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AMTA WorkshopSelf-injury
VMT: The Cutting Edge of Therapy
AMTA WorkshopSelf-injury
VMT: The Cutting Edge of TherapyProfessor Graham Martin
[email protected] Sophie Martin
14.9.2012
Professor Graham [email protected] Sophie Martin
14.9.2012
Religious Mortification
Mortification of the flesh literally means "putting the flesh to death". The term is primarily used in religious and spiritual contexts.
Self InjuryDeliberate destruction of body tissue ‘without
suicidal intent’ (Favazza, 1989)
Majority occurs in community; ie ‘hidden’
Reliable ‘whole of population’ data lackingOnly one prior study of 928 (Briere &Gill, 1997)
When it does come to medical attention (eg Emergency Dept), consumers often treated badly - because ‘self-inflicted’
More serious the injury, more often admitted
Costs to society high, but difficult to estimate
Theoretical Frame, Klonsky, 2007
Affect-Regulation (Crouch & Wright, 2004)
Anti-dissociation (Miller & Bashkin, 1974)
Anti-Suicide (Messer & Fremouw, 2008)
Interpersonal Boundaries (Claes & Vandereycken, 2007)
Interpersonal Influence (Messer & Fremouw, 2008)
Self-Punishment (Linehan, 1993)
Sensation-seeking (Klonsky, 2007)
Findings from the 2009 Australian National
Epidemiological Study of Self-injury
Martin, G., Swannell, S., Harrison, J., Hazell, P. & Taylor, A., 2010. The Australian National Epidemiological Study of Self-Injury
(ANESSI). Centre for Suicide Prevention Studies, Discipline of Psychiatry. The University of Queensland. Brisbane, Australia. ISBN 978-0-9808207-0-6. Available in Soft Cover, or downloadable in .pdf
format from http://www.suicidepreventionstudies.com
ANESSI Key FindingsLifetime prevalence 8.1% (978 of 12,006
subjects)
Females 8.74% (530 of 6063)Peaked 20-24yrs (110/451, 24.4%), followed by 15-
19 age group (95/574, 16.6%)
Males 7.54% (448 of 5943)Peaked 20-24yrs (79/436, 18.1%) followed by 25-34
age group (119/957, 12.4%)
NSSI Lifetime Prevalence
978/12,006978/12,0068.1%8.1%978/12,006978/12,0068.1%8.1%
Four Week PrevalenceOverall 1.1% (n 133)
Females 1.19%, 72 of 6063 Peaked 15-19yrs (23/574, 4%)followed by 20-24 (16/450, 3.6%)
Males 1.02%, 61 of 5943Peaked 10-14 yrs (9/388, 2.3%)followed by 15-19 (14/629, 2.2%)
72% more than once
Nature of Self-injurylast 4 weeks
MalesHitting body on hard surface (37.1%), cutting (23.7%),
burning (17.5%)14.5% medical treatment; none to ED, none admitted
FemalesScratching (48.7%), cutting (48.2%), hitting body on
hard surface (29.2%), burning (8.1%)19.4% medical treatment; 3 to ED, and all 3 admitted
Overall, 26% used two methods, 19% used three, 7% used four, and 3% used five or more methods (Tot 55%)
Frequency of self-injury during the month ranged from once to fifty times (mean 7, mode 1)
Motivations‘To manage emotions’ (41%, 25/61 males, and
58%, 42/72 females)
‘Need to punish self’ (26%, 16/61 males, and 18%, 13/72 females)
‘Communicating to others’ (5%), ‘reminding the self he/she is alive’ (4%), ‘influencing others’ (4%), ‘getting a high’ (3%), ‘scarification’ (1.5%), ‘to prevent suicide’ (1.5%) and ‘voices telling them to’ (1%).
Other (24%) - ‘habit’, ‘compulsion’, ‘curiosity’ ‘distraction’, ‘for a laugh’, ‘to prove toughness’.
Self-injury & Suicidality
Lifetime self-injured (of 978 from 12,006)32.9% had attempted suicide compared
to 2% non self-injurers (OR 24.1)
Self-injury in last 4 weeks (ie of 133)48% (64/133) suicidal ideation in the
month compared to 7.7% (915/11826) of non self-injurers (OR 11.25)
14 (10.5%) reported a suicide attempt in the previous 12 months, compared to non-self injurers (33 of 11,873, 0.28%) (OR 41.60)
Help-seeking in last monthMost (95/133, 71.4%) told at least one
family member or friend about their self-injury
Only 42/133 (31.6%) asked for help.
Only19/133 (14.3%) received medical treatment for their injuries
Only three (2.3%) attended an emergency department; the same three were admitted to hospital overnight.
So, is other other work on help-seeking which may
help us to help our patients or clients?
Rotolone and Martin (2012)
Archives of Suicide Research. 16:2, 147-158.
312 participants (97 males, 215 females) 1st Year Psychology. Mean age 20.8±4.3
106 students had self-injured (34.0%)
‘Past self-injurers’ (68, 21.8%) were very similar to ‘Current self-injurers’ (38, 12.2%) in terms of frequency and severity of SI
37 of 68 ‘Past self-injurers’ (54.4%) had sought therapy or counselling for self-injury, 29 (78.4%) reporting it as helpful in reducing/discontinuing.
