New Developments in Understanding

1
New Developments in Understanding Treating
Self-Injury

• Presenter
• Barent Walsh, Ph.D.
• Executive Director
• The Bridge of Central Massachusetts, Inc.
• 4 Mann Street
• Worcester, MA 01602
• Phone [phone]
• email barryw_at_thebridgecm.org

2
Differential Classification of Self-damaging
Behavior
DIRECT
INDIRECT
High Lethality
Suicide SINGLE EPISODE
Situational Risk-TakingSINGLE EPISODE
Suicide Repeaters MULTIPLE EPISODES
High Risk Stunts Late Phase Anorexia MULTIPLE
EPISODES
Medium Lethality
Atypical or Major Self-Injury SINGLE EPISODE
Acute DrunkennessSexual Risk-Taking SINGLE
EPISODE
Chronic Substance Abuse, Bulimia, D/C
Psychotropic Meds MULTIPLE EPISODES
Low Lethality
Common Self-Injury MULTIPLE EPISODES
Modified, Pattison Kahan (1983)
3
Checklist for Direct Self-Harm Behaviors

• Suicide Attempts__ Overdose __
  Hanging__Self-Poisoning __ Use of gun __
  Jumping from height
• Major Self-mutilation __ Self-enucleation __
  Autocastration
• Atypical Self-Injury __ Injury to face, eyes,
  genitals, breasts __ Damage involving multiple
  sutures
• Common Forms of Self-Injury __ Wrist, arm and
  leg cutting __ Self-burning, self-hitting,
  excoriation

4
Checklist for Indirect Self-Harm Behaviors

• Substance Abuse __ Alcohol Abuse __ Marijuana
  Use __ Cocaine Use __ Inhalant Use (glue,
  gasoline) __ IV Drug Use __ Hallucinogens,
  Ecstasy __ Other (specify)
• Eating Disordered Behavior __ Anorexia Nervosa
  __ Bulimia __ Obesity __ Use of laxatives __
  Other (specify)

5
Checklist for Indirect Self-Harm Behaviors
(cont)

• Physical Risk Taking __ Walking on high-pitched
  roof __ Walking in fast traffic
• Situational Risk Taking __ Getting into
  strangers cars __ Walking alone in dangerous
  areas
• Sexual Risk Taking __ Having sex with strangers,
  unprotected anal sex
• Unauthorized discontinuance of psychotropic
  medications
• Misuse/Abuse of prescribed psychotropic
  medications

6
Differentiating Suicide Attempts from Self-Injury

• Q1. What was the expressed and unexpressed intent
  of the act?

SUICIDE ATTEMPT (Shneidman) To escape pain, to
terminate consciousness
SELF-INJURY (Walsh) Relief from unpleasant
affect (tension, anger, anxiety, sadness,
emptiness)
7
Differentiating Suicide Attempts from Self-Injury

• Q2. What was the level of physical damage and
  potential lethality?

SUICIDE ATTEMPT Serious physical damage, lethal
means of self-injury
SELF-INJURY Little physical damage, non-lethal
means used
8
Differentiating Suicide Attempts from Self-Injury

• Q3. Is there a chronic, repetitive pattern of
  self-injurious acts?

SUICIDE ATTEMPT Rarely a chronic repetition, some
overdose repeatedly
SELF-INJURY Frequently a chronic, high rate
pattern
9
Differentiating Suicide Attempts from Self-Injury

• Q4. Have multiple methods of self-injury been
  used over time?

SUICIDE ATTEMPT Usually one method
SELF-INJURY Usually more than one method over time
10
Differentiating Suicide Attempts from Self-Injury

• Q5. What is the level of psychological pain?

SUICIDE ATTEMPT Unendurable and persistent
SELF-INJURY Uncomfortable and intermittent
11
Differentiating Suicide Attempts from Self-Injury

• Q6. Is there constriction of cognition?

SUICIDE ATTEMPT Extreme constriction, suicide as
only way out, tunnel vision, seeking final
solution
SELF-INJURY Little or no constriction, choices
available, seeking a temporary solution
12
Differentiating Suicide Attempts from Self-Injury

• Q7. Do they feel hopeless and helpless?

SUICIDE ATTEMPT Hopelessness and helplessness
are central to their dilemma
SELF-INJURY Periods of optimism, some sense of
control over their own situations
13
Differentiating Suicide Attempts from Self-Injury

• Q8. Was their a decrease in discomfort following
  the act?

SUICIDE ATTEMPT No immediate improvement,
treatment required for improvement
SELF-INJURY Rapid improvement, rapid return to
usual cognition and affect, successful
alteration of consciousness
14
Differentiating Suicide Attempts from Self-Injury

• Q9. What is the core problem?

