Transcript Understanding Self-Harm

Understanding Self-Injury
Mental Health & Assessment
Suicide Prevention Symposium
Octavianne “Tavie” Maroncelli, LCSW
June 4, 2012
Activity
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Think about a personal situation when you
became incredibly stressed or angry
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Write on the provided note card one or two
ways you responded
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No need to write your name on note card
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Hand in note cards
Before we get started…
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What is your understanding of Self-Injury?
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What do you hope to gain from this
presentation?
Agenda
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Defining self-injury
Delineating difference between suicidal ideation
and self-injury
Reasons why people self-injure
Harmless video clip (8 minutes)
BREAK
Signs of Self-Injury Video (29 minutes)
Who is self-injuring
Our charge as mental health providers
Myths and Facts about
Self-Injury
Self-injury, such as wrist-cutting,
should be considered a suicide
attempt.
MYTH
FACT
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Self-injury is generally not about suicide

Few die by cutting the wrists
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Concerning Methods
-Gunshot
- Hanging
- Overdose
- Ingesting poison
- Jumping from a dangerous height
Self-injury is explainable.
FACT
Many studies have tried to explain
reasons for self-injury. They include:

To reduce emotional distress such as anxiety,
sadness, anger or shame

To “feel” something after bouts of numbness
known as dissociation
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To communicate distress or change the
behavior of others
Individuals who self-injure
are separate and distinct
from suicidal people.
MYTH

Self-injurious behavior is distinct from suicidal
behavior, can co-occur

Professionals must continually assess for
suicidal intent
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People who self-injure are statistically more
likely to attempt suicide than those who do
not self-injure
Self-Injury Defined
A volitional act to harm one’s body without
intention to die as a result of the behavior.
(Favazza, 1996, 1987; Simeon & Favazza, 2001)
The deliberate, impulsive mutilation of the
body, or body part, not with the intent to
commit suicide, but as a way of managing
emotions that seem too painful for words
to express. (Conterio, 1998)
DSM-IV TR
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No formal classification
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“Self-mutilation” is listed as a commonly
occurring symptom with several specific
disorders
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Borderline Personality Disorder
Depression
Eating Disorders (anorexia and bulimia)
Obsessive-Compulsive Disorders (OCD)
Post-Traumatic Stress Disorder (PTSD)
Dissociative Disorders
Anxiety and Panic Disorders
Impulse Disorder Not Otherwise Specified
Terms
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Self-Injury
Self-Harm
Self-Mutilation
Non-suicidal SelfInjury (NSSI)/ Nonsuicidal Self-Harm
Repetitive SelfMutilation Syndrome
(RMS)
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Para Suicidal behavior
Cutting
Self-Abuse
Self-Inflicted Violence
(SIV)
Self-Injurious behavior
Terms to Avoid
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“Suicidal Gesture”
◦ Inaccurate and misleading
◦ Can lead to empathic failure“You don’t get it!”
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“Self-Mutilation”
◦ Too extreme and sensational
◦ Self-injury  mild to moderate damage
Self-Injurious Behaviors
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Cutting
• Bruising or breaking
bones
Skin-picking
• Banging head
Hair-pulling
• Any behaviors that
Burning
cause immediate harm
Punching Oneself
Scalding
Scratching
Scab-picking
Inserting objects into
body
Things to remember
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Separate self-injury from suicide, when they co-exist
treat them as co-morbid
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Self-injury is not the problem so don’t make that the
primary focus
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Self-injury lets us know that there’s a problem
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Goal is to help the person have more coping
mechanisms, not for the self-injury to stop
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Recovery from the problem takes time, resources
and someone who cares
The Cycle of Self-Injury
Intense, unsettling feelings
TENSION
SHAME
DRAMATIC
PHYSICAL RELIEF
COPING STRATEGY
(Self-Injury)
SUICIDE
SELF-INJURY
Intent:
- Permanently escape misery
- Intense
- Persistent Psychological
pain
 Method:
- Hanging
- Gunshot
- Overdose
Intent:
- Relief from pain
- Too much or too little
emotion
- Frequent
 Method:
- Several methods
(previous slide)
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Difference Between Suicide
& Self-Injury
Rate of Suicide Completion
Firearms
 Suffocation
 Poising
 Fall
 Other
 Drowning
 Fire / Burning
 Transportation
 Cutting
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59.3
(2/3)
24.8
(1/4)
6.4
2.9
2.5
0.8
0.5
0.5
0.4 %
(Walsh, 2006)
Reasons Why
bullying
 abuse (sexual, emotional
or physical)
 neglect
 difficulty identifying
 school/work pressures
feelings
 family financial difficulties  eating disorders
 relationship troubles
 drug/alcohol problems
 family problems
 coming to terms with
sexuality
 bereavement
...any experience / event that
 loneliness/isolation
causes negative feelings,
 emotionally “numb”
thoughts and tensions
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Three Major Categories “Why”
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Affect regulation – Trying to bring the body
back to equilibrium in the face of turbulent or
unsettling feelings
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Communication – Expressing something
which they cannot verbally express
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Control / punishment – Includes trauma
reenactment, bargaining and magical (if / then)
thinking, protecting others and self-control
Constructivist Theory
People who self-injure usually have not
developed 3 important self-capacities:
◦ The ability to tolerate strong affect
Self-injury offers affect-regulation.
◦ The ability to maintain a sense of self-worth
Self-injury is a way of communicating.
◦ The ability to maintain a sense of connection to others
Self-injury communicates.
(Deiter, Nicholls, & Pearlman, 2000)
Other possible reasons why
from society / popular media
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Movies
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Television
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Books
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Internet (NY Times article 2/21/2011)
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Popular public figures / celebrities
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Musicians
“People generally do things for reasons that make
sense to them. The reasons may not be apparent
or may not fit into our frame of reference, but
they exist and recognizing their existence is
crucial to understanding self-harm. With
understanding of the reasons behind a particular
act of self-harm comes knowledge of the coping
skills that are lacking. When you know what skills
are missing, you can start trying to introduce
them.”
Martinson, D. (1998). Why do people deliberately injure themselves?
http://www.palace.net/llama/psych/why.html.
Self-injury is NOT done for
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Sexual pleasure / gratification
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Body decoration
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Religious ritual
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Cultural compliance
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Spiritual enlightenment through ritual
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Fitting in or being “cool”
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Suicide (usually)
Sun Dance
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One of the most religious
ceremonies of the Sioux
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Twelve-day summer ritual of self-sacrifice
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Testimony to individual courage and endurance
in serving the Great Spirit
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By dancing and enduring the pain of selfinflicted wounds, each participant reasserted
his identity as an Indian warrior
Not “just to get attention”
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A pejorative response, stigmatizing
◦ Often in response to distress
◦ Many other ways to get attention
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Can be a secondary reinforcement of Self-Injury
◦ Those who inadvertently reinforce the behavior need
to be part of the response plan
Harmless Video
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Video clip / UK resource (8 minutes)
Harmless Video
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Mark:
Affect Regulation
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Jennie:
Communication
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Fiona:
Control / Coping
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Therapist
- No contract
- Engage so they return
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Satveer: Judgment
BREAK
5 minutes
 Treats
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Our Initial Response
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Use the Student’s Language
◦ For example: “cutting, scratching, carving”
◦ It’s joining, respectful, empowering
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Rule out Suicidal Intent
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Avoid Inflammatory Terms
◦ Not “suicidal”
◦ Not “self-mutilating”
Signs of Self-Injury
Prevention Program - ACT
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School Personnel section (11 minutes)
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Student section (18 minutes)
Who is Self-Injuring?
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Age of onset typically between 12–15 years old
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New research suggests that the behavior may
continue into 30’s
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More females than males (small difference)
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Impacts many races / ethnicities / cultures / SES
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Many report that they self-injure repeatedly for
years
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Difficult to know absolute numbers because it is
typically very secretive
Case Study - Pair and Share
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5 minutes
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Share any “A-ha’s” with the large group
Wordle
Wordle.com
 Entered all of the coping mechanisms
everyone wrote (beginning activity)
 The larger words are ones entered
multiple times
 Provides visual image of all of the coping
skills we have used
 Some healthy, some not healthy and some
neutral
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Warning Signs
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Unexplained frequent
injuries, including cuts
and burns
Wearing long pants and
sleeves in warm weather
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Inability to function at
home, school or work
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Inability to maintain
stable relationships
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Changes in social
interactions or interests
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Low self-esteem
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Overwhelmed by feelings  Increased isolation and
/ Excessive rage,
withdrawal
depression
Journal of Mental Health Counseling entitled “Superficial
Self-Harm: Perceptions of Young Women Who Hurt
Themselves”
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Published in 2008
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Sought to explore young women who hurt
themselves, including what effective support
may look like
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The sample of 96 females (18 years and older),
included females who currently or historically
participated in self-injury and did not have a
mental health diagnosis (e.g., schizophrenia,
autism, or dissociative identity disorder)
What Support is Helpful?
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Acknowledging seriousness of behavior
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Given the opportunity to talk
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No judgment
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Appropriate reactions from others
How Can We Help?
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Staff training / gatekeepers
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Be calm / matter of fact when a student is telling you
about it, showing you care
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Have discussions in private
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Convey it’s okay to talk about but limit any
discussion to an inability to cope, requiring help
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Refer to the designated mental health professional in
your school (guidance counselor, social worker or
psychologist) - Who will assess for suicidal ideation and
next steps
How Can We Help? (Cont.)
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Show concern for the injuries themselves
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Convey respect for the person’s ability to talk
to someone and their effort to survive
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Help them make sense of their self-injuring,
getting to the root of the problem
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Help them to create supportive networks
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Don’t see stopping the self-injury as main goal
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It takes time
What is NOT helpful?
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Minimizing the behavior
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Perseverating on the self-injurious behavior
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Assumptions about the reasons why
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Class discussions
Child & Adolescent Self-Harm in
Europe (CASE) Study
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In 2008, over 30,000 15 – 16 year olds completed an
anonymous questionnaire in school
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Australia, Belgium, England, Hungary, Ireland, the
Netherlands and Norway
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Of 1660 young people in the CASE Study who report
an episode of self-harm:
- 48.4% said they got no help for their last
episode
- 29.7% received help from friends
- 12.2% visited the hospital
- 6.9% saw a psychologist or psychiatrist
- 6.8% were helped by their families
Physiological Concerns
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People who self-injure tend to be dysphoric
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The tension becomes unbearable
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Self-injury serves the function of bringing
temporary relief
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Self-injury quickly calms the body
(Herpertz, 1995)
Steps for Social Workers &
School Psychologists
1. Interview the student to determine the motive
for the self-injurious behavior.
◦ Consider how this student’s family and
culture may view self-injury
◦ To address contagion ask if other students
are involved
Steps for Social Workers &
School Psychologists (Cont.)
2. Ask directly if the student is thinking of dying,
or is suicidal.
◦ “Are you thinking of killing yourself?”
◦ “When you cut your thigh how were you
feeling? Did you want to die?”
◦ If the student’s intent is suicide you will need
to do the Suicide Risk Assessment
◦ Call Ellen Kelty at 303-728-4121 or Liz
Jagiello at 720-423-8034 if you need to
consult on a case involving self-injury
Steps for Social Workers &
School Psychologists (Cont.)
3. Contact the parents or guardians.
4. Consider how this student’s family and culture
may view self-injury and mental health
treatment.
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Provide handouts
Provide resources for counseling
Second Wind Fund of Metro Denver will
serve students that self-injury and has a list
of providers who specialize in this area
Steps for Social Workers &
School Psychologists (Cont.)
5. Provide information and handouts to principal
and teachers regarding self-injury.
6. Consult with Ellen Kelty if several students are
involved.
7. Follow-up with the student and parent /
guardian.
The Role of the School Nurse
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If the student presents with acute (fresh)
injuries refer to the school nurse to assess the
severity, nursing intervention and referral for
medical intervention if needed
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Collaborate with the nurse in your building as
they may have more information on the case
School Mental Health
Best Practice
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Address medical needs and insure physical safety
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Assess for suicidal ideation and / or co-morbidity
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Develop short-term plans for safety (not a safety contract)
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Notify and collaborate with parents / guardians
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Control the contagion effect
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Educate school staff
“The assumption is that the alternative to
self-injury is ‘acting normally’,
but on the contrary…
the alternative to self-injury is total loss of
control and possibly suicide.
It becomes a forced choice from among
limited options.”
(Solomon & Farrand, 1996)
Resources
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Handouts (packet of helpful information)
Research articles (can email to you)
References & Recommended Resources from Signs of
Self-Injury (included in the handouts packet)
Books
- Treating Self-Injury by Barent W. Walsh (2006) (ED of The
Bridge of Central Massachusetts)
- See My Pain by Susan Bowman & Kaye Randall (2007)
- Self-Injury: A Manual for School Professionals by S.A.F.E.
Alternatives / 800-DONTCUT (366-8288)
- Stopping the Pain by Lawrence E. Shapiro (2008)
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Phone Numbers & Websites (later slide)
Curriculum (Signs of Self-Injury, SOS)
Phone Numbers & Websites
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S.A.F.E. (Self Abuse Finally Ends) Alternatives /
www.selfinjury.com /1-800-dontcut
(1800-366-8288)
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Self-Injury Foundation / 1-888-962-NSSI (6774)
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Recover Your Life /
http://www.recoveryourlife.com/
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National Suicide Prevention Lifeline
1-800-273-8255
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Harmless UK Website
http://www.harmless.org.uk/
Handouts
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“Suggestions for School Counselors / Social
Workers / Psychologists”
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“Suggestions for the Family”
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“Responding to Self-Injury: Best Practice
Recommendations for Schools”
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“Coping Strategies and Distractions”
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“Non-Suicidal Self-Injury, Coping Strategies, and
Sexual Orientation”
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“Assessing your immediate need to self-injure”
Comments / Experiences /
Questions
More Myths and Facts
* Copied from Signs of Self-Injury Curriculum
MYTH: Self-injury is mostly about attention-seeking or
manipulating others.
FACT: “Attention-seeking” or “manipulation” is not an
adequate explanation for self-injury. There are far more
effective ways to gain attention or influence others than
to physically hurt one’s own body. Use of language such
as “manipulative” or “attention-seeking” usually
suggests caregiver frustration with the self-injuring
person.
MYTH: Like anorexia, self-injury is mostly a
problem in females.
FACT: Studies have found rates of self-injury to
be almost equal in both sexes:
60 – 65% female
35 – 40% male
MYTH: Most individuals who self-injure have
been sexually abused.
FACT: Studies of clinical samples (those made
up of people in treatment) have shown larger
percentages of self-injuring individuals with
histories of sexual abuse. This does not appear
to be true for community samples of middle
school, high school and university students.
MYTH: Self-injury is a fad. Ignore it and kids will
grow out of it.
FACT: Self-injury should not be minimized or
referred to as a “fad”. Self-injury involves real
tissue damage and potential scarring. Self-injury
is indicative of serious distress that requires
assessment and treatment by a professional.
There is no evidence that most people who selfinjure spontaneously “grow out of the behavior.”
MYTH: Most who self-injure are mentally ill and
probably won’t get better.
FACT: Self-injury is now occurring in highly
accomplished, high functioning individuals who
are doing well in school / work and have stable
relationships. Self-injury should not be equated
with mental illness. The behavior is treatable and
the prognosis for a full recovery is very good –
regardless of pre-existing mental illness.
MYTH: Professional tattoos and piercings are
the same as self-injury.
FACT: Body modification obtained from
professionals (such as tattoos and piercings) is
generally considered separate and distinct from
self-injury as it is a deliberate, planned and public
act lacking aspects of emotional regulation. Selfinjury tends to be a more private behavior that
at its core is about regulating painful emotions.
MYTH: Self-injury is not a problem in my
school.
FACT: Based on an emerging body of research,
self-injury is occurring at high rates in many
middle and high schools throughout the United
States. Rates of 10 – 20% in school settings have
been commonly reported. The large majority of
middle and high schools in the United States
report some type of self-injury.
*I’ve also read studies indicating that elementary-aged students
are self-injuring as well.