APEX©- an Effective Model for Treating Non-Suicidal Self-Injury

Following my personal experience of trauma, I observed how stigma, judgement and daily micro-aggressions underline why it is so hard for people to disclose traumatic events and why many resort to self-harming responses. The Personal is the Professional (C. White & Hales, 1997) is one of the earlier books in the narrative literature that made sense to me about how ‘insider-knowledge’ helps us understand trauma through a different lens. Perhaps the window of tolerance is not the sole domain of the traumatised person, as there is a narrowness of tolerance in society with its propensity to victim blame. It is probable that professionals whose own window of tolerance is narrow may worsen rather than alleviate human struggles. Much has been written about the window of tolerance of clients, but we must acknowledge the implications of the window of tolerance in professionals and the risks that this may lead to in terms of people not feeling heard or understood. As my window of tolerance widened, I could sit longer with others’ unbearable pain. We cannot fully meet another if our own window is so narrow that we cannot bear to hear about their trauma or comprehend how injury to self is an expression of the depth of their pain.

So how do you sit with a shattered soul? Gently, with gracious and deep respect. Patiently, for time stands still for the shattered, and the momentum of healing will be slow at first. With the tender strength that comes from an openness to your own deepest wounding, and to your own deepest healing. Firmly, never wavering in the utmost conviction that evil is powerful, but there is a good that is more powerful still!’ (Steele, 1989, p. 25)

Understanding Self-Injury in the Field of Trauma and Dissociation

Many clients I have worked with over the years self-harmed to relieve a range of difficulties. I have found little to guide how best to work effectively with non-suicidal self-injury (NSSI) specifically. There are approaches that address emotion regulation (e.g. Linehan, 1993, 2015) where self-harming is considered ‘therapy interfering’ and is discouraged rather than explored. Eye movement desensitization and reprocessing therapy works with target memories that link between NSSI that has served as a coping mechanism (e.g. Mosquera & Ross, 2016) but does not seek to understand the harming itself. NSSI should not be confused with suicide attempts as this requires a different approach, although NSSI can heighten suicide risk (Duarte et al., 2020).

For effective change, we know therapy works based on the relationship (Miller et al., 2004). So, attitude towards the client seemed pivotal in effectively addressing NSSI. There are encouraging models such as the care, collaborate, connect model (Stallman, 2019) along with cognitive behavioural therapy (CBT) approaches (e.g. Taylor et al., 2023), but these do not have the matched need/strategy component that APEX© offers. In this paper, I provide client examples (with their permission) that were de-identified in an amalgamation to ensure client privacy. Feedback from training about the model often mentions the value of these practical examples from clinical practice. The APEX© model requires an attitude shift to enable a process of change from self-harming by being open first to learning how it helps relieve the distress, and then to match alternative ways of coping to meet that need differently.

Why APEX©

APEX© is the acronym of all the components of the model: Attitude of curiosity, Purpose of harming, Emotional first aid kit and X factor). The word ‘APEX’ also conveys the need to reach the top of the mountain and have a 360° view in achieving victory over the urge to harm.

Developing the APEX© Model

The National Institute for Clinical Excellence (NICE) guidelines for self-harm (2004; 2011; 2022) define self-harm as ‘intentional self-poisoning or injury, irrespective of the apparent purpose’. The 2004 guidelines related to the emergency room for injuries requiring medical attention, and included details such as ‘always use local anaesthetic when suturing’. These guidelines were based on the available literature and feedback from service users. It was remarkable that the guidelines had to name the need for anaesthetic, as otherwise it was often not used. Clients have described how they were refused anaesthetic because they were told ‘you like pain’, so it was little wonder these early guidelines had to specify anaesthesia use. The narrow window of tolerance of the professional presuming a person cuts to enjoy pain raises more questions about attitude than it answers about how self-harm helps. This led me to wonder what else may help in less risky ways. It also indicated that attitude (i.e. shifting from a position of judgement to a position of curious enquiry) may be significant for the person who self-harms. There are several psychotherapies, including narrative therapy, that help us to take this position and externalise problems from people (e.g. M. White, 1995, 2000; M. White & Epston, 1990; Wingard, 1996). This makes the problem the problem, so the person ceases to be the problem. Of note, shame ceases to silence a person when you ask about harming in this way. When asked ‘how it helps’ rather than ‘why do you do it’, people frequently say, ‘no one ever asked me that before’. This opens possibilities for change. The early versions of the APEX© approach were offered to people in mental health services and forensic services and drew on ‘insider knowledge’ of people whose distress was alleviated through self-harming.