SUICIDE ATTEMPT Depression, rage about their
inescapable, unendurable pain
SELF-INJURY Body alienation, exceptionally poor
body image for clinical populations
15
Cautionary Notes Self-Injury vs. Suicidal
Behavior
While self-injury is generally not about suicide,
some individuals who self-injure do become
suicidal. It is important to emphasize that
while the behaviors are distinct, both can occur
within the same individual.
16
Cautionary Notes Self-Injury vs. Suicidal
Behavior
In a recent survey, Nock and Kessler (2006)
reported that individuals who cited suicide as
their reason for self-injuring (as opposed to
emotion regulation or interpersonal functions)
were more likely to ultimately die by suicide.
17
Increased Prevalence of Self-Injury in the U.S.
Early 1980s 400 per 100,000 Late 1980s 750 per
100,000 Late 1990s 1000 per 100,000
Today, an estimated 150,000 to 360,000
adolescents self-injure in the U.S.
18
Prevalence Details Re SI

• In community samples, a range of 15 to 20 of
  youth report self-injuring at least once
• In clinical samples, more females report SI than
  males In community samples there is no gender
  difference
• Age of onset for the majority is 13 to 15 for a
  minority it can be younger.
• SI may be more common among Caucasians GLBTQ
  youth (Nixon Heath, 2008)

19
Increased Prevalence of Self-Injury in the U.S.
Data from the 2005 Massachusetts YRBS indicated
that 19 of high school students in Massachusetts
reported having self-injured during the past
year. Also, a recent study from Cornell and
Princeton Universities, using a sample of almost
3000 students, found that 17 indicated having
self-injured (Whitlock et al. 2006b).
20
Groups in Which Self-Injury Was Commonly Reported
From 1960 to 1990

• Outpatients with serious emotional disturbance
  or mental illness
• Persons presenting at psychiatric emergency
  rooms
• Seriously persistently mentally ill persons
  in day treatment or partial hospitalization
  programs

21
Groups in Which Self-Injury Was Commonly Reported
From 1960 to 1990

• Seriously and persistently mentally ill
  adults living in community-based residential
  or supported housing programs
• Patients in short and long-term psychiatric
  units
• Youth in special education/residential schools
• Prison inmates

22
Groups in Which Self-Injury Is Now Commonly
Reported
Since 1990

• Youth in middle and high schools serving regular
  education students
• Young adults enrolled in colleges and
  universities
• Adults in the community at large

23
Speculations Regarding the Increased Prevalence
of SI
SocioCultural Influences

• School and work environments are fraught with
  high levels of stress
• Multi-tasking lifestyles are conducive to
  persistent low-level stress and anxiety
• Heavy emphasis on competition in schools the
  workplace is conducive to isolation distrust

24
Speculations Regarding the Increased Prevalence
of SI
SocioCultural Influences, cont

• Youth enter into intimate relationships at an
  earlier age, resulting in a level of emotional
  intensity for which they may not be prepared
• The media heavily market a reliance on
  over- the-counter and prescription medications
  to alter mood, achieve desired feeling

25
Speculations Regarding the Increased Prevalence
of SI
SocioCultural Influences, cont

• Modification of consciousness is viewed as
  something that can be quickly and affordably
  achieved via use of alcohol or street drugs.
• Families, schools, and peers rarely teach
  healthy self-soothing skills.
• Helicopter parents ??

26
Speculations Regarding the Increased Prevalence
of SI
Direct Modeling Influences in the Media

• Popular television shows, music videos and
  movies portray self-injurers
• People prominent in the media report
  self-injuring (Angelina Jolie, Princess Diana,
  Johnny Depp, Shirley Manson)
• Many Web sites and chat rooms are dedicated to
  topic of self-injury (Whitlock et al., 2006a)

27
Speculations Regarding the Increased Prevalence
of SI
Adolescent Peer Group Dimensions

• Adolescents routinely experience powerful
  emotions and lack the coping skills to manage
  them.
• Adolescent peer groups view extensive substance
  use as a normative rite of passage.

28
Speculations Regarding the Increased Prevalence
of SI
Adolescent Peer Group Dimensions, cont

• Substance use often begins at early ages, in
  middle and even grammar school.
• Substance use forestalls normative
  problem solving and the development of healthy
  self-soothing skills.

29
Speculations Regarding the Increased Prevalence
of SI
Adolescent Peer Group Dimensions, cont

• Adolescents place high value on being viewed as
  outrageous outsiders by peers and adults.
• Peer group cohesion is enhanced by behaviors
  that adults condemn or fear.

30
Speculations Regarding the Increased Prevalence
of SI
Adolescent Peer Group Dimensions, cont

• Youth are action-oriented. Self-injury is
  dramatic, visible, and produces immediate
  results.
• Self-injury is viewed as not much different
  from these popular forms of body art or
  modification.

31
Speculations Regarding the Increased Prevalence
of SI
Internal Psychological Elements

• Self-injury works it (temporarily) reduces
  tension and restores a sense of psychological
  equilibrium.
• Self-injury has powerful communication aspects.
• Self-injury provides a sense of control and
  empowerment

32
Biological Elements in Self-Injury

• Psychiatric diagnoses associated with biological
  vulnerabilities (e.g. BPD, depression,
  schizophrenia, bipolar illness)
• Limbic system dysfunction and the link to
  positive response to anticonvulsants (e.g.
  tegretol, depakote)

33
Biological Elements in Self-Injury

• Serotonin levels and the link to diminished
  serotonin levels, impulsive aggression, and
  self-injury (with consideration to those who
  respond positively to SSRIs)

34
Endogenous Opioid System
EOS link to analgesia during self-injury
Addiction hypothesis - some support for this
hypothesis is found indirectly in successful
treatments using naltrexone.
Pain hypothesis - individuals have a
constitutionally underperforming EOS that is
unmasked by the environment.
35
Diminished Pain Sensitivity
Some self-injurers have diminished responsiveness
to pain as demonstrated in controlled laboratory
tests (e.g. cold pressor and tourniquet pain
tests). SI individuals show a increased
threshold for pain even when they are not
distressed.
36
Definition of Self-Injury
"Self-Injury is intentional, non-life-threatening,
self-effected bodily harm or disfigurement of a
socially unacceptable nature, performed to reduce
psychological distress." (Walsh, 2006)
37
Eight Levels of Care in the Treatment of
Self-Injury

• I. The Informal Response
• The Importance of Language
• Interpersonal Demeanor

• II. Crisis Intervention
• Level of Physical Damage
• Bodily Location

38
Eight Levels of Care in the Treatment of
Self-Injury

• III. Behavioral Assessment Contingency
  Management
• Environmental, Cognitive, Affective Behavioral
  Concomitants

39
Assessing Self-Injury

• Antecedents (Events in Environment)
• Antecedents (Biological Elements)
• Antecedents (Thoughts, Feelings, Behaviors)
• Wounds
• Start Time of SIB Episode
• End Time of SIB Episode
• Extent of Physical Damage (Length, Width
  Were Sutures Obtained? If Yes, How Many?)
• Body Area(s)

40
Assessing Self-Injury, continued

• 9. Use of Tool- (Yes/No-If Yes, Type)
• Room or Place of SIB
• Alone or With Others During SIB
• Aftermath of SIB (Thoughts, Feelings, Behaviors)
• Aftermath of SIB (Biological Elements)
• Aftermath of SIB (Events in Environment)
• Reactions of Others to Your SIB
• Other idiosyncratic details

41
Eight Levels of Care in the Treatment of
Self-Injury

• IV. Replacement Skills Training
• Negative Replacement Behaviors
• Mindful Breathing
• Visualization
• Non-Competitive Physical Exercise
• Writing - Playing/Listening to Music - Artistic
  Expression
• Diversion Techniques

42
Eight Levels of Care in the Treatment of
Self-Injury

• V. Cognitive Treatment
• Identifying Triggers Using Them to Practice
  Replacement Skills
• Identifying Automatic Thoughts, Intermediate
  Beliefs, and Core Beliefs That Support SI
• Replacing Negative Cognitions with Adaptive
  Thoughts and Beliefs
• The Key Role of Body Image

43
Eight Levels of Care in the Treatment of
Self-Injury

• VI. Exposure Treatment for Resolution of Trauma
• The Link Between Sexual Abuse, Body Alienation,
  and Recurrent Self-Injury
• Resolving the Effects of Trauma via Exposure
  Treatment
• Other Sources for Body Alienation and Related
  Self-Injury

44
Eight Levels of Care in the Treatment of
Self-Injury

• VII. Group Treatment of Contagion
• Avoiding Group Activities that Promote Contagion
• Using Groups for Skills Training

45
Eight Levels of Care in the Treatment of
Self-Injury

• VIII. Family Treatment
• Teaching Families to Understand Manage
  Self-Injury Strategically
• Resolving Family Dilemmas that Support Self
  Injury
• Teaching Families Replacement Skills

46
Basic Features of a School Protocol to Manage SI
Staff Training

• This protocol can only be implemented with
  adequate advance training of school staff.
• Staff is trained regarding the forms of direct
  and indirect self-harm and how to provide a
  thorough assessment.
• Staff is trained to understand how self-injury
  and suicidal behavior are markedly different in
  terms of 9 characteristics.

47
Basic Features of a School Protocol to Manage SI
Responding to Self-Injury in Individuals

• School Administration identifies point persons to
  be contacted when self-destructive behavior
  surfaces within the school. Point persons are
  usually guidance counselors, social workers
  and/or school nurses.

48
Basic Features of a School Protocol to Manage SI
Responding to Self-Injury in Individuals

• Staff refers all students with self-destructive
  behavior or plans to the designated point
  persons. Point persons assess whether the
  behavior should be considered suicidal behavior,
  other life-threatening behavior, or common, low
  lethality self-injury.

49
Basic Features of a School Protocol to Manage SI
Responding to Self-Injury in Individuals

• If the behavior or plan is deemed to be suicidal
  or otherwise life-threatening, emergency
  procedures are followed.

50
Basic Features of a School Protocol to Manage SI
Responding to Self-Injury in Individuals

• If the behavior is deemed to be common
  self-injury, the point person calls the students
  parent while the student is present.
• The point person explains that he/ she has
  learned the child has self-injured and explains
  that the behavior is cause for concern but not
  usually about suicide.

51
Basic Features of a School Protocol to Manage SI
Responding to Self-Injury in Individuals

• The point person requests that the parent follow
  up immediately with outpatient counseling for the
  child and family.
• The point person requests that the parent call
  back to confirm that the outpatient appointment
  has been made.

52
Basic Features of a School Protocol to Manage SI
Responding to Self-Injury in Individuals

• If the parent does not call back, the point
  person re-contacts the parent and requests that
  the outpatient referral be pursued.
• If after repeated requests the parent fails to
  act, mandated reporting for neglect or abuse must
  be considered

53
Basic Features of a School Protocol to Manage SI
Responding to Self-Injury in Individuals

• The point person generally stays in periodic
  contact with the parent to monitor progress.
• In some cases, the point person obtains consent
  from parent and child to communicate with the
  outpatient clinician.

54
Basic Features of a School Protocol to Manage SI
Responding to Self-Injury Among Groups

• Point persons should assess if multiple students
  are triggering the behavior in each other.

55
Basic Features of a School Protocol to Manage SI
Responding to Self-Injury Among Groups
2. Contagion may be due to the following
influences a. Limited communication skills b.
Desire to change the behavior of others c.
Response to caregivers, family members -
Competition for caregiver resources -
Anticipation of aversive consequences
56
Basic Features of a School Protocol to Manage SI
Responding to Self-Injury Among Groups
2. Contagion may be due to the following
influences d. Other peer group influences
- Direct modeling influences -
Disinhibition - Competition - The role of
peer hierarchies - Desire for group cohesiveness
57
Basic Features of a School Protocol to Manage SI
Managing Preventing Contagion

• Point persons identify the primary high status
  peer models.
• Use of a contagion map or sociogram can be
  helpful.

58
Schematic Representation of Self-Injury Contagion
59
Basic Features of a School Protocol to Manage SI
Managing Preventing Contagion

• Point persons explain to peer models that they
  are hurting their peers by communicating about SI
  to others.
• Self-injurers are encouraged to talk with
  the point persons, family, therapists, but not to
  peers about SI as such talk is triggering.

60
Basic Features of a School Protocol to Manage SI
Managing Preventing Contagion

• Students are asked not to appear in school with
  visible wounds or scars
• Point persons involve parents when necessary
• Some students may need to have extra sets of
  clothing in school to cover wounds or scars.
• In rare cases, students may have to be dealt with
  disciplinarily

61
Diverse Cognitive Processes and their Role in SI
CORE BELIEFSIm incompetent. Im unlovable.
INTERMEDIATE BELIEFS (attitudes, rules,
assumptions) Attitude I deserve all this
emotional pain. Rule Self-injury reduces pain
better than anything else. Assumption It will
always be this way.
AUTOMATIC THOUGHTS Get the razor! I need to act!
62
Before After CognitionKey Automatic Thoughts
Cognitions that Support SI
Alternative Adaptive Thoughts

• With these emotions, I have to cut now
• Self-injury provides such quick relief
• Self-injury causes others to respond to me

• I can use my new skills to manage emotion
• Self-injury has long term negative effects
• Self-injury causes many to avoid me

63
Before After CognitionIntermediate Beliefs
Alternative Adaptive Thoughts
Cognitions that Support SI

• I deserve this rejection
• Self-injury works immediately

• I deserve someone who treats me with respect
• I can live with some discomfort while I use my
  skills.

64
Before After CognitionIntermediate Beliefs
Cognitions that Support SI
Alternative Adaptive Thoughts

• Self-injury is the best solution
• Self-injury works immediately

• Self-injury is one of many solutions and not
  necessarily the best.
• I can live with some discomfort while I use my
  skills. I can surf the urge to self-injure.

65
Before After CognitionCore Beliefs
Cognitions that Support SI
Alternative Adaptive Thoughts

• Im unlovable
• Im incompetent

• A number of people truly care for me
• Im a competent worker cook

66
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