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Working with Self-injurious Youth in Schools
NYASP 2014
Steve Hoff, Licensed PsychologistAssociate Professor of School Psychology,
The College of Saint Rose, Albany NY
THE ALBANY-SCHENECTADY RAILROAD, THE OLDEST IN THE UNITED STATES
The Mohawk and Hudson Company – in 1832 the first passenger train in America was run over sixteen miles from Albany (intersection of Madison and Western Aves) to Schenectady
Amazing Albany
According to the US patent office, Seth Wheeler of Albany patented what was called perforated wrapping paper ("toilet" was a sensitive word in 1871). He patented the idea to have the product wrapped around a central tube in 1891, and is also often credited with patenting a bracket to hold those tubes.
Google hits for ‘self-harm’
◦ October 2014 – 3,020,000
Self-Injury in Pop-Culture
Goth Culture
Google Images hit for “Emo”
Luv-Emo Website – Pics Boys
Luv-Emo Website – Pics Girls
Barbie
Italy Fashion Industry – Considering Skinny Model Ban, 2006
Liposuction – Online Ad for Plastic Surgery Practice
The direct, deliberate destruction or alteration of one’s own body tissue without conscious suicidal intent
Favazza, Bodies under siege (1987)
Self-mutilative behavior is deliberate, non-life-threatening, self-effected bodily harm or disfigurement of a socially unacceptable nature
Walsh & Rosen, Self-mutilation: Theory, research and treatment (1988)
Definitions
Knife Inflicted Wounds
Eraser Burns
Plastic CD Cover “Carving”
Cigarette Burns
4% of general adult population21% of clinical populations
12% - 38% of college and high school studentsWhitlock & Knox, Archives of Pediatric Adolescent Medicine (2007)
Prevalence by gender◦ 11 year study of adolescents 12 – 18
487 males, 1633 females (70% female) – but more male cutting likely-at 12 years, M:F ratio was 1:8-at 18 years, M:F ration was 1:2
Hawton, Journal of Child Psychology and Psychiatry (2003)
“Unfortunately, many middle schools and high schools in the US are experiencing an explosion of self-injury among their students”
Walsh, Treating self-injury (2006)
Prevalence
Why Self-injury?
• How do I understand the presenting problem?
• What is the WHY behind the behavior(s)?
• What is the Intervention?
Case Formulation
Normal Adolescent Development
• Puberty - It comes, but on a variable timetable. Some kids mature early, some late. Boys – body hair, change of voice; Girls – menstruation, breast development
• Body image - Cultural/media images and expectations• Authority - Children start to pull away. Less idealized view of parents • Peers - Increasingly important. Bullying and cliques can increase• “Finding their Tribe” - Looking for belonging and meaning. “Where do I fit
in”? Social groups, rejection, popularity. • Risk taking – Increases. Smoking, drugs, sexual experimentation• Inconsistent judgment – Thinking and judgment are at times brilliant and
at times not• Personality changes – Introspection, egocentrism, self-consciousness,
moodiness
Middle school AdolescentsWhat to expect:
Emotional distress. The self-injurer is seeking relief – emotion regulation
◦ Depression◦ Alienation◦ Identity issues◦ Grief/loss◦ Abuse
Motives
“NSSI functions as a means both of regulating one’s emotional/cognitive experiences and of communicating with or influencing others”
Nock, Why do people hurt themselves? New insights into the nature and functions of self-injury (2009)
Motives (continued)
Emotion Before During After
Anxious 76% 30% 14%
Calm 6% 45% 72%
Confused 63% 29% 28%
Clear-headed 11% 34% 47%
Depressed 88% 39% 36%
Elated 4% 22% 19%
Emotional State
Internet survey of adolescent self-injurers. Murray, Warm and Fox Australian e-Journal for the Advancement of Mental Health (2005)
n=128
Brain systems involved in self-injury◦ Limbic system: regulates mood/affect and pain◦ Dopaminergic systems◦ Serotonergic systems◦ Hypothalmus/pituitary/adrenal axis
Studies suggest many systems involved – not a single pathway
Brain Function and Psychopharmacology
Many different medications are used to treat:◦ Antidepressants
SSRIs (Prozac, Zoloft) ◦ Antipsychotics (Abilify, Zyprexa, Risperdal,
Clozaril)◦ Mood stabilizers (Depakote, Tegretol, Lithium,
Topomax)◦ Anxiolytics (Ativan, Valium)
No medication intervention is well established Must consider long term vulnerability and
development, and current contextHarper in Walsh, Treating self-injury (2006)
Brain Function and Psychopharmacology (continued)
School must have a clear protocol for managing self-injury
Must be informed by a systems-wide approach
School
Self-injury Suicide Risk Assessment
Level of Care
Intervention/Services
Self-injury/Suicide Risk Assessment Flow Chart
“Even though most cases of DSH do not end in overt suicide, DSH reflects that potential underlying psychological pathophysiology, and likelihood of eventual death from self-murder, cannot always be predicted or prevented. It is important to take all acts of DSH as serious, and to offer comprehensive management to prevent future acts of DSH and potential suicide”.
Greydanus and Apple, The relationship between deliberate self-harm behavior, body dissatisfaction, and suicide in adolescents (2011)
The Risk…
Differences in:◦ Depressive symptoms◦ Suicidal ideation◦ Social support ◦ Self-esteem ◦ Body satisfaction◦ Disordered eating
Brausch and Gutierrez, Differences in Nonsuicidal self-injury and suicide attempts in adolescents (2010)
Differences in NSSI and Suicide Attempts in Adolescents
Parents/Family Work Parents must be notified Parents must be educated about self-injury Parents must be part of a clear support plan
and must follow through on responsibilities re: outpatient care
Family therapy may be indicated if family issues are a key component
What is the level of risk?◦ Question student about the frequency, duration,
intensity of self-injury Where does the self-injury occur – school, home,
other? Other dangerous behaviors? Drugs, risk taking, etc.
◦ Suicidal intent?◦ What is the level of peer involvement and need
for follow-up?
School - Assessment
Train staff to recognize and report◦ What is self-injury? ◦ What should staff be on alert for? ◦ Pay attention in ‘hot spots’ in the school:
lunchroom, schoolyard, bathroom, gym◦ Who should staff tell? School psychologist,
guidance counselor, social worker, nurse, administrator, etc.
School – Staff Training
Other self-destructive behavior (substance abuse) Depression/emotional negativity Poor self-esteemMiller & Brock - Identifying, Assessing, and Treating Self-Injury
at School (2011)
Risky sexual practices Possession of things that could be used for cuttingLieberman et al. (2009) Non-suicidal self-injury in the schools:
Prevention and intervention. In Nixon & Heath Self-injury in youth: The essential guide to assessment and intervention.
Warning Signs - Behavioral
Scratches or burns that don’t appear accidental
Frequently bandaged wrists and arms Reluctance to change clothes or participate
in gym Wearing long sleeves in hot weather
Warning Signs - Physical
Reasons for self-injury contagion Peer connectedness and identity Competition to be ‘the real cutter’ Expression and communication of feelings
Response to manage contagion Individualize and contain – divide and conquer Engage self-injurers, individually, in meaningful ways, e.g.
sports, arts, being a helper, USE THE RELATIONSHIP Build system-wide support plan: family, community, etc. for
each individual student May have to implement disciplinary response – limit set
School – Contagion
Individual◦ Support work in school, intensive work with outpatient
clinician Groups
◦ Problem solving◦ Self-esteem building◦ Stress management◦ Social skills training/building peer relationships◦ CAREFUL with groups around cutting◦ Activities
Sports The Arts: Music, Drama, Visual Arts, Dance Adventure Based Counseling groups Therapeutic animal contact
Family work – when appropriate
School - Services
CLINICAL INTERVENTION
Think strengths (Brooks – “Islands of Competence”)
Get the child to express her feelings Acknowledge that she is hurting and that
cutting is her way of coping Treat her with respect, express your belief
that she is capable and worthy of self-respect, able to be responsible and in control
Be willing to talk about specifics of cutting & what’s behind it
Talk about alternatives to cutting
TREATMENT CONSIDERATIONSDo’s!
Think illness/pathology Assume that she is cutting to get attention Be shocked, angry, disgusted, disapproving Minimize the importance that cutting holds
for her Power Struggle
TREATMENT CONSIDERATIONSDon'ts!
History of conflict in relationships Difficulty having healthy connections Few, if any, positive relationships with
adults Relationship with YOU can change her
perception of what relationships CAN BE
TreatmentAttachment and Corrective Emotional Experience
The Relationship
Six personality traits necessary to help a teen in crisis:
Confidence UnderstandingEmpathy NurturingKnowledge Optimism
Steven Levenkron, Cutting, understanding and overcoming se mutilation (1998)
Body Based Therapies“The body keeps the score”
(van der Kolk,1996)
Rational Emotive Behavior TherapyAlbert Ellis
Dialectical Behavior TherapyMarsha Linehan
Therapeutic Approaches
Wisdom/Compassion/Mindfulness
Self-compassion
Wisdom and Compassion in Psychotherapy
Germer & Siegel (2012)
Therapeutic Approaches (cont’d)
DIBs – Dispute Irrational Beliefs Double Standard Dispute – “what if this
were your friend’s problem?” Catastrophe Scale- “0 is resting at home,
100 is being shot” Reframing – “not devastating, upsetting” or
“what are the positives of this situation?” Blow-up Technique – combined with humor –
blow out of proportion to show irony, have client laugh at their fear
REBT Strategies
MUST use homework in REBT◦ Student practices what you came up with
together◦ Practice happens in the real world and the results
are brought back in to the work
REBT - Homework
Activity
REBT Practice Time
DBTTry to change AND try to Radically accept
• Mindfulness• Interpersonal Effectiveness• Emotion Regulation• Distress Tolerance
Linehan – Treating BPD (1993)
Interpersonal Effectiveness
Emotion Regulation
CAT EMOTION CHART
Distress Tolerance…
The Senses
Jen and the Cardinal
PROS AND CONSDestructive behavior I wanted to do: __________________
Tolerating distress PROS________________________________________________________________________
NOT tolerating distress PROS________________________________________________________________________
Tolerating distress CONS________________________________________________________________________
NOT tolerating distress CONS________________________________________________________________________
Suicide Risk
Multiple contributing factors to consider:◦ Conduct a thorough psychiatric exam, indentifying risk
factors and protective factors and distinguishing risk factors that can be modified from those that cannot
◦ Can use scales. Beck Depression Inventory, etc.◦ Ask directly about suicide/intent◦ Determine level of risk: low, moderate, high◦ Determine treatment setting and plan
Multiple attempters at much greater risk
M. David Rudd, Ph.D. Treating Suicidal Behavior (2001)
Suicide Risk Assessment
Learned skills in problem solving, impulse control, conflict resolution, and nonviolent handling of disputes
Family and community support Access to effective and appropriate mental health
care and support for help-seeking Restricted access to highly lethal methods of
suicide Cultural and religious beliefs that discourage suicide
and support self-preservation instincts
National Youth Violence Prevention Center (2004)
Suicide Risk AssessmentProtective Factors
Taking Care of the Caregiver: This Means YOU!
• Seeing self-injury, and the results, can be shocking, even sickening – it is okay to feel this way
• Manage our own stress– Mindfulness, relaxation, alonetime, exercise, etc.
