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In the Western world, public awareness of self-injurious behavior seems to have increased dramatically in the last ten years. As the topic of several popular films (Thirteen, Secretary) and popular television talk shows, self-injury is becoming much more visible. With this in mind, reaching a better understanding of the behavior, which in turn may lead to more effective treatment, is timely.
Numerous texts have emerged on the market -- directed at both popular audiences and clinicians -- that are of varying degrees of usefulness concerning how to better understand, and treat, self-injury. Walsh's book is a refreshing, and practical, addition to this literature. Although intended primarily for clinicians and others working with people who self-injure, Walsh effectively engages, and educates, anyone interested this complex behavior.
The book is usefully divided into two parts. In Part 1, Walsh attempts to define self-injury, the contexts in which it occurs, and how it is different from suicide. Walsh makes a convincing argument as to why the behavior should not be considered a suicidal act, illustrating the meaning of the behavior to clients using their own stories. He goes to great lengths to emphasize the importance of context when assessing those who self-injure, noting it occurs across several populations, including college students who otherwise appear to be high-functioning. However, I found it odd that feminist theories of self-injury, although deemed insightful, were quickly dismissed by the author because they apparently do little to explain male self-injury. This seemed at odds with his considerable effort to explain the link between childhood sexual abuse -- which is typically a gendered crime, with male perpetrators and female victims -- body alienation, and self-injury later in the book. Given the diversity of clients that engage in this behavior, something that Walsh admits himself, perhaps it is better to have several theories regarding specific population groups of self-injurers rather than the 'come one come all' approach to self-injury that is articulated in this book.
The strength of the book lies in its approach to clinical treatment of those who self-injure, the focus of Part 2. In keeping with other scholars, Walsh frames the behavior within a biopsychosocial model, which focuses on five interrelated dimensions: environmental; biological; cognitive; affective; and behavioral Noting the pros and cons of recent research and practice concerning self-injury, such as replacement coping skills and 'safety contracts', Walsh emphasizes the significance of attending to individual histories and idiosyncrasies in assessment and designing treatment. Of particular importance is his idea of the 'self-injury log' in which clients record the frequency and intensity of self-injurious acts. This simple, but practical, idea undoubtedly will help clinicians and clients to ascertain the extent of their problem and address it accordingly. It is noteworthy that Walsh consistently advocates an empathetic and sensitive approach to clients who self-injure, and points out the consequences of some typical negative reactions to the behavior, which of course disadvantage the client. Walsh is explicit about the role of trust and safety in dealing with these clients.
I found Walsh's attention to the role of cognitive and moral development skills in self-injury -- or lack of it -- problematic. Given his statement early on in the book that the prevalence of self-injury appears to be rising for adolescents and young adults, I expected a deeper analysis of the potential relationship between psychological development, coping and self-injury and how to address it.
Part 3 of the book is devoted to specialized self-injury topics. This part of the book is extremely useful for those who are confronted with self-injury in 'group' settings, such as schools, residential homes and so on. Because schools and services often develop policies reactively to such behavior, Walsh's protocol serves as a useful guide to help students, staff and other workers dealing efficiently and effectively with those who self-injure in a proactive manner.
Walsh's tone is even throughout the book. His use of vignettes shows the extent of his professional experience, whilst conveying that he really does care about this vulnerable and complex population group. The main points of chapters are usefully bullet-pointed at the conclusion of the chapters, providing a 'quick and dirty' reference. Although the 'all encompassing' nature of the book results in some points being glossed over, it makes an important contribution to literature on self-injury and it vital reading for any clinician working with those who self-injure.
© 2007 Renee Kyle
Renee Kyle, Ph.D., University of Wollongong
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