Helping Teens and Families Manage SelfInjurious Behavior

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Helping Teens and Families Manage Self-Injurious
Behavior

• Training Institute
• May 2009
• Kim Poling, LCSW
• Tina Goldstein, PhD

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Objectives Morning Session

• Overview prevalence of non-suicidal
  self-injurious behavior (SIB)
• Distinguish suicidal behavior from non-suicidal
  self-injurious behavior (SIB)
• Understand the functions of SIB
• Review strategies for assessing risk
• Create a Safety Plan
• Negotiating a Treatment Contract
• Conceptualize SIB Using a Chain Analysis

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Objectives Afternoon Session

• Emotion regulation strategies
• Distress tolerance strategies
• Family Strategies

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What is Non-Suicidal Self-Injurious Behavior
(SIB)?

• Specific types of self-destructive actions to the
  body, e.g.
• - Cutting
• - Scraping
• - Burning
• - Head banging
• The individual does not have suicidal intent at
  that moment

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What is Non-Suicidal Self-Injurious Behavior
(SIB)?

• SIB occurs most often in the context of Axis II
  personality pathology (esp. Borderline
  Personality Disorder)
• Can occur in the context of mood disorder or
  impulse control disorder without Axis II features
• Also occurs in developmentally disabled and
  psychotic populations

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What is NOT considered SIB?

• Drug or alcohol use
• Getting into fights
• Reckless behavior like driving fast

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Facts About SIB

• SIB is frequently a hidden behavior
• Often accompanied by shame
• Precipitant is often interpersonal rejection or
  disappointment in self that leads to negative
  self-judgments

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Facts About SIB

• Individuals who engage in SIB can usually
  distinguish SIB from suicidal behavior
• One of the strongest risk factors for suicide
  attempt is a history of SIB
• Individuals who engage in SIB are at increased
  risk for suicide attempt

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Prevalence of SIB

• 14-39 of community adolescent samples
• 40-60 of adolescent psychiatric samples

Darche 1990 Ross Heath, 2002 Favazza
Conterio, 1989
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Prevalence of SIB

• 76 of teens report that the idea to engage in
  SIB was their own
• 12 claim they got the idea to self-injure from a
  peer
• 19 of teens have not told anyone about their SIB
• Nixon et al., 2002

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Adolescence A Period of Risk

• Adolescence is most commonly reported age of
  onset for SIB
• Dramatic biological, cognitive, social, and
  emotional changes occur
• Environmental and constitutional factors
  contribute
• Adolescents have the highest prevalence rates of
  behaviors that carry the potential for harm to
  self and/or others

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Suicide Continuum
Passive Death Wish
Suicidal Ideation without method
Suicidal Ideation with method
Attempt
Completion
Self-Injurious behavior with unclear intent
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Distinguishing SIB from Suicidal Behavior

• 1. Intent/Wish
• Suicidal behavior is accompanied by some degree
  of wish and intent to die i.e. the teen believes
  that the behavior could result in death.
• e.g., Was there any part of you that wanted to
  die when you were cutting yourself?
• What did you expect would happen when you
  engaged in the behavior?
• 2. Motivation
• Carefully assess motivation (e.g., to die, to
  escape, to influence someone, to communicate
  feelings, to relieve emotional distress).
• What did you expect would happen as a result?

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Understanding SIB

• SIB is identified by the individual as
  non-suicidal, and is typically aimed at relieving
  distress.
• It is frequently characterized by
• An irresistible impulse to self-harm
• Mounting agitation no escape from tension
• Cognitive constriction- few alternatives
  considered
• Rapid, temporary relief following the act

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Functions of SIB

• Study of reasons teens engage in SIB
• - to cope with feelings of depression 83
• - to release unbearable tension 74
• - to cope with nervousness/fear 71
• - to express frustration 71
• - to get attention or care from others 9
• Nixon et al., 2002

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Functions of SIB

• Escape or reduce painful emotions
• Distract from painful memories or thoughts
• Self-expression of emotions
• Self-punishment
• Reduce tension/anger
• Get attention, social support, or help
• To feel alive

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Characteristics of Self-injurers

• The individual may have difficulties
• Labeling their emotions
• Effectively regulating emotions
• Trusting internal experiences as valid
• responses to external events
• Tolerating distress
• Effectively solving problems
• (Miller, 1999)

