Transcript No Slide Title

Understanding and Responding to
Students who Self-Mutilate
Rich Lieberman
Los Angeles Unified
School District
Suicide Prevention Unit
(818) 705-7326
[email protected]
CUTTERS:
Challenges to School
Site Crisis Teams
 Overwhelming
numbers of referrals
 Low risk suicide
assessment
 Behaviors appear
contagious
MYTHS
 The
 All
cutter is attempting suicide.
cutters have been physically
or sexually abused.
CONTINUUM OF SELFDESTRUCTIVE BEHAVIOR
STRESSORS
WARNING
SIGNS
SUICIDE
HOMICIDE
DEFINITIONS
 Inclusion
of other Self-Injurious
Behaviors (SIB)
 Distinguish from ritual tattooing,
branding and piercing
 Not related to cognitive
impairment
DEFINITIONS (2)
“The definition of self-mutilation is
that it is a direct, socially
unacceptable, repetitive behavior
that causes minor to moderate
physical injury.”
Suyemoto&Kountz (2000) Self-Mutilation
The Prevention Researcher Nov., Vol. 7 No 4
CLASSIFICATIONS OF
PATHOLOGICAL SELFMUTILATION
 Major
Self-mutilation
 Stereotypic Self-mutilation
 Moderate/Superficial Selfmutilation
CLASSIFICATIONS:
Major Self-mutilation

Infrequent act that occurs suddenly,
with a great deal of tissue damage and
bleeding.
 Most commonly associated with
psychosis and acute intoxication.
 Religious or sexual themes may be
present.
CLASSIFICATIONS:
Stereotypic Self-mutilation
“Driven by a biological imperative to harm
themselves shamelessly and without guile”
Favazza

Most common form: head banging
 Most common population:
Institutionalized/psychotic
 Self-injurious behaviors (SIB)
CLASSIFICATIONS:
Stereotypic Self-mutilation
• Autism (head banging, lip/wrist
biting)
• Retts disorder (hand washing)
• Tourettes (multiple simple and
complex tics, variety SIB)
• Use of medication is common
though behavior therapy is primary
modality.
CLASSIFICATIONS:
Moderate/Superficial Self-mutilation

Most common: skin cutting, burning
• Compulsive: Hair pulling, scratching.
• Episodic: Rapid respite from
distressing thoughts/emotions/tension;
regain sense of self control.
• Repetitive: Addiction to self harm.
DIAGNOSIS
Repetitive Self-mutilation
Syndrome (RSM)
RSM is recurrent failure to resist impulses
to harm one’s body physically without
conscious suicidal intent.
Bodies Under Siege
Self-mutilation and Body, Modification in Culture
and Psychiatry
Armando R. Favazza, M.D.
Hopkins University Press
Baltimore/London
DIAGNOSIS (2)




RSM can be associated with many
disorders.
Borderline personality disorder
Depression: mood & anxiety disorders
Impulse disorders: Episodic/gratifying
•
•
•
•

Alcohol & substance abuse
Suicide attempts
Eating disorders
Repetitive self-mutilation
Post traumatic stress disorder
Repetitive Self-mutilation
Syndrome
PREVALENCE & ONSET





Onset: late childhood-early adolescence
Rates higher in adolescence: approximately
1400 per 100,000
Rates higher in females
Rates higher in psychiatric pop.
Behaviors may become chronic and persist
for 5-10 yrs. or longer if left untreated.
Repetitive Self-mutilation
Syndrome
PREDISPOSING FACTORS






Onset linked to “stressful” situations
Physical/sexual abuse in childhood
Early history of hospitalization/surgery
Parental alcoholism/depression
Perfectionist tendencies/dissatisfaction with
body
Inability to tolerate and express emotions
WHY DO PEOPLE ENGAGE IN
SELF-INFLICTED VIOLENCE?
 Meets
a multitude of needs
 Relief from overwhelming feelings
 Communication
 Stop inducing or preventing
dissociation
Alderman, T. (1997) The Scarred Soul: Understanding and
Ending Self-Inflicted Violence (New Harbinger Press,
Oakland, CA.)
WHY DO PEOPLE ENGAGE IN
SELF-INFLICTED VIOLENCE?
 Self-punishment:
scars/blood
concrete reminders
 Physical expression of pain
 Re-enacting previous abuse
WHY DO PEOPLE ENGAGE IN
SELF-INFLICTED VIOLENCE?
Bottom Lines

Euphoric feelings
 Establishing control
“Self-mutilation is an active, direct,
concrete representation of
intense anguish.”
PHENOMENOLOGY
“Although self-mutilators sometimes
report feeling guilty or disgusted after
an incident, most adolescents report
feeling relief, release, calm or
satisfaction…ending the anger,
tension or dissociation.”
Suyemoto K.(1998) The functions of self-mutilation.
Clinical Psychology Review, 18(5), 531-554
PHENOMENOLOGY (2)

Precipitating event: usually the
perception of an interpersonal loss or
abandonment
 Poor coping skills
 Reacting to overwhelming emotions by
dissociating
 Isolation
FAMILY AND DEVELOPMENTAL
FACTORS