I called this a HOPE Plus approach, which reflects the background that led me to this point.

History of working in mental health services

Observed no models that specifically target self-harm

Practical approach needed for clients and staff

Evidence-based and effective approach

Plus practice-based insider knowledge; an ‘experience consultant’ assisted in the design and delivery of the initial programme.

Key Aspects of the APEX© Model

• Attitude of curious enquiry to enable targeting self-harm specifically.

• Purpose of the harming clarified in a psychological approach.

• Emotional first aid kit of alternatives developed to match these purposes, including problem-solving methods.

• X factor of a client-led contract for reinforcing the approach.

• Group-based approach offered, although APEX© can be offered to individuals.

• The group version of this approach is designed for 12 weeks.

• Service users were consulted in the design.

APEX© in te reo Māori

The following is a starting point In considering how the model fits within Māori kaupapa.

Taumata (summit) is the closest te reo Māori for APEX© and, within which we have these four elements:

Aroha (Attitude of caring)

Kaupapa (Purpose)

Kete Matauranga (Emotional first aid kit/baskets of knowledge)

Tohu Motuhake (Unique factor or X factor)

It has been noted that this spells AKKT (or ‘act’ in English) and that it is appropriate that we do take action about NSSI. Acceptance and commitment therapy (ACT) may also be useful to help with the attitude element of this approach (Hayes et al., 2016). The approach has to be helpful across many populations and diverse groups (e.g. other non-Western backgrounds and Rainbow communities). Indeed, the APEX©/AKKT model has been used with many such clients over time and there are openings for further research with those populations. A unique element of the model is that when it is offered in groups it enhances the group processing and understanding, and may appeal to different cultural groups in a less individualised way. Attitudes about these differences in different cultures around the meaning of the harming and perhaps how it reflects the distress of being othered through a Western lens would be helpful.

The 2011 NICE guidelines outlined what was psychologically useful in terms of interventions for self-harm, and were further developed in 2022. The below summary of what was recommended illustrates how the components of the APEX© model fit these guidelines.

• Target self-harm specifically.

• Use a psychological approach.

• 3–12 weeks to be focused on this work, preferably the longer option.

• Group-based approaches considered most effective.

• Problem solving approaches should be included.

• Service user consultations should influence the design.

The guidelines highlight the locus of control of the person in determining their recovery and this is the ‘X factor’ in APEX© (using the XYZ self-contract the person develops with their matched alternatives, which is described later).

With a strong emphasis on narrative ideas, the group programme includes some cognitive behavioural problem-solving strategies as well as art therapy, where a less verbal approach helps express feelings and tell stories in meaningful ways. The groups are offered with a triage intake process and risk assessment completed first, then 2-hourly groups are offered each week for 12 weeks. The Alternatives to Self-Harm (APEX© informed) group sessions were not developed for processing painful material, but to help understand the function of harming and develop alternative ways to meet that purpose. The first two sessions set the frame for safety and confidentiality and group rules. Each session has a structure based on the rule of thirds (Kluft, 1991), with each session having a grounding at the start, followed by reflections on new strategies tried and a new skill to practice. The sessions end with grounding. The pre- and post-measures used are described elsewhere (Clare, 2014, 2017). On returning to New Zealand in 2010, I offered APEX© for individuals, and outcomes continued to demonstrate its effectiveness. I also presented the model at conferences internationally. The approach is based on a collaborative relationship, where it is agreed that reduction, not necessarily elimination, is a realistic initial goal. There is emphasis on the value of tailored treatment to fit individual needs.

Comparison of APEX© with Treatment as Usual (TAU)

During my career, I have seen many clients in a range of settings where self-harm was a predominant issue, including community and acute mental health, intellectual disabilities, forensic and tertiary counselling services. A thematic analysis across these settings in terms of TAU led me to identify what I coined the ‘AILS’ approach, which is cyclic in its nature. AILS is an acronym of the components of what is problematic about TAU, as outlined in Table 1 below.

Comparison of APEX© with Dialectical Behaviour Therapy (DBT)

DBT (Linehan, 1993, 2015) uses CBT and mindfulness skills and is a model that is commonly used with emotion regulation difficulties. The outcomes for DBT in terms of reduced risk are helpful and often cited, but there are some problems with engagement for many who engage in NSSI. Table 2 outlines the differences between APEX© and DBT specific to NSSI.

For many people, self-harming can increase when they enter therapy and before they have developed ways to cope with intense emotions to keep grounded. Many individuals find therapy, or the prospect of it, too emotionally charged at first. If this is group-based, all their experiences from earlier group involvement (e.g. family) can add to this. Several approaches offer skills but the requirements of engaging with group rules can be daunting if one of them is to cease self-harming before the skills to do otherwise are learned, which is part of the DBT approach. There is a clear lack of logic in stating that a person must cease to engage in the problematic behaviour before they have any skills to do so.

APEX© acts as a complement to other approaches and is not necessarily a replacement, and it demonstrates a marked improvement to a simple TAU approach (the AILS approach). As with all these options, there is no ‘one size fits all’, and given the complexity of those who have emotional intensity difficulties, a variety of options is clearly useful.

Attitude

Fundamental to successful treatment of NSSI is that the attitude of the care staff is more helpful if harming is accepted as a means of coping in the first instance. This stance is captured well in the position of curious enquiry that is the basis of a narrative approach (M. White & Epston, 1990). Although such a stance is not the sole domain of narrative therapy, it is a style that is clearly helpful according to the evidence-base (NICE, 2004; 2011). Such an attitude decentres the professional and centring of the client becomes possible. If a person is the problem, consider how this might heighten the risk for self-harm. Externalising the problem of harming and its effects enables some curiosity and the possibility of generating alternatives to tackle it.

Purposes of Self-Harming

It is also worth considering that the purposes of harming can change and are not all the same, even for the same person. So if a person cuts to relieve built-up anger in one situation, cuts to reduce the risk for more serious injury in another or cuts to gain control in yet another situation, then the matched skills needed are different.

During the delivery of the original groups, a consistent finding was that clients had several reasons why they harmed. In a meta-analysis of reasons people gave for how self-harm helped, Sutton (2007) found eight common themes, all beginning with the letter C. Groups using the APEX© model added the ninth ‘C’ to this list as follows.

1. Coping and crisis intervention

2. Calming and comforting

3. Control

4. Cleansing

5. Confirmation of existence

6. Creating comfortable numbness

7. Chastisement

8. Communication

9. Compliance/connection or fitting in with peers (especially youth)

When the purpose for the harming is clarified, it becomes possible to generate alternatives to match those needs, based on the meaning for the person. Adopting an open attitude enables this enquiry into purposes of the actions of harming, and generating a range of other options in the form of an emotional first aid kit tailored to the person. For example, if the purpose is fitting in or compliance/connection, then we can begin to generate other ways this can be met.

Emotional First Aid Kits and Errors That Arise

It is crucial that the emotional first aid kit is tailored to fit the purpose, and it is here where many errors occur because of presumptions about what works. For example, I have come across several ideas being applied without consideration of how these strategies may or may not fit the purpose that harming is meeting for the person. If the ideas are randomly used, effectiveness is random too. To illustrate this, consider the idea of using a red pen.

I was due to see ‘Jenny’ in a forensic hospital ward. In her notes, there were several pages of red pen scribbles. The nurse explained they had heard that a red pen was known to be helpful sometimes for people who cut, so without any explanation to Jenny, she was told to request a red pen and paper when she had the urge to harm. The setting required that Jenny went to the nursing station, waited for a response, obtained the paper and pen, and then return to her room to engage in this ‘alternative’ all at the point in time when the impulse was to cut or harm the self for immediate relief.

The nurse was unsure if it had made a difference, so when I met with Jenny, I asked her about the drawings:

Diane: Your notes contain several pages of red pen drawings. Can you tell me about these?

Jenny: Oh that is something the nurses suggested I do whenever I have the urge to cut. I must ask for the paper and a red pen and then draw my feelings on the paper.

Diane: Does that help you, and if so, how?

Jenny: No not at all but it seems to make the nurses less anxious!

In this example where the strategy did not meet the purpose, we then looked at the purpose of harming for Jenny so that more meaningful emotional first aid kit ideas could be generated. She described her need for something active and immediate that would express her frustrations, so scribbling on paper with a red pen did not meet that need. The lengthy process of obtaining the pen was also problematic when the urge to harm was immediate. Once the purpose was clarified, alternatives could be tailored for an emotional first aid kit that could be used in the moment. Jenny came up with several actions, which included push-ups, power walking and dancing to music. The red pen idea was not helpful for her as it was offered randomly, without matching the strategy to the purpose of the harming.

There was another occasion when ‘Robert’, a man with dissociative identity disorder, told me that he was cutting his arms when ‘we needed to see the red’, telling me ‘we need to feel alive’. This difficulty was part of the ongoing effects of early trauma where he had many dissociative parts and often felt numb. Seeing red was what parts of him needed, and cutting served that purpose. When we considered the possibility of substituting a soft red felt pen on such occasions, he was sceptical but open to trying it, but it turned out to be helpful quite often. This illustrates how matching the purpose and the strategy (emotional first aid kit idea) can play a part in reducing the risk and increasing a sense of control. The red pen idea was part of his emotional first aid kit thereafter, but only when it matched the purpose of the harming. It is also important to note that this conversation about purpose became more complex when negotiating many parts within a dissociative client, and transactional discussion with parts was necessary. This was assisted by using Fraser’s Table (Fraser, 2003) to create a safe space to meet with parts and look at the issues in a supportive way.

Another person I worked with was ‘Megan’, who was a revolving door patient in acute mental health services. She was in her 40s and since her late teens had often been admitted following incidents of cutting her arms and bleeding on her kitchen floor. She told me about her trauma history and how when she cut, she felt a sense of control and that the red blood dripping helped her calm herself. She said how she would do this when her children were at school and clean up afterward so they were not exposed to it. How to meet those purposes? She liked the idea of ice cubes as she could hold an ice cube to feel in control of her feelings and see it dripping and clean it up, but there was something missing. She came up with the ingenious idea of making ice cubes with cranberry juice so that when she held the ice cube, she had the red sticky mess dripping onto the floor and then she could clean up. This offers a good example of how sometimes a mix of complex reasons for NSSI can be met by a mix of complex goals rolled into one simple strategy that then becomes part of the emotional first aid kit.

X Factor: the Self-Contract

When attitude is in place, purpose has been established and an emotional first aid kit has been worked on, the final part of the APEX© model is the X factor. The X factor pulls all this together into a self-contract. In the AILS approach, contracts have notoriously been about the professional demanding that the person complies with their rules. For example, Nancy Regan, who was First Lady to US President Ronald Regan, adopted the stance that the answer to the drug problem among the youth of America was to ‘Just say no to drugs’. We are all aware that the USA and other countries worldwide have not reduced drug addiction this way! If only.

The XYZ contract is a self-contract, whereby the person identifies the purpose or purposes of the harming. After some experimentation with the emotional first aid kit matching the purpose of the harming, the person identifies some preferred options that seem to be helpful and effective most times. For each purpose, they create a list of three preferred alternatives: X, Y and Z. These are three matched alternatives they previously found met the purpose and that they are prepared to use all three before harming.

The person makes a deal with themselves: ‘before I self-harm to get control/feel calm/release frustration etcetera, I will do X, Y and Z’. This acts as a delay tactic and enables a greater sense of personal agency for the person in managing the urge to harm. The three choices (X, Y and Z) must be linked to the purpose of the harming at the time and must be SMART (specific, measurable, action-oriented, realistic and timely). For example, calling a friend may help but only if that person is available 24/7. Therefore, one of the choices may be better described as ‘call someone like my friend or a 24/7 crisis line’ so that it covers all time frames.

Going back to ‘revolving door’ Megan who discovered the value of cranberry juice ice cubes, she later used other strategies matched to other purposes, and in time she built her XYZ contract. After eight sessions, she was discharged and never returned to the mental health team but later went on to engage in further trauma therapy. In follow-up months later, she said the deal maker for her was the XYZ contract. It was her deal with herself that made the difference.

Conclusions and Outcomes to Date

The APEX© model works in groups or with individuals in various settings. The option to use modules to manage inter-semester needs in school settings is available. Many of those attending training have used it in their practice with encouraging feedback on the success of the model across a range of age groups and settings.

Themes drawn from client feedback and outcomes over 20 years include: a greater understanding of the purpose of harming; enhanced confidence and hope; a wider repertoire of coping strategies that are effective alternatives; reduction in risk; a benefit to focus specifically on harming and the reduction in shame related to this; and readiness to engage in other therapies. This approach has been offered to a range of ages (from children aged 8 years to adults and older adults) both in the UK and New Zealand with similar outcomes.

Presentations have been offered since 2012 and workshops since 2018. Feedback from participants indicates the value of understanding the importance of attitude and curiosity to enable a discussion about purpose that can then identify alternatives. The matching of purpose and alternative is a theme that reflects why participants find APEX© effective for both clinicians and their clients. These points are highlighted in the following examples of qualitative feedback from clients. ‘Georgie’, a woman aged 54 years, had a 30-year pattern of stockpiling her prescription medication and then overdosing on it when she found life too difficult, but never with the intention to die. At the conclusion of the group, she said ‘When I started, I was stockpiling pills but now I am stockpiling good ideas.’ ‘Isobel’ who had been a revolving door patient for decades said, ‘I used to be so ashamed about the harming, but you are a people whisperer and now I feel confident and want to speak out myself to others, so they do not have to be ashamed’.

Limitations and Further Possibilities

As an improvement, more attention to the support team is recommended where each participant is encouraged to involve supportive others in their recovery process, as in the STEPPS™ programme (e.g. Black & Blum, 2017) using a ‘reinforcement team’. This support system the person identifies helps to maintain the progress made and reduces a sense of isolation that many participants have voiced feeling when they leave the group situation. In Māori and other Indigenous cultures, the whānau or extended family is crucial in a recovery approach. APEX© offers this collective approach which augurs well for the future of such programmes in different cultural contexts.

Training continues to be offered to other professionals in New Zealand and work is planned to provide training for parents of young people who self-harm so that a practical approach is achievable for how they can adjust and adapt this method to help their children. Further consideration is being given to ways to ensure that this model can be adapted for the Māori cultural context in Aotearoa.

It is also planned to publish the APEX© Leaders Guide as a useful resource to enable replication of the model and to obtain more comprehensive quantitative data. It will include the outcome measures and guidance on the overall structure of the approach. An adherence rating scale has also been developed to ensure that groups are consistent across different settings. It is hoped that by using this guide, research can be conducted and outcomes compared with the promising outcomes observed to date. If this can be replicated in larger numbers, it is hoped that the APEX© model can assist in relieving the burgeoning difficulty of NSSI that we see across services and settings today.

Implications for practice

The APEX© model has repeatedly demonstrated effectiveness in reducing non-suicidal self-injury. It is taught across Aotearoa and has been presented both nationally and internationally. It has been adapted to a range of settings, including mental health, forensics and tertiary education, and can be adapted for use with youth. The next steps are to publish a Leaders Guide on the session-by-session approach in group settings, further develop its use in a Kaupapa Māori setting and offer training for caregivers of youth who self-harm. This paper makes recommendations for practice-based research for this model to be used more widely.

Implications for Māori

This model has been designed and provided in the context of Aotearoa New Zealand and work is in progress to consider ways to enhance its use with mana whenua; this is noted in this paper.

Disclosure statement

The author has no competing interests to declare. Any participant information is included with consent and was anonymised and amalgamated to protect privacy. This allowed use of examples to illustrate how this approach can be used in practice.