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A Model of Emotional Vulnerability
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Teen with high emotional vulnerability
Teen with average emotional vulnerability
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Emotional Response
1
1. High sensitivity - immediate reactions -
low threshold for emotional reaction 2. High
reactivity - extreme emotional reactions -
faster rise time 3. Slow time to recovery -
long lasting emotional reactions - more
sensitive to next emotional stimulus
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Borderline Personality Disorder (BPD)

• Many individuals who self-injure display BPD
  traits
• Emotional dysregulation (affect lability)
• Interpersonal dysregulation (chaotic
  relationships)
• Self-dysregulation (identity disturbance)
• Behavioral dysregulation (self-injury)
• Cognitive dysregulation (paranoia)

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What We See in Teens Who Self-Injure

• Critical, hostile statements toward self
• Feelings of guilt, shame, anger when experiencing
  strong emotions
• Difficulty tolerating strong negative emotions
• These reactions serve to intensify the pain of
  the original emotion and further support the
  self-critical backlash

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What We See in Families of Teens Who Self-Injure
The Invalidating Environment

• Families may
• Indiscriminantly reject
• Punish emotional displays and intermittently
  
• reinforce emotional escalation
• Over-simplify the ease of problem-solving and
  meeting
• goals
• Indiscriminantly indulge

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Assessing Current Safety

• Assess for the presence or absence of suicidal
  ideation and intent and the degree of severity
  (frequency, intensity, duration) over the past 48
  hours or since last visit
• Negotiate Safety Plan
• Collaborate and review Safety Plan with family
• If family conflict is a common precipitant to
  suicidality or SIB, help teen and family
  negotiate a truce

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What is a Safety Plan?

• Research suggests a signed written no-suicide
  or no self-injury contract may not be
  sufficient to deter self-injurious behavior
• The safety plan is different than a no-suicide/no
  self-injury contract
• It is a promise between teen, parents and
  therapist that teen will contact a responsible
  adult or therapist before acting on self-harm
  urges
• The safety plan specifies how the patient
  responds if he/she has thoughts of self-harm
• The safety plan is tailor-made for each patient
  and is created collaboratively with the therapist

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Formulating the Safety Plan

• Negotiate with teen to defer acting on self-
• injurious thoughts/urges for a specified
  period.
• During this time, he/she agrees to try other
• potential solutions that you work into the
  safety
• plan.

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Formulating the Safety Plan

• Secure and/or Eliminate Means
• Negotiate to remove or limit
• accessibility of means of self-
• injury from the teens environment

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Formulating the Safety Plan

• Identify Vulnerability Factors
• How will you know the safety plan needs to be
  used?
• Identify social situations, events, themes,
  songs, substances, etc. that tend to trigger
  thoughts or urges to self-injure
• Negotiate with teen to avoid activities that may
  increase self-injury urges for a period of time
• Use chain analysis to identify warning signs from
  prior instances of self-injury

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Formulating the Safety Plan

• Insert Skills
• Step 1. Start with internal strategies
• Include skills teen agrees to try when aware of
  high urges
• Identify multiple skills (often includes
  distraction)
• Prioritize

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Formulating the Safety Plan

• Move to external strategies
• Step 2. Identify people (friends, siblings) who
  can help
• distract the teen
• Step 3. Identify key responsible adults in the
  environment who can help if internal and external
  distraction strategies are not effective.
• Include professionals (e.g., therapist, clinic)
  and emergency numbers in the event key adults are
  unavailable

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Formulating the Safety Plan

• Troubleshoot
• What could get in the way of implementing the
  safety plan?
• Problem-solve barriers
• Discuss ALL possible obstacles to keeping the
  safety plan
• On a scale of 1-10 how likely do you think you
  are to do X in the event of urges to self-injure?
• Problem-solve these obstacles with teen and
  parents
• Trust your clinical instincts (eye contact, body
  language)

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Sample Safety Plan

• Setting the Stage
• Making the Environment Safe
• 1. ______________________________________________
  _______________
• 2. ______________________________________________
  _______________
• 3. ______________________________________________
  _______________
• Identifying Warning Signs
• 1. ______________________________________________
  _______________
• 2. ______________________________________________
  _______________
• 3. ______________________________________________
  _______________
• Safety Plan
• Step 1 Internal Strategies
• 1. ______________________________________________
  _______________
• 2. ______________________________________________
  _______________
• 3. ______________________________________________
  _______________
• Step 2 External Strategies-- People who can help
  distract me

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Negotiating Treatment Contract

