addictive behavior” . Therefore, treatment modalities that historically have been useful in the addiction population may also be beneficial in targeting the underlying feelings and behaviors associated with self-injury.
Self-Harm Treatment Model
Self-harm can be treated much in the same way as any other addiction. Most addiction treatment is based on a Twelve Step model in which the addict begins with Step One: accepting powerlessness over alcohol. Those engaging in self-injurious behaviors can apply these same Twelve Steps to their self-harm. They accept powerlessness over engaging in self-harm and identify how it has made their life unmanageable. Clients in treatment for substances are given recovery assignments to complete on a daily basis. Self-harm clients are given these same assignments except that they identify the triggers, cravings, consequences, and so forth of their self-harm behavior.
In a residential setting, adolescents identify that their self-harm behaviors are most often the result of a need to regulate emotions, punish themselves, feel something, prevent suicide, establish interpersonal relationships (so parents or professionals will take them seriously), provide sensation, and have autonomy or control. Adolescents have indicated that without engaging in self-harm behaviors, they feel they could not stay alive and need to engage in these behaviors to regulate this pain.
Dialectical behavior therapy (DBT) was originally developed by Marsha M. Linehan to treat people with borderline personality. DBT combines standard cognitive behavioral techniques for emotional regulation and reality testing with concepts of distress tolerance acceptance and mindful awareness. Research indicates that DBT is also effective in treating patients who present varied symptoms and behaviors associated with spectrum mood disorders, including self-injury. DBT’s specific skills address the problem areas that are often typical of those who engage in self-harm behaviors. For instance, for confusion about self, clients can utilize mindfulness skills; for impulsivity, clients learn distress tolerance; for emotional instability, clients practice emotional regulation; for interpersonal problems, clients learn interpersonal effectiveness; and for the adolescent family dynamics, clients learn to walk the middle path. These skills can be taught to both individuals and family members in individual and group sessions (MacPherson, Cheavens & Fristad, 2013).
Although self-harm behaviors are treated as any other addiction in a treatment setting, they require additional safety protocols. The safety of the client who engages in self-harm behaviors and enters residential treatment in a “home” like environment, rather than institution or hospital setting, is the number-one priority. In a residential setting, sharps are locked up; however, those who engage in self-mutilation can cut themselves with hundreds of common household items. Paperclips, curtain hooks, picture frames, and anything with sharp edges are removed from any area in which the resident may be alone (for example, bedroom, bathroom, and so forth). Unlike other clients who are substance abusers, those who engage in self-harm cannot shower or sleep with the door closed. Clients who engage in self-harm are shadowed 24/7 (meaning a staff member is present with them at all times) and kept “eyes on” by staff until their behavior stabilizes. They sign a “no-harm contract” on a daily basis in which rewards are offered such as listening to music and/or additional recreational or therapy time when they are able to meet the contract.
Sarah was a fifteen-year-old female who was admitted to treatment due to self-harm behaviors. Sarah’s assessment revealed that she had a long history of multiple process addictions and that her ongoing cutting was only her current addiction. Prior to engaging in self-harm, Sarah had displayed addictive behavior around sex, alcohol, and eating. Sarah was unable to identify the causes behind any of her addictive behaviors in any of these areas, but she had also been unable to refrain from at least one of these behaviors during the past year.
As with all clients who engage in self-harm, Sarah was immediately placed on a no harm contract and introduced to various staff members who could assist Sarah and speak with her if she became triggered to self-harm. All sharps were removed from her possession and she was not allowed to utilize a razor unsupervised until the close of her treatment stay.
Sarah’s multiple process addictions were all treated through a program of recovery grounded in the Twelve Step model. Sarah identified herself as an addict and was able to apply this to the entire spectrum of her process addictions, including her self-harm. She attended nightly AA/NA/OA Twelve Step meetings and actively worked the Twelve Steps with a sponsor.
Sarah’s process addictions were validated and disclosed after multiple family sessions, and her family was able to provide relief through sharing their own history of addictions and by offering her increased support through attending Twelve Step meetings with her.
While some clients enter treatment for self-harm behaviors, others may begin engaging in self-injurious behaviors as the result of addiction transfer. While abstinent, and in early sobriety, clients often demonstrate the need to act out in addictive ways and may have the desire to begin cutting. Addiction transfer is often seen within the treatment setting, as it is typically the first extended period where clients are abstinent from their drug or process addiction of choice.
Susie was a seventeen-year-old who was admitted to treatment due to family-child relational problems and long-standing depression. Upon admission, Susie was found to have cuts covering the majority of her body, including self-directed negative statements carved into her upper leg. Upon assessment, it was revealed that Susie had an extensive history of substance abuse and dependence that had spanned over the period of two years. Prior to beginning her addiction to cutting, Susie had engaged in daily ecstasy and marijuana use and habitual opiate and hallucinogen use for a period of a year until discontinuing at the age of sixteen. In her assessment, Susie reported that she engaged in cutting during her abstinence from substance use and following learning of her parent’s divorce. Although Susie had been able to refrain from substances during the past year, she had remained increasingly active in her cutting and described using it in times of loneliness, hopelessness, and high stress.
Upon entering treatment, Susie was immediately placed on a no harm contract and verbally committed with a therapist to refrain from harming herself while in treatment. Susie was also informed of her “sobriety date” from cutting, and encouraged throughout her stay to develop pride in this date and utilize positive coping skills in an effort to meet this target. Susie’s therapist worked consistently with her to build self-worth and positive feelings that were counterintuitive to self-harming. She was encouraged to develop alternative coping skills to utilize during times of high stress, including painting, drawing, and running. Susie committed to a daily program of recovery grounded in the Twelve Steps. Susie attended nightly AA/NA meetings and worked the Steps around her addiction to cutting. She reframed her thinking to view her cutting in terms of powerlessness and unmanageability, and she sought total abstinence from all self-injurious behaviors. Susie was able to complete her treatment stay without engaging in any further self-harm behaviors and remained abstinent from these behaviors long after discharge.
In most cases, while utilizing DBT and their new positive coping skills, reinforcement and rewards are motivation for adolescents to abstain from self-harm. It is our hope that our experience will help improve recognition and treatment of this complicated dual diagnosis disorder.
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