08/12/16

When Pain Feels Good

© sapegina |stockfresh.com

© sapegina |stockfresh.com

Counter-intuitively, self-harm or self-injury is best seen as an attempt to relieve pain than to cause pain. An NPR program, “The History and Mentality of Self-Mutilation” noted that in the late 19th century, two American doctors described a strange phenomenon. Women were puncturing themselves with sewing needles. The practice was so common, that doctors began to refer to the so-called “hysterical” women who did this as “needle girls.” Hysteria was the “it” psychiatric condition of the time. Sigmund Freud’s first published book was one he co-authored with Josef Breur, Studies on Hysteria. But self-harm has a longer history, dating back even to the time of the Greeks.

Self-harm is found in situations as wide ranging as monasteries, nunneries and modern-day prisons. Within a religious context, the practice is called flagellation. The practice of mortifying the flesh for religious purposes within the Roman Catholic Church dates to 1054. Within Roman Catholic ritual, the fourth of the modern Stations of the Cross is the Flagellation of Christ. This station is based upon the scourging of Christ, just before he was delivered up to be crucified (Mark 15:15). Typically occurring before a crucifixion, scourging was with a cattail whip that had pieces of bone or metal tied into it.

In the 14th century, the Flagellants were condemned by the Roman Catholic Church as a cult. But a mild form is still practiced within a few strict monastic orders. And some members of the Catholic lay organization, Opus Dei, use a “discipline” during prayer. This is a cattail whip of knotted cords, which is repeatedly flung over the shoulders during private prayer. Reportedly, Pope John Paul II practiced this discipline regularly.

Armando Favazza, who has studied self-injury for several years, said its practitioners use it as a way to silence a swirl of pain and anxiety. “They describe it as popping a balloon. All the anxiety just seems to go away.” A 19 year-old woman interviewed in the NPR story said she has her own “kit”, consisting of a new pack of razors, a pair of scissors and a pink towel. Whenever she was stressed, she turned to her kit. Before cutting her mind is exploding. But when she feels pain, there’s a kind of peace. “I’ll just be really calm and my thoughts will finally kind of be making sense, instead of them like racing through my head and nothing quite clicking. Just kind of centralizes my thought on one thing.”

A 2010 article, “Self-Injurious Behavior in Adolescents” by Janis Whitlock defined self-injury or non-suicidal self-injury (NSSI) as “the deliberate, self-inflicted destruction of body tissue without suicidal intent and for purposes not socially sanctioned.” Most often, it is not a suicidal gesture, while it can result in severe harm or death. Studies tend to find what is referred to as common NSSI in 12% to 37.2% of American high school-aged individuals and 12% to 20% of late adolescent and young adult populations. “Overall, about a quarter of all adolescents and young adults with NSSI history report practicing NSSI only once in their lives.” The available evidence suggests that 40% of repeat NSSI report stopping within the first year, and 79.8% report stopping within 5 years of starting.

Unpublished data indicates females are slightly more likely to practice self-harm than males. In my counseling experience, I’ve talked with both males and females who attempted NSSI. This is also not an isolated American phenomenon. NSSI is present in a variety of countries and cultures globally. “Although most widely investigated in industrialized regions such as Europe, North America, Australia, and New Zealand, NSSI also occurs with some regularity in other industrialized and non-industrialized countries as well.”

Self-injury is strongly linked to childhood abuse, especially childhood sexual abuse; eating disorders, substance abuse, PTSD, depression and anxiety. While it is common among adolescents, NSSI often goes undetected. Some signs can include wearing long sleeves or pants during hot weather; constant use of wristbands/coverings, unwillingness to participate in activities with less body coverage, like swimming or gym class; and frequent bandages. Whitlock also highlighted what she saw as five key studies of NSSI. See her linked article for the details.

Moran et al. published a natural history study of self-harm in the British journal The Lancet in 2012. More girls (10%) than boys (6%) reported self-harm in adolescence. There was a substantial reduction of self-harm during late adolescence. During adolescence, self-harm was associated with depression and anxiety, antisocial behavior, high-risk alcohol use, cannabis use and cigarette smoking. While most adolescent self-harm resolved spontaneously, when mental health issues are associated, treatment mat be needed.

Most self-harming behaviour in adolescents resolves spontaneously. The early detection and treatment of common mental disorders during adolescence might constitute an important and hitherto unrecognised component of suicide prevention in young adults.

A Cochrane study by Hawton et al. in 2015 looked at pharmacological treatment for self-harm. The conclusion was: “There is currently no clear evidence for the effectiveness of antidepressants, antipsychotics, mood stabilisers, or natural products in preventing repetition of SH [self-harm].” They found no significant treatment effect for newer antidepressants, fluphenazine (an antipsychotic), mood stabilizers or natural products. While a significant reduction in self-harm behavior was found with flupenthixol (an antidepressant), the quality of the evidence for the study was very low. No data on adverse effects, other than the planned outcomes related to suicidal behavior, were reported.

We have reviewed the international literature regarding pharmacological (drug) and natural product (dietary supplementation) treatment trials in this field. A total of seven trials meeting our inclusion criteria were identified. There is little evidence of beneficial effects of either pharmacological or natural product treatments. However, few trials have been conducted and those that have are small, meaning that possible beneficial effects of some therapies cannot be ruled out.