• Initially teens with history of SIB may not be
  able to agree to abstain entirely from the
  behavior
• Explore teens concerns about their SIB and
  negative consequences of the behavior to increase
  motivation for change (remain non-judgmental)
• Negotiate with teen to try specific emotion
  regulation strategies first, and to delay SIB for
  longer periods after the urge begins
• Negotiate with teen to avoid triggers for
  self-injury

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Creating a Validating Therapeutic Environment

• Therapist validates the emotional need behind the
  behavior
• AND
• Elicits negative consequences about specific
  problem behaviors from the teen
• All in a non-judgmental manner, e.g.
• Youre doing the best you can, and you can do
  better

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Creating a Validating Therapeutic Environment

• Levels of Validation (Miller Comtois, 2002)
• Unbiased listening and observing
• Accurate reflection
• Articulating the unverbalized
• Validation in terms of past learning or
  biological dysfunction
• Validation in terms of present context
• Radical genuineness

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Break

• Time for a 15 minute break!

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Developing the Treatment Approach

• Protocol driven treatments (one size fits all,
  what to do instructions) work with severe and
  chronic Axis I problems
• Principle-driven treatments (based on principles
  that tell you how to figure out what to do) are
  needed with multi-diagnostic and/or Axis II
  patients
• 
  
• Miller, 2002

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What is a Chain Analysis?

• The chain analysis is a detailed assessment of
  any behavior
• Often teens have difficulty identifying
  precipitants or contributing factors for their
  behaviors (I dont know why I did that, I just
  did.)
• The chain helps orient the teen to the idea that
  behaviors happen for valid reasons even if we
  are not initially aware of them.
• The chain helps you, the teen, and the family
  make sense of behaviors. This can help the teen
  develop a better sense of control.

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How to Conduct the Chain Analysis

• Start by asking teen to walk you through the
  events that led up to the most recent incident of
  SIB
• Analyze the chain of events moment-to-moment over
  time
• Highlight, observe patterns, and comment on
  implications
• Prompt for
• Thoughts What were you thinking? Self-talk?
• What went through your head?
• Feelings How were you feeling?
• What kind of a mood were you in?
• What did you notice in your bodyphysical
  sensations?
• Behaviors What did you do?
• How did you act?
• Vulnerabilities Why then? consider sleep,
  eating, prior events
• Consequences What happened afterwards?
  consider reinforcement and punishment

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Sample Chain Analysis Form
Start
End
What is the problem?
Vulnerabilities Consequences
What could you do differently next time?
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An Alternate Chain Analysis Form
Who When Where
What did you need?
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Use of the Chain Analysis to Inform Case
Conceptualization

• The specific vulnerabilities, self-statements,
  and feelings (internal factors), as well as the
  triggering events and consequences of the SIB
  (external factors) will help you to develop the
  case conceptualization and treatment plan

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Prioritize Treatment Needs

• The therapist and teen together decide which
  skill areas to target first.
• Ask yourselvesbased on the chain analysis, which
  of these is most strongly linked to SIB?
• Emotional Dysregulation
• Difficulty Tolerating Distress
• Family Conflict
• Lacking Communication Skills
• Insufficient Problem Solving

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LUNCH BREAK !
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Emotion Regulation Skills
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Emotion Regulation Skills

• Emotions education
• Self-Care
• Emotions Thermometer
• Mindfulness of your current emotion
• Use of the chain analysis
• Opposite action

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Emotions Education

• Learning to be nonjudgmental toward self
• Teach teen how to observe and describe different
  emotions, without labeling them as good or bad,
  but simply to be aware of them
• Emotion dysregulation may result when teen is
  overly harsh toward self for having strong
  feelings, or for judging specific feelings as
  wrong, or badthey then feel more distressing
  emotions in turn

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Emotions Education

• Action urges and choices
• A negative emotion often leads to an
  irresistible urge to act in a self-destructive
  manner
• Teach teen that just because we may have an urge
  to act on a distressing emotion, we are not
  obligated to act on it
• Distinguish between urge to act and the
  action itself

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Self-Care

• Teach parents and teens how self-care helps to
  decrease vulnerability to negative emotions
• Emphasize importance of maintaining regular sleep
  schedule
• Eating balanced diet, treating physical illness,
  getting regular exercise, avoiding substance
  abuse and planning at least one activity a day
  that makes you feel good and in control

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Self-Care HEAR ME

• Health (treat physical illness)
• Exercise regularly
• Avoid mood altering drugs
• Rest (balanced sleep)
• Mastery (one rewarding activity daily)
• Eating (balanced diet)

