"It was like a partnership of the two of us against the cutting": investigating the counseling experiences of young adult women who self-injure.

Self-injury is an increasing phenomenon among young adult women. This qualitative study explored the counseling experiences of 10 young adult women with a history of self-injurious behavior: It examined the nature of the client-counselor relationship and how self-injury was treated. It also accessed the participants' thoughts and feelings about their experiences in counseling. Implications for training and treatment are set out, as are recommendations for research.

INTRODUCTION

Self-injury is a pervasive and dangerous problem, especially among adolescents and young adults (Nock & Prinstein, 2005; Nock, Teper, & Hollander, 2007). Self-injury typically occurs within the age range of 13-23, a period of developmental significance (Favazza & Conterio, 1989). An estimated 35% of college students report a history of self-injurious behavior (Gratz, 2001), and the prevalence of self-injury in adolescent community samples appears to range from 14% to 39% (Nock & Prinstein, 2005).

The incidence of self-injury has been found to be three to four times more common in women than men (McAllister, 2003). According to Shaw (2002), "self-injury is a gendered and developmental phenomenon" (p. 192), shaped and constructed within the context of multiple forms of gender oppression. Young women are subject to intense sociocultural forces throughout their lives, particularly throughout adolescence and young adulthood (Parker, Bermudez, & Neusitifter, 2007). Images of unattainable physical ideals, the emphasis upon sexual attractiveness and sexual availability, and restrictive power differentials of gender all shape identity formation in conflicting contexts. Simultaneously, young women struggle to learn how "to hear and trust one's own voice at the same time that one attends to the voices of others" (Knudson, 2004, p. 40).

Feminist perspectives have "recast theories of clinical disorders, focusing particularly on problems of high prevalence among women" (Marecek, 2001, p. 306). A social and contextual construction of gender relocates women's problems from the individual and internal to the social and external. This relocation shows how women's problems or symptoms can be understood as methods of coping and surviving rather than as signs of dysfunction or mental illness (Foster & May, 2003). Shaw (2002) argued that direct destruction of the body is symbolic of the struggle against the dominant cultural story of what it means to be female. Thus, the act of self-injury may be a means of expressing feelings of discontent and anger and a form of psychological resistance articulating a need to be heard and to be taken seriously.

In spite of the research on women and self-injury, little is known about self-injury among young women in marginalized or nondominant groups. While many contend that self-injurious behavior may be more common among White European American women (e.g., Bhugra, Singh, Fellow-Smith, & Bayliss, 2002), similarly high rates of self-injury have been found in samples of minority and disenfranchised groups (Marshall & Yasdani, 1991; Whitlock, Eckenrode & Silverman, 2006).

TREATMENT OF SELF-INJURY

Self-injury presents considerable challenges to the mental health counselor because there is a lack of empirical data to support specific treatment protocols (Muehkenkamp, 2006; Trepal & Wester, 2002), and it has been identified as a behavior resistant to treatment. Treating self-injury may be particularly time-consuming and potentially frustrating for mental health counselors, who may feel unable to either form a therapeutic relationship with a client who self-injures or make an impact on the behavior (Dieter & Nichols, 2000; Kiselica & Zila, 2001; Stone & Sias, 2003). Mental health counselors' reactions, if void of empathy specific to self-injury, can have deleterious psychological and emotional effects upon self-injuring clients (Levenkron, 1998; Nafisi & Stanley, 2007).

A review of the literature on empirically supported treatments for self-injury found that, although the results have been mixed, cognitive-behavioral and problem-solving treatment approaches are effective in reducing symptoms (Muehlenkamp, 2006). However, without a trusting therapeutic relationship, treatment is less likely to be successful (Trepal & Wester, 2007). In fact, many individuals who self-injure indicate a high rate of dissatisfaction with the treatment they receive (Favazza & Conterio, 1989; Shaw, 2002). Thus, postmodern approaches that rely on client-informed therapies and include attention to wider sociocultural and sociopolitical realities may offer more nuanced models for treatment of self-injury that invite the voices of young women to be heard (Hansen, 2002). However, such models can be challenging for mental health counselors, who also are obligated to address the risks of self-injury and thus rely more on treatment to reduce symptoms. Moreover, little research on application or outcomes has been done on postmodern frameworks for counseling women who self-injure, further complicating the search for sound treatment models.