What helps ? (Rotolone & Martin 2011)
What helps ? The strongest overall predictor of self-
injury (past + present) was low social support (OR 0.54, CI 0.36-0.79)
Self-esteem was the other significant predictor of past + present self-injury (OR 0.29, CI 0.11-0.72)
In a second regression, Resilience was the only variable to predict current versus past status (OR 0.32, CI 0.13-0.76)
In other work we concluded that help-seeking is the key to
change.Martin, G. & Page, A., 2009. National Suicide Prevention Strategies: a
Comparison. Centre for Suicide Prevention Studies, Discipline of Psychiatry. The University of Queensland. ISBN 978-0-9808207-9-9. Commissioned review, DOHA, Canberra. Downloadable in pdf format (accessed 24.1.2013) http://www.livingisforeveryone.com.au/Library-
Item.html?id=82
‘Help-seeking’ is:Recognising & accepting that you have a problemKnowing there is a possibly successful treatmentKnowing to whom or where to goFinding the help accessibleFinding the help responsive and knowledgeable
Are there Effective Therapies for SI?
Hospitalisation is expensive with poor effectiveness (Linehan, 2000).
A meta-analysis on PST was inconclusive (Townsend et. al., 2001).
“Few therapies with a satisfactory research base are available to guide clinical practice” (Muehlenkamp, 2006)
Effective Therapies for SI?
A Cochrane review on therapies for borderline personality disorder concludes “all therapies remain experimental and the studies are too few and small to inspire full confidence in their results” (Binks et al., 2006).
Two other recent reviews are equally cautious (Ost, 2008; Kliem etal., 2010).
Effective Therapies for SI?Hawton et al., Cochrane Review 2009
From results of 23 RCTs, “more evidence is required to indicate what the most effective care is for this large patient population”.
Promising results found for PST, a card to allow emergency contact with services, depot flupenthixol for recurrent repeaters of self-harm and long-term psychological therapy for female patients with borderline personality disorder & recurrent self-harm.
Dialectical Behaviour Therapy
(Marsha Linehan) Problem solving
Behavioral Analysis
Insight Strategies
Cognitive Restructuring
Dialectics
Contingency Management
Behavioral Rehearsal
Exposure therapy
MindfulnessMarsha Linehan
Dialectical Behaviour TherapyEvidence is improving. Eg…
Pasieczny N, Connor J. in Behav Res Ther. 2011. Effectiveness of DBT in routine public mental health settings: An Australian controlled trial.
“After six months of treatment the DBT group showed significantly greater reductions in suicidal/non-suicidal self-injury, emergency department visits, psychiatric admissions and bed days.”
Dialectical Behaviour TherapyEvidence for the 12 week Adolescent Version
of DBT is not yet good.
Fleischhaker C et al in Child Adolesc Psychiatry Ment Health. 2011. DBT-A: a clinical Trial for Patients with suicidal and self-injurious Behavior and Borderline Symptoms with a one-year Follow-up.
12 adolescents were treated. 9 patients fulfilled five or more DSM-IV criteria for borderline personality disorder.
Voice Movement TherapyBased on the pioneering methods of
vocal facilitator Alfred Wolfsohn and influenced by the theatre work of actor and director Roy Hart; the acoustical analysis of otolaryngologist Dr Paul Moses; the characterological bodywork of Wilhelm Reich; and the psychological principles of C.G. Jung.
The TherapyTherapist is experienced actor/singer with B.
Theatre Arts USQ plus 6 months training in Martha’s Vineyard, plus a 2 year Masters
10 week course (2 ½ hrs) + TAU.
Waitlist randomization of two groups of 5-7 subjects
Each session begins with Voice work and Body movement and finishes with group voice.
By week 10 they sing in 3-part harmony.
Voice Movement TherapyVMT is not teaching or coaching. While initial
sessions may be scary from their novelty and sharing experience with previously unknown peers, it is overall a non-threatening, acceptable and fun therapy. We explicitly acknowledge that small group process, and shared experience of having been traumatised, and/or a self-injurer, is a powerful change agent with its impact on the sense of emptiness and isolation.
Voice Movement TherapyThrough working with voice, bodily
expression of emotion, and personal reflection, VMT provides shared meaning to, and words for, emotional experience, as well as suggesting emotion regulation strategies. Through mindfulness VMT improves distress tolerance. Through personal acceptance VMT changes impulsivity. In turn, these impact on self-esteem, anxiety, depression, and social avoidance.
What is different about VMT?it does not focus directly on self-injury leaving
that to the discretion of the young person.
It gains access to the emotional state through exercises that are fun, easily understandable.
It rediscovers the pleasure of music and movement and builds strengths to manage negative emotion. It builds mindfulness about the self, through all of the exercises, but never names this, not does it provide didactic teaching about the concept.
Are there other therapies?Do we have to base all our therapies on
variants from CBT?
Would ACT or MBCT be of assistance to our patients who self-injure?
Are there other Experiential Therapies which might do the job?
Very little Art Therapy, Music Therapy seems to have been researched in the context of Self-injury
Australia needs….Funding allocated to this preventable problem
For a program of education of key professionals
For longitudinal studies to clarify the long-term outcomes
For further development of new therapies
For randomized controlled studies on therapies we should invest in