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Emotions Thermometer

• Goal Increase awareness of emotional
  temperature
• Steps for teaching the Emotions Thermometer
• 1. What do you call it when youre about to lose
  control?
• Label one end of the Emotions Thermometer with
  this term and the opposite end with feeling in
  control or relaxed
• 2. What makes you emotion, e.g., furious?
• Ask him/her to remember when he/she last felt
  emotion.
• Have the teen identify associated
• thoughts (e.g., Im going to lose it)
• physical sensations (e.g., feeling hot,
  balling up my fists)
• action urges
• consequences

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Emotions Thermometer

• Steps for teaching the Emotions Thermometer
• What is the highest point at which you are still
  in control?
• Label just above this the boiling point
• Identify specific steps for avoiding the
  boiling point
• What is the highest point the point at which you
  could still use skills to avoid the boiling
  point?
• Label this the action point
• Explain that at the action point, the teen
  needs to do something to calm down to prevent
  getting to the boiling point.
• What could you agree to try at the action point?
• Identify skills

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Emotions Thermometer
0
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Mindfulness of Current Emotion

• Steps in the process
• 1. Observe your emotion
• 2. Experience your emotion
• 3. You are not your emotion
• 4. Practice accepting your emotion

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Mindfulness of Current Emotion

• 1. Observe your emotion
• Note its presence just observe it
• Step Back
• Get Unstuck from the emotion

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Mindfulness of Current Emotion

• 2. Experience Your Emotion
• As a wave, coming and going
• Try not to block or suppress the emotion
• Dont try to get rid of the emotion
• Dont push it away
• Dont try to keep the emotion around
• Dont hold on to it
• Dont intensify it

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Mindfulness of Current Emotion

• 3. Remember You are not your emotion
• Do not necessarily act on your emotion (that is,
  let destructive action urges pass)
• Remember times when you have felt different.

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Mindfulness of Current Emotion

• 4. Practice accepting your emotion
• Do not judge your emotion as wrong, bad, too
  painful, unfair, embarrassing, etc.
• Do not judge yourself for feeling the emotion
• Accept your emotion as it is in the moment

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Chain Analysis as an Intervention

• Review the behavior chain carefully with the teen
• Ask what NEEDS were you attempting to meet
  through the behavior, even if the results were
  not what you might have wanted?
• Once these needs have been identified , help teen
  to develop self-respect for these needs (teach
  teen to validate these needs) and formulate
  alternative ways to take care of these needs

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Chain Analysis as an Intervention

• Identify on the chain the point of no return
• Determine how to break links between prompting
  event and point of no return
• Identify ways to break links between problem
  behavior and consequences

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Chain Analysis as an Intervention

• Needs-Important to teach teen that if they can
  identify their needs and learn different
  behaviors to get their needs met, they can have
  more power
• Once you know the needs, you are smarter. Once
  you have new tools for handling the needs, you
  are more powerful
• (Wexler, 1993)

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Chain Analysis as an Intervention

• Figure out what to do
• Identify goals, needs, desires
• Generate solutions
• Evaluate solutions
• Choose a solution to implement
• Troubleshoot the solution

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Chain Analysis as an Intervention

• Possible Solutions to Any Problem
• 1. Solve the problem
• 2. Change your emotional reaction to the problem.
• 3. Tolerate the problem.
• 4. Stay miserable.
• 5. Make things worse.

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Changing Emotion by Acting Opposite the Current
Emotion

• Every emotion has an action associated with it.
• Fear Run
• Anger.. Attack
• Sadness..Withdraw
• Shame.Hide

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Changing Emotion by Acting Opposite the Current
Emotion

• Opposite Action
• Emotion is strongly influenced by our bodily
  posture and facial expressions.
• By altering posture, behavior and facial
  expressions we can delay, interrupt or
  de-escalate the progression of a problematic
  emotion.

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Opposite Action for Guilt or Shame

• Repair the mistake.
• Say youre sorry
• Make up for what you did to the person you
  offended
• Try to avoid making the same mistake in the
  future.
• Accept the consequences for what you did.
• Then let it go.

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Opposite Action for Anger

• Keep ones palms open when inclined to punch.
• Whisper when inclined to scream.
• Breath deeply and slowly rather than angrily
  hyperventilating.
• Gently avoid the person you are angry with rather
  than attacking.
• Put yourself in the other persons shoes, and
  imagine sympathy or empathy for the person,
  rather than blame.

