No Slide Title
Download
Report
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