Families characterized by divorce,
neglect or deprivation of parental care
 Parental loss = emotional distancing
and inconsistent parental warmth
 Often a history of childhood
physical/sexual abuse
TREATMENTS
 Biological
 Psychological
and Social
 Cognitive/Behavioral Therapy
“There is no single, correct
therapeutic approach.
Prevention is key.”
Favazza
TREATMENTS:
Biological
 Serotonin
(SSRIs)
 Preferred treatment for depression
and anxiety disorders.
 Primarily affect on
impulsivity/compulsivity
TREATMENTS:
Psychological and Social
 Making
and maintaining a
relationship
 Breaking the habit
 Maintaining change
Tantam & Whitaker (1992)
TREATMENTS:
Psychological and Social
 Analyze
precipitating events
• Identify thoughts and emotions
• Where/how wounds
• Goal: Reduce tensions
 Gain
control over cutting
Hawton (1990)
TREATMENTS:
Cognitive/Behavioral Therapy
 Connection
between thoughts and
behaviors
 Facilitated by directing attention
away from environment and
towards thoughts
 Replace negative perceptions with
focus on positive qualities.
SCHOOL INTERVENTIONS:
General strategies for Educators
 Consider
outside referral
 Strategies related to increasing
abilities to verbalize and express
emotions
 Teach coping skills: loss
 Connectedness with caring adults
SCHOOL INTERVENTIONS:
General strategies for Educators

Talk about self-inflicted violence
 Be available and supportive (keep your
negative reactions to yourself!)
 Set reasonable behavioral limits
 Do not discourage self-injury
SCHOOL INTERVENTIONS:
General strategies for Educators
 Substitute
behaviors
 Stress management techniques
 Alternative therapies include art
therapy and EMDR
 Recognize the severity
SCHOOL INTERVENTIONS:
General strategies for Educators
Substitute behaviors
 Help
seeking behaviors
 Journals/drawing
 Get active: exercise
 Advocacy: reaching out to others
 Cognitive-behavioral approaches
SCHOOL INTERVENTIONS:
General strategies for Educators
Substitute behaviors
 Rubber
bands
 Holding books out at arms length
 Standing on tip toes
 Substitute ice or magic marker for
sharp implement
SCHOOL INTERVENTIONS:
General strategies to limit contagion

Divide
 Assess for suicide risk
 Get parents involved and supported
 Utilize school/district/community
extracurricular resources
 Do not have assemblies, presentations
or show videos
WARNING SIGNS OF
YOUTH SUICIDE

Suicide notes
 Threats
 Plan/method/access
 Depression (helplessness/hopelessness)
• Masked depression (risk taking
behaviors, gun play, alcohol/substance
abuse)

Giving away prized possessions
WARNING SIGNS OF
YOUTH SUICIDE

Efforts to hurt self
• Running into traffic
• Jumping from heights
• Scratching/cutting/marking the body

Death & suicidal themes
 Sudden changes in personality, friends,
behaviors
SCHOOL SITE
CRISIS TEAM

Members:
• Designated reporter
• Administrator
• Support personnel

Assess and Advise
 Collaborate with law enforcement and
local mental health resources
SUICIDE INTERVENTION
Procedures
 Assessment
of risk
 Duty
to warn
 Duty to refer
 Caveats:
• Collaboration
• Documentation
RISK ASSESSMENT
 LOW:
Ideation?
 MODERATE: Previous suicidal
behaviors?
 HIGH: Current plan
method/access?
SUICIDE INTERVENTION:
Risk Assessment
 LOW: Ideation?
“Have you ever thought about suicide
(harming yourself)?”
• Current thoughts
• Past thoughts (<6 months)
• Non-verbal warning signs
(writing/drawing)
SUICIDE INTERVENTION:
Risk Assessment
 MODERATE:
Previous suicidal
behaviors?
“Have you ever tried it before?”
• Previous attempts/gestures/RARD
• Previous hospitalizations
• Previous trauma (abuse, victimization)
• Medications
SUICIDE INTERVENTION:
Risk Assessment
 HIGH
RISK: Current plan?
“Do you have a plan to kill yourself now?
How would you do it?”
• Method? Assess access
• Firearms mentioned?
• Refusal to sign no-harm agreement
SUICIDE INTERVENTION:
Risk Assessment:
Exacerbating factors
 Precipitating
events
 High stressors (family, school, loss)
 Poor access to resources
SUICIDE INTERVENTION:
Intervention strategies
 LOW RISK:
 Reassure and supervise student
 Warn parent
 Assist in connecting with school and
community resources
 Suicide-proof environments
 Mobilize a support system
 No-Harm agreements
 Transportation issues
SUICIDE INTERVENTION:
Intervention strategies
 No-Harm
agreements emphasize:
 Connectedness
with adults
 Help–seeking behaviors
 Communication skills
 Grief resolution
 Linkages with community and
district resources
SUICIDE INTERVENTION:
Intervention strategies

MODERATE /HIGH RISK:
 Supervise (restrooms, bus)
 Release to:
 Parent
(may not be appropriate if child
is high risk)
 Law enforcement
 Psychiatric mobile responder

Release adult to: 3rd party; IUSD Employee?
Call District Office.
SUICIDE INTERVENTION:
Duty to Warn
Would
calling the parent place the child in
greater danger? If so, call Children’s
Protective Services.
Warning
parents
Available/Cooperative?
Assessment
Mental
information
Health insurance
Release
Educate
of information
parents on depression; suicidal/self injurious
behaviors; “She is doing this for attention!”
SUICIDE INTERVENTION:
Duty to Refer
Emergency response
Collaborating with
Local
teams
law enforcement
district resource guides
Cultural/developmental/sexuality factors
District
resources (Special Ed)
Understanding and Responding
to Students who Self-Mutilate

Very complex behavior that fulfills a
multitude of needs
 Dispel myths
 Contagion: often runs in peer groups
 Respond individually
 Assess for suicide risk
Understanding and Responding
to Students who Self-Mutilate

Warn and involve parents
 Utilize school/community resources
 Do not discourage self harm
 Do teach substitute behaviors that
focus on help-seeking/communication
skills, reduction of tension and
isolation