CURRENT TRENDS IN RESEARCH RELATED TO SELF-INJURY

Although rates of self-injury appear to be increasing, the research that has been done suffers from three major limitations. First, many of the treatment studies related to self-injury were conducted within an inpatient or medical environment, which may bias the results. For example, in emergency rooms patients who self-injure have reported being subjected to troubling practices, such as increased observation, seclusion, and restraint (Weber, 2002). According to Favazza (1989) and Shaw (2002), these approaches are likely to develop mistrust and fear of helping professionals. Moreover, in a study conducted within an inpatient psychiatric treatment facility, participants expressed both a fear of rejection by treatment providers and a desire to be understood (Crouch & Wright, 2004). Within a general hospital setting, patients reported that sympathy and listening were critical helping components and often lead to less subsequent self-injury (Pierce, 1986; Treloar & Pinfold, 1993). These findings raise valuable points about the proper treatment of self-injury and the value of empathy and listening for clients who harm themselves. However, research is sorely needed to specifically explore outpatient counseling for self-injury in order to identify variables related to that context.

A second research limitation is the variation in nomenclature and definitions of self-injury applied as the dependent variable, such as deliberate self-harm (Gratz, 2001), self-mutilation (Nock& Prinstein, 2005; Haines & Williams, 1997; Favazza & Rosenthal, 1993), nonsuicidal self-harm (Laye-Gindhu & Schonert-Reichl, 2005), self-cutting (Rao, 2006), self-injurious behavior (Favaro & Santonastaso, 2002), and self-soothing (Alderman, 1997; McCallister, 2003). Consequently, participants with a range of behaviors, from cutting to suicide attempts, have been lumped together in the samples. Findings from such studies may not provide an accurate picture of individuals who self-injure.

Third, many studies have failed to access the voices and perspectives of the self-injuring clients themselves. Thus, little is known about how those who self-injure view the treatment they are given (Pierce, 1986). For example, psychological interventions have generally been built on evidence gathered from clinicians rather than clients (Crouch & Wright, 2004). The past two decades have seen only a few studies that speak to individuals' perspectives on the care they received after acts of self-injury and those typically occur within a hospital or inpatient setting. In particular, researchers have neglected to examine how young adults perceive their counseling experiences (Smith-Jobski, 1993). Dunne, Thompson, and Leitch (2000) argued that "we know almost nothing about the experience of therapy for young people and about what within the therapy hour makes a difference to them" (p. 79). Similarly, Smith-Jobski (2003) encouraged mental health counselors to conduct more qualitative inquiries with adolescents and young adults to examine their experiences in counseling, to investigate their perceptions of the client/counselor relationship, and to investigate their ideas about barriers they perceive to receiving counseling services. The examination of young adults' experiences in counseling could provide mental health counselors with a deeper understanding of the counseling process and ultimately may result in more effective interventions that lead to better outcomes (Buston, 2002).

The current study sought in an empirically sound manner to fill the three major gaps in the literature by investigating the phenomenon of self-injury with young adult women. First, we examined the individual outpatient mental health counseling experiences of young adult women with a history of self-injurious behavior, thus broadening the arena in which self-injury is investigated. Second, we clarified the definition of self-injury as the deliberate alteration or destruction of the body without conscious suicidal intent and as behavior that is contrary to culturally sanctioned forms of body modification (Hodgson, 2004). Finally, the qualitative methodology allowed us to access the lived experiences and voices of young adult women with a history of self-injurious behavior--an area of investigation that has largely been ignored (Crouch & Wright, 2004).

The overarching research question addressed was: What are the counseling experiences of young adult women with a history of self-injury? More specifically, we asked, from the perspective of these women (a) what is the nature of the client-counselor relationship; (b) how was their self-injury treated during the counseling relationship; and (c) what are their thoughts and feelings about their experiences in counseling?

CONCEPTUAL FRAMEWORK 

To explore the counseling experiences of young adult women who self-injure, the study employed a qualitative research design, since this is the paradigm that best fits the social constructionist and feminist notions underlying the questions. Essentially, all qualitative research aims at eliciting an understanding of how informants construct their world. A qualitative investigation of young adult women and self-injury serves as a venue for women's voices to be heard. Personal stories have been generally neglected in the research. Therefore, the present study was designed to use phenomenological methods to reveal the constructed meanings of the counseling experiences of young adult women with a history of self-injurious behavior.

A phenomenological research method focuses on exploring how human beings make sense of experience and transform their experiences into consciousness, both individually and as shared meaning (Patton, 2002). The psychological approach to phenomenology, which focuses on extracting general meaning from individual rather than group experiences, is particularly well-suited to studies related to the therapeutic experience. Through the process of data analysis, the researcher reduces the experiences to a central meaning, an "essence" (Moustakas, 1994). Such a strategy requires methodically capturing and describing the counseling experiences of young adult women with a history of self-injury as they construct, remember, perceive, and make meaning of their counseling experiences (Patton).

METHODOLOGY

Before the study was conducted, institutional review board (IRB) approval was gained through the university IRB committee. The next step was to select participants.

Consistent with the phenomenological methodology, purposeful sampling was used. This method selects individuals based on their knowledge or experience of a phenomenon for the primary purpose of sharing that knowledge (Streubert & Carpenter, 1999). Participants were 10 women aged 18-23 recruited from a small mid-Atlantic public university.

To recruit participants, flyers were displayed throughout the college. The flyers gave information about the study and personal contact information for the researcher. An advertisement with the same information was posted online on the university's website for students. Students interested in the study made contact by phone or e-mail. In the initial contact, they were given a detailed description of the study, duration (2 hour-long interviews), and places, and any questions or concerns were answered. During the first interview each participant signed a consent form before beginning, and was told that the interviews would be recorded. The consent form explained that participants' identities would be protected at all times; no names would be used. The form also indicated that all records and tapes of interviews would be destroyed when the study ended.

Of the 10 women who participated, 8 were undergraduates and 2 were graduate students. All were single and without children. Of the 10, 8 were White European-Americans, 1 was African-American, and 1 was Latina. All were no longer actively cutting and were no longer in counseling for self-injurious behavior. However, because the term actively was not specifically defined, they presented with significant variance in their most recent experience with self-injury. One woman had last cut herself a few months before her participation, another had last cut herself almost four years before.

THE QUALITATIVE INTERVIEW

Consistent with the phenomenological strategy, two face-to-face semi-structured interviews composed of open-ended questions were conducted using an interview guide (available from the authors). Participants were administered a brief demographic sheet before the first interview that asked about age, race, family, and origin; length of time actively engaging in self-injury; time in treatment; and type of treatment received. The data collection process continued until the data became saturated (Moustakas, 1994)--when no new information could be elicited. The interviews provided exhaustive information about the counseling experiences of young adult women with a history of self-injurious behavior.

DATA ANALYSIS

In phenomenological research the beginning steps of data analysis are epoche, which is the process of setting aside judgments, and bracketing, the process of phenomenological reduction. They allow the researcher to set aside judgments so as to focus on the true nature of the phenomenon (Patton, 2002). In order to do so, the researchers kept a reflexive journal throughout the entire study that documented personal reflections and all methodological decisions and rationales. After the data were bracketed, we searched for themes in each participant's experiences. In identifying themes and patterns we looked specifically for convergence and divergence between participants. Throughout, data analysis took place with a committee of four members of the counseling faculty; after each interview was coded, we discussed the coding and reached agreement through a series of committee meetings. The results section represents the findings from these meetings and the data analysis.

RESULTS

Three primary themes relevant to the research questions emerged from the data analysis: (a) my counselor; (b) the counseling process; and (c) counseling reflections. With regard to the first theme, my counselor, subthemes identified were helpful behaviors and unhelpful behaviors. For the second theme, the counseling process, analysis identified the following subthemes; techniques utilized in the counseling session, forms of treatment experienced by the participants, and the focus of treatment. For the third theme, counseling reflections, subthemes related to participants' feelings in counseling and suggestions for the future.

My Counselor

The first theme related to the first research subquestion: What is the nature of the counselor-client relationship? The participants talked at length about their experiences and their relationships with counselors.

Helpful Behaviors

For those interviewed, the most helpful counselor behaviors were respectful listening, understanding, and acting as a friend.

Listening. The participants valued a counselor who was able to actively listen and communicate understanding. One participant said, "[My counselor] was just a really good listener and I think that was very beneficial." Another also talked about the value of listening: "She definitely seemed to sympathize with me. And she sat there with me and let me cry to her and let me get, like, months of pent-up feelings off my chest."

Understanding. As with listening, a counselor who communicated understanding rather than judgment was extremely important. For one participant, the fact that her counselor understood her unique needs was deeply appreciated. She said,

   He was a counselor specifically for gifted students, or gifted kids
   and adults, and he was very intelligent himself, so I always felt
   like I could talk. I didn't have to worry about saying things that
   smart kids would say.... And, I guess he understood more the
   problems that smarter kids have.

A friend. The majority of participants referred to their counselor as a friend. One participant said, "I think a personal connection is really key in any therapist/patient relationship." Another who worked with several counselors referred to her favorite as "kind of a mentor or friend." She went on to say, "It was like a partnership of the two of us against the cutting." Without exception, these participants believed their relationships with their counselors extended beyond the clinic or their weekly sessions. This belief led to positive views of counseling and, remarkably, their eventual recovery and abstention from self-injury.

Unhelpful Behaviors

All the women discussed behaviors that they viewed to be unhelpful, including counselors who failed to demonstrate understanding and counselors who forced uninvited ideas upon them.

A lack of understanding. Participants had negative views of counselors who demonstrated lack of understanding. One participant believed that her counselors sometimes approached her with the attitude, "I have seen this a hundred times." She reported not feeling unique or particularly "cared about."

Forcing ideas. Of the 10 women interviewed, 5 spoke about how their counselors were forceful. For example, one said that her counselor pushed her and failed to consider her emotions during sessions. Another talked about how "sometimes counselors will put words in your mouth so you sort of fit their category in a neater way." The women also spoke about how counselors forced religion onto them during sessions. This communicated to them a lack of true understanding. One said, "She told me I needed God" to get better. Another said, "I didn't really appreciate the handing out of the scripture verses to tell me that I am loved no matter which way I am and I have to accept myself for who I am." This participant found the approach to be extremely unhelpful.

Thus the participants viewed listening, an understanding stance, and a friend-like relationship to be helpful counselor behaviors. Counselors were perceived as unhelpful when they demonstrated a lack of understanding and forced ideas upon the participants during the counseling process.

The Counseling Process

The second theme, the counseling process, related to the second research subquestion: How was their self-injury treated? As each of the women talked about the process of counseling, two major subthemes were apparent: counseling techniques and focus of treatment.

Counseling Techniques

All 10 participants commented on techniques their counselors used during the counseling process, including behavioral alternatives, talking, and behavioral contracts.

Behavioral alternatives. Six of the participants remarked on the behavioral alternatives their counselors suggested. Some believed the alternatives were helpful, others found them unhelpful. One participant enjoyed her counselor's encouragement to think about or make a list of alternative behaviors. This approach allowed her to be "actively engaged as opposed to passively engaged in sessions."

Five of the women found that alternative behaviors were not helpful. One believed that alternatives were only temporary solutions:

   There were periods where I managed to assuage the need to
   self-injure by picking up another healthy or acceptable behavior,
   at the urging of a counselor ... if that makes sense. It didn't
   really last too long because they were terribly simplistic
   behaviors that were sort of short-term answers.

Another participant stated that she and her counselor experimented with several different alternatives (breathing relaxation, yoga, running, working out, drawing, etc.), but she found these to be mostly unhelpful. She said, "Alternatives are just that. They are alternatives ... and nothing that I have heard of thus far is really going to substitute."

Talking. Many of the participants noted that simply talking during sessions was helpful. One said that counseling was "just time to talk to someone without having the pressures of what they are going to say or think about you." Another echoed this comment, saying it was nice to "just talk" with her school counselor in high school. Finally, another recalled one counselor with whom she enjoyed working: "It was just so nice to have someone who cared and I could talk to about these things. I just need to talk." For the majority of the participants, counseling offered a much-needed forum to externalize in words what they were experiencing internally.

No-harm contracts. Almost without exception, the participants considered no-harm contracts ineffective. Two called them "a joke." When another was asked what she would have done if her counselor had asked her to sign a behavioral contract, she responded, "I would have crumpled it up and thrown it at them." She continued,

   I won't make a promise unless I can keep it. Or. 1 try not to. I
   need to feel a deep sense of obligation to that person and that
   particular cause to make that promise. So that wouldn't have worked
   for me.

Another participant said candidly, "I never understood why when a patient stays they're going to cut themselves or kill themselves, you whip out your handy-dandy piece of paper to make them promise that they're not going to do anything." Another alluded to the potential dangers of using no-harm contracts. She suggested that counselors need to provide their clients with new improved coping skills before making them stop using their old coping skills: "You can't strip someone of their old clothes until you have a new set available."

Focus of Treatment

The majority of the participants talked about what their counselors focused on in counseling for self-injury. When asked about how self-injury was addressed in the context of counseling sessions, one stated, "She always made it a big issue. She would ask how my last week had gone and acted like the most important indicator about how my week had gone was whether I had cut myself or not." For this participant, whether or not she refrained from cutting had little or nothing to do with how her week went. Another participant spoke about how her counselor focused on the issues beneath her self-injury, which she referred to as her "underlying stuff". She remarked, "The underlying issues are really the key to the behavior. Instead of just putting a Band-aid on the issue, if you could treat the actual thing that is causing it, that is better."

In summary, in sharing their feelings about their views of specific counseling techniques, participants expressed conflicting ideas about behavioral alternatives, viewed talking to be therapeutically helpful, and generally found no-harm contracts to be unhelpful. In terms of the focus of treatment, participants did not like counselors putting too much emphasis on the self-injurious behavior. Rather, they reflected about the value of counseling that targeted the underlying issues.

Counseling Reflections

The final theme related to the third research subquestion: What are their thoughts and feelings about their experiences in counseling? All 10 women reflected upon their behaviors and feelings in counseling and made suggestions for women who self-injure and counselors working with them. This theme, counseling reflections, has two subthemes: feelings in counseling and suggestions for the future.

Feelings in Counseling

Without exception, the women spoke about their negative feelings in counseling, but the type of negative feeling was unique to each women, and their descriptions were quite poignant. Upon reflection, one participant believed that she "failed at counseling" because she was not able to stop harming herself and was unable to establish a relationship with her counselors. She said:

   It makes me think of ... it is on the laundry list of things that I
   didn't do well. Yes, because my attitude was that this is another
   thing that I did that I frankly failed. If you can fail at building
   a relationship with someone that you are paying to have a
   relationship with, then there is a problem.

Asked about their feelings in counseling, other participants remarked that they often felt "frustrated" and remembered "going through the motions and feeling like I was pretty alone and having to do work on my own." She concluded, "The help that I was getting wasn't really what I needed. In some ways I wish that it was more positive and that I had a therapist that I really could have worked with."

Most of the women discussed how they hid self-injury from their counselors, making it difficult for the counselor to focus on it. For example, the women spoke about how they often manipulated their counselor into thinking that they were improving and the cutting had subsided. One participant said she simply avoided conversations about self-injury because she "didn't want to confront it in any way." Another did the same: "I had one [counselor] convinced that I was fine ... it was great, except that I was getting worse." This particular client was extremely honest about how she often manipulated her counselor in sessions. It was after admissions like these that many of the women made suggestions for counselors working with women who self-injure.

Suggestions for the Future

Asked what they would suggest to women who were harming themselves, all 10 study participants suggested that clients get help or seek. counseling if they were harming themselves. Even though her own experiences in counseling were negative, one woman said, "I would tell them to definitely explore counseling ... I don't think that you should be silent about your insecurities and your pains and you do need to get that out in some form of counseling." Another said, "A lot of people who self-injure think that there is something wrong with them, that they are a bad person because they [cut themselves]." She continued, "Go to counseling ... it is just like buying a pair of jeans--shop around."

Without exception, each of the women interviewed provided suggestions for counselors working with women who self-injure. Asked what they would tell counselors working with college-aged women who self-injure, most of the women emphasized that it was important for the counselor to be nonjudgmental. One said,

   I think the bottom line is to just try not to alienate them
   further. Because there is already the knowledge that what you are
   doing is very bizarre and not normal, and you need to be careful of
   inadvertently stigmatizing them further.

Another participant asked that counselors

   ... try not to treat clients like they are an anomaly that just
   happened.... Treat them like a normal human being who, instead of
   crying, cuts. Or instead of dealing with something, they just cut.
   It is just a way to deal with the inside stuff. So, just treat them
   like normal human beings and try to address everything around them,
   not just the cutting. Because, if they focus on the cutting, then
   nothing is getting fixed.

The women spoke with the most energy and enthusiasm when asked about suggestions for counselors. Some even spoke louder in response to this question, as if they wanted counselors to "hear" what they had to say.

In summary, the third theme illustrated the participants' reflections about the counseling experience. They shared their negative feelings, including feelings of frustration, as though they "failed" at the counseling relationship. Nevertheless, many of the participants recommended counseling to other young adult women who self-injured. They also urged counselors to approach counseling in a nonjudgmental way.

DISCUSSION

The purpose of this study was to explore how young adult women who self-injure construct their counseling experiences. It aimed to glean elements that make up the essence of the experience of being in counseling for these young women. The findings are not intended to be representative of the experience of all women in therapy for self-injury. As with any qualitative study, the reader needs to decide how the study's findings apply to a particular setting. This section is translated directly from the three research subquestions. From the perspective of these women: (a) What is the nature of the client-counselor relationship? (b) How was their self-injury treated in the context of the counseling relationship? (c) What are their thoughts and feelings about their experiences in counseling?

The first subquestion inquires directly about the counseling relationship. For these women, the quality of the counseling experience was primarily related to the counseling relationship, which supported findings that the quality of the counseling relationship is the common factor among outcome studies across diverse theoretical orientations (Bachelor & Horvath, 1999; Lambert & Bergin, 1994). Without a trusting relationship, women are likely to keep their self-injury hidden and less likely to communicate with their mental health counselors about their behaviors in the future (Walsh, 2006). Further, the findings suggest that the counseling relationship functions as a significant environment within which young women may explore their relational worlds. Thus, the role of the mental health counselor may extend beyond symptom reduction into the developmental context of a particular young woman.

Most of the women in this study preferred to have a partnership or collaborative relationship with their counselors; they disliked counselors who assumed more of an expert status. The reason a feminist approach may be ideal for this population is that feminist therapy honors women's experiences, which are considered central to understanding their distress (Shaw, 2002). This model also creates a forum for mental health counselors to listen, understand, and provide support, encouragement, and validation. Moreover, where a relationship is egalitarian, a collaborative and mutual relationship ensues (Brown & Brian, 2007; Rogers & Oney, 2005). Feminist approaches also provide models that reject manipulation, demystify the process of counseling, and emphasize equalization of power between counselor and client (Shaw). Within this model, the feminist mental health counselor aims to empower the client through a nonjudgmental, nonexpert stance (Nafisi & Stanley, 2007). Such an approach provides an opportunity

   ... to support these young women as they attempt to articulate what
   they want for themselves--not in disconnection with the needs of
   others, but as a way of including themselves as they grapple with
   the issues of what and how much to give to others (Mirken, 1994,
   p.80).

Feminist theory, then, appears to be an ideal framework for constructing a therapeutic approach for women who self-injure.

The second research subquestion accesses how the participants' self-injury was treated throughout the counseling process. As they reflected upon this, the majority of the participants viewed counselor directive and behavioral approaches to be unhelpful. Although early approaches to self-injury called for the use of no-harm contracts in treatment, both Walsh (2006) and Hyman (1999) denounced their use with individuals who self-injure, and the participants in this study mostly agreed. The majority of them did not take contracts seriously and found them to be ineffective. However, two women made it clear that, within a trusting and collaborative counseling relationship, the contracts served as a reasonable constraint.

The complexity of self-injury and the findings of this study together suggest that the use of more directive approaches should be tailored to each unique client. Developing a contract can establish mutual responsibility between the client and the mental health counselor. An effective contract delineates the goals, processes, and measurable outcomes of therapy, not just the cessation of a symptom (Nafisi & Stanley, 2007; Walsh, 2006). Further, the process and pace of counseling ideally would vary according to the needs of each client. These strategies help to decrease the power differential between the client and the mental health counselor, reducing the hierarchical nature of the therapeutic relationship found in many traditional approaches. Moreover, mental health counselors could help young women articulate their struggles related to self-injury and make meaning of them in such a way that they see and act for change both within themselves and within society. Counselors who change the frame of reference for looking at an individual's behavior shift from an intrapersonal to an interpersonal definition of a client's problem.

The women's responses in this study indicate that symptom-focused treatment overlooked their internal struggle. Underlying issues, for many of them, were what they wanted to explore, however tentatively. Indeed, the data suggest that the most helpful counseling did address these issues. While it is important that the self-injury be addressed in the context of the counseling relationship, focusing on what drives this behavior--developmental and personal issues as well as internalized gendered expectations about what it means to be female--also seems important to these young women, although they simultaneously rejected the dominant assumption that intrapsychic factors are the source of women's psychological disturbances. Mental health counselors, therefore, should not rely on the absence of cutting or a reduction in the rate of self-injury as the only indicator of progress in counseling.

The third subquestion relates to the feelings and thoughts the participants had about their experiences in counseling. The majority of participants in the current study were reluctant to talk about their self-injury with their counselors. Others reflected upon their experiences with frustration and with feelings that they were failures in the counseling process. Some participants even went so far as hiding self-injury from their counselors, or manipulating the counselors into thinking that they were no longer cutting themselves.

How does such secrecy serve these young women? The fact that many women hid their self-injury seems to confirm that they were aware of the social stigma attached to it (Ellis, 2002). It is likely that social influences play a large role in the development and continuance of self-injuring acts. It is critical for mental health counselors to be aware of the context in which self-injury occurs. Ignoring the larger context "denies these women agency, reifying Western stereotypes of women as irrational and internally driven, and ignores the social context in which this behavior occurs" (Ellis, 2002, p. 54).

IMPLICATIONS FOR TRAINING AND TREATMENT

Self-injury is a pervasive issue affecting young adult women. Despite the best intentions of mental health professionals, individuals who self-injure often view their treatment experiences as unhelpful, negative, and even damaging (Johnstone, 1997). This was certainly the case for the majority of participants in this study; many of the women felt that their counselors were unable to meet their unique needs. Thus, up-to-date specialized training on the complex issues related to this population is imperative. Further, clinical training for treating self-injury ideally should focus on collaborative models that incorporate feminist theory.

Findings of qualitative research like this study may only be logically generalizable (Rossman & Rallis, 2003) but may still serve as valuable indicators for improving treatment. Our results indicate that the quality of the counseling experience for these women was primarily related to the counseling relationship. Participants spoke highly of counselors who listened, understood, and did not judge them. Mental health counselors need to be aware of the power of the therapeutic relationship when working with clients who self-injure. Spending ample time to nurture this relationship, building trust, and validating the client's experiences all are vital to establishing an atmosphere in which differences are tolerated and ultimately valued so that treatment may be successful.

Considering the influence of the therapeutic relationship, mental health counselors may also want to periodically check in with their clients about the status of the relationship and how they are feeling about the therapy (Nasafi & Stanley, 2007). Feedback may come in the form of subjective rating scales or client-counselor dialogue after sessions. Client feedback allows the therapist to make changes to treatment plans and informs the client that her therapist values her and her recovery.

Participants in this study also valued a collaborative relationship with their counselors. A collaborative therapeutic relationship builds on the strengths and abilities of the client and addresses her unique needs. Each woman's subjective experiences and constructed knowledge are valued as well as the counselor's expertise. The counselor helps each client to set her own personal goals. During sessions, having conversations about counseling itself facilitates this collaborative relationship. These conversations can cover both the meaning and limits of the therapeutic relationship. Further, developing a contract that delineates the goals, processes, and measurable outcomes of therapy may establish mutual responsibility between the client and the counselor. The process and pace of counseling would vary according to the needs of each client.

A collaborative relationship means the counselor avoids making demands or giving advice and prescriptive orders to the client. Thus, it would also reject the use of narrow no-harm contracts. The majority of participants in this study did not see the value or usefulness of contracts. With this in mind, it would be beneficial for mental health professionals to examine the potential risks and benefits of using no-harm contracts with clients who self-injure. No-harm contracts tend to focus on outer symptoms, but the majority of the women interviewed wanted their counselors to look deeply into the underlying issues rather than the self-injury.

Emphasizing the emotions, psychology, and motivations beneath the wounds will be beneficial for both client and counselor. Thus, the mental health counselor might ask clients questions like: "If your wounds could speak, what would they say about you?" "What are your wounds trying to communicate?" "What feelings drive you to self-injure?" "What wounds exist beneath your scars?" Such questions allow the counselor to delve deeply into issues beneath the visible cuts and scars.

RECOMMENDATIONS FOR RESEARCH

Clearly more research in this area is needed; the phenomenon of self-injury is multifaceted and seems to be increasing. Investigations into family perceptions of self-injury would provide a layered and systemic conceptualization of the interacting processes related to the phenomenon and perhaps illuminate new avenues for prevention, assessment, intervention, and treatment. Large-scale profiles as well as smaller qualitative studies would provide needed depth. Such studies would ideally strive to sample a diverse population of young women.

Many of the women interviewed, especially those with a history of an eating disorder, used the term "self-injury" to describe a range of self-harming behaviors; they considered anorexia and cutting to both be forms of self-injury. With this in mind, we recommend investigations that compare different forms of self-injury in terms of age of onset, family functioning, contextual variables, and any comorbidity. Such studies would provide a more solid foundation for examining self-injury and formulating strategies for counselor education about both the condition and treatment models. Extending this research to treatment approaches and outcomes could follow.

Finally, the social construction of women's roles and images within both an historical and a contemporary sexist culture creates a complex and potentially dangerous milieu, impacting young women in ways that are typically explained as individual intra-psychic dysfunction. Further research is needed to create a comprehensive feminist understanding of self-injury and a corresponding feminist treatment model.

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Laurie M. Craigen is affiliated with Old Dominion University. Victoria Foster is affiliated with the College of William and Mary. Correspondence concerning this manuscript should be addressed to Laurie M. Craigen, Assistant Professor, Department of Educational Leadership and Counseling, Old Dominion University, Norfolk, VA, 23529. E-mail: [e-mail].