In a 2004 article in The Journal of Biblical Counseling, “Self-Injury: When Pain Feels Good,” Ed Welch said anything that arouses unwanted emotions can trigger the self-harm cycle. Trouble in relationships or anything that can provoke shame could be triggers. Beliefs that you have violated a personal, cultural or religious taboo can initiate it. “Perhaps you just don’t tolerate your own humanness with its imperfections, weaknesses, dependencies and sins.” Welch described the cycle of self-harm as following the pattern in this graphic: self harm

These beliefs, personal experiences, and external circumstances mix into a stew of raw emotions that can include anger and frustration, anxiety, or a jumping-out-of-your-skin agitation. Without alternatives, self–injury gradually becomes the preferred response to these feelings because it works. You regain control. Your emotions are back in check. The screams within have been temporarily silenced.

Welch is approaching the issue of self-harm from a biblical, religious perspective. So his advice and action steps will include addressing the spiritual side of self-harm: “Self-injury is, at its root, about God. Avoid Him, and we miss true hope.” In order to address self-injury: 1) Allow other people in; ask for help. 2) Grow in honesty; don’t hide your behavior. 3) Feed yourself with Scripture; the Psalms are a good place to start. 4) Write out the meaning and purpose of your self-injury. 5) When you fail, don’t give in to hopelessness. “All human beings sin and fail. It is what we do!” 6) If you keep moving back into self-injury, notice the intentionality of your behavior. Are you putting barriers between yourself and your self-abuse strategies?

If you are interested in the complete article by Ed Welch, you can purchase it in booklet form on Amazon or at the Christian Counseling and Education Foundation (CCEF). The booklet is $3.99, but if you purchase it in its original form in The Journal of Biblical Counseling, you can purchase the full digital issue it appeared in (JBC Volume 22:2) for $4.99.

09/17/14

Counseling Inside or Outside the Church

Stanton Jones, a psychology professor at Wheaton and the co-author of the book Modern Psychotherapies, described an encounter he had with Jay Adams while he was in graduate school at Arizona State University in the 1970s. With the publication of Competent to Counsel in 1970, Adams initiated what has become known as the Biblical counseling movement.  Jones asked Adams if he had any advice for him as a Christian studying psychology.  Adams responded by suggesting that he drop out of graduate school. “If you want to serve God as a counselor, you can only do so by going to seminary, studying the Word of God rather than the words of men, and becoming a counselor.” Jones didn’t take the advice.

This exchange illustrates what has been a split among conservative Christians over the care (cure) of souls. David Powlison wrote an article in the Spring 2007 issue of the Journal of Biblical Counseling entitled: “Cure of Souls (and the Modern Psychotherapies)” that looks at this divide from the perspective of a Biblical counselor. Dave is the Executive Director of the Christian Counseling and Education Foundation (CCEF), which was founded by Jay Adams. He is also the senior editor of the Journal of Biblical Counseling. Powlison’s article is made available here by CCEF, where it was included as an appendix to his book: The Biblical Counseling Movement: Its History and Context.

Powlison proposed that two acronyms refer to the divide between what has been traditionally known as Christian Counseling (VITEX) and Biblical Counseling (COMPIN). His thinking is that the traditional labels have given rise to objections from both sides. Biblical counseling can imply that “whatever [its] advocates believe and do comes with the full authority of the Bible” and anything else is unbiblical. What do you do when biblical counselors refer to Biblical Counselors as psychoheretics? Christian counseling suggests that: “what [its] advocates believe and do is distinctly Christian.” But what if what they teach is at odds with their professed faith? Powlison rightly noted that: “In both cases, the reality beneath the label is a complex maybe/maybe-not.”

Both sides say that Christians can learn something from psychology; and both say the Bible gets the final say. But the stalemate comes with how each position tends to see the role Scripture in counseling. Does it provide control beliefs for a Christian model of counseling, while secular psychologies make a VITal EXternal contribution? Or is Scripture a COMPrehensive INternal resource for the construction of a Christian model of counseling, where secular psychologies “do not play a constitutive role in building a robust model.”

Powlison went on look at the intellectual, methodological, and institutional characteristics of evangelical counseling; and how these characteristics will be shaped by either a VITEX or a COMPIN vision of counseling.  He structured this within three sections addressing epistemology (what knowledge matters most for helping people), motivation theory (how do we fundamentally understand people) and the social structure of how to educate, license and oversee counselors.

He concluded by stating his firm commitment to the view of counseling he has labeled COMPIN. He did not think that the VITEX epistemological priorities could help the church to understand and help people. He called for the development of a systematic theology of counseling, a paradigm that would: 1) guide our interaction with the people entrusted to our care; 2) guide our interaction with the secular models of counseling; and 3) become institutionally incarnated. “We need a fresh practical theology of the cure of the souls.”

So will your counseling be primarily within the church community, or outside of it? The COMPIN model is a paradigm for counseling WITHIN THE CHURCH community. It could also be done in a private practice or parachruch context, but would not be well received in secular counseling situations. And its credentials would probably not meet the educational requirements for most licensures outside of the church. On the other hand, VITEX has the ability to “integrate” with secular counseling programs and credentialing organizations and is a model for Christians who will be counseling OUTSIDE THE CHURCH. The secular structure required for this integration will not provide a solid foundation for a biblical understanding of human nature and motivation or developing a fully orbed biblical counseling epistemology.

I generally advise Christians seeking a career in counseling to get a both-and education—especially if they see themselves only counseling within the church. Get at least a masters degree in counseling from a secular or VITEX institution, and a certificate or a masters degree in counseling from a COMPIN organization like CCEF or a seminary like Westminster Theological Seminary. The COMPIN training will temper the paradigm bias of secular and VITEX counseling programs. And the VITEX training will help the Biblical counselor develop a more effective “apologetic” for reaching individuals in the church who have a secular view of the issues that brought them to counseling.

Would you pursue a both-and counseling education if you wanted to counsel within a church setting?