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Opposite action for Sadness or Depression

• Get active
• Approach, dont avoid
• Do things that make you feel effective and
  self-confident
• Use the half-smile

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Opposite Action for Envy

• Someone else has something that you think you
  WANT or NEED. (If you cant have it, they
  SHOULDNT.)
• Based on a fundamental belief that you are
  DEPRIVED.
• Radical Acceptance you have to radically accept
  that you dont have it (opposite action).

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Steps to Practice Using Opposite Action

• What emotion am I experiencing?
• What is the action (what is the emotion trying to
  get me to do)?
• Do I really want to reduce this emotion?
• What is the opposite action?
• DO the opposite action.
• Practice, practice, practice!

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Break

• Time for a 15 minute break!

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Distress Tolerance Skills
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Distress Tolerance Skills

• Acceptance
• Self-Soothing
• Relaxation

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Distress Tolerance Skills

• A crisis survival strategy
• Vital skill to teach teen as they will not always
  be able to decrease painful emotions, or get what
  they need interpersonally, so they will need to
  learn how to tolerate distressing emotions.

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Distress Tolerance Skills

• Linehan (1993) Learning how to bear pain
  skillfully
• Teaching teens to suspend judgment an emotion
  simply is
• Teaching teens to accept painful feelings vs.
  trying to get rid of them quickly

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Distress Tolerance Skills

• 3 Myths about acceptance (Miller, 1997)
• If you refuse to accept something, it will
  magically change.
• If you accept your painful situation, you will
  become soft and just give up (or give in).
• If you accept your painful situation, you are
  accepting a life of pain.

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Distress Tolerance Skills

• CBT component of Distress Tolerance
• Acceptance self-talk
• Learning to talk to yourself nonjudgmentally e.g.
  Im doing the best I can, I know if I can just
  get through this difficult time things will get
  better.
• Acceptance self-talk counters the negative,
  critical shoulds that often accompany painful
  emotions.

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Distress Tolerance Skills

• Main emphasis is teaching teens how to soothe
  themselves .
• Teens may be resistant to this, as their relation
  to the world is predominantly action and other
  oriented.
• Self-soothing skills involve neither action in
  the external behavior sense nor an explicit
  relation with others.

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Distress Tolerance Skills

• Some teens have belief that others should soothe
  them when distressed and have difficulty
  believing that they can depend on themselves.
• Others may feel that they dont deserve to be
  soothed and may feel guilty, ashamed, angry when
  they try to self-soothe (Linehan, 1993) .

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Self-Soothing through the 5 Senses

• An accessible and easily taught
  self-soothing/distress tolerance skill is the use
  of the 5 senses
• Vision, hearing, smell, taste, touch
• Usually at least 2-3 of the five senses are
  engaged or capable of being engaged at any given
  moment as a distraction from distress.

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Self- Soothing

• Vision
• Focus on an aspect of nature, or any visual
  detail
• Hearing
• Music, nature sounds, relaxation tape, fan noise
• Smell
• Lotion, candle, perfume, favorite food cooking
• Taste
• Hot chocolate or tea, ice creamtaste slowly
• Touch
• Pet your dog, cat, soothing bath, hug, blanket

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Relaxation Skills

• Deep Breathing with a Self-Statement, Counting
  Backward
• Deep Breathing with Pleasant Imagery
• Leaving the scene for a break
• Guided Imagery for Relaxation (Spaceship to the
  Moon and back Falling Leaf)
• Progressive Muscle Relaxation

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Family Strategies
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Talking with Families

• SIB is primarily NOT a manipulative behavior
• Intent is primarily to affect INTRApersonal not
  INTERpersonal state
• In the short run, SIB is often associated with
  relief of negative emotion, however in the long
  run, SIB often leads to shame
• Precipitant is often interpersonal rejection or
  disappointment in self that leads to self
  condemnation

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Walking the Middle Path Dialectical Dilemmas
for Adolescents and Families
Excessive Leniency
Fostering Dependence
Normalizing Pathology

Pathologizing Normative Behavior
Forcing Autonomy
Authoritarian Control
Miller, Rathus Linehan, 2005
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Creating a Validating Family Environment

• Help both parents and teen to understand how
  their reactions to each other may be
  invalidating.
• Kernel of Truth
• Coaching parents to become more aware of the ways
  in which their communication may be overly
  negative and critical.
• Validation isnt agreeing with and doesnt have
  to be warm and fuzzy.

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A How To Guide to Validation for Families

• 1. Actively listen. Make eye contact and stay
  focused.
• 2. Be mindful of your reactions to avoid
  invalidation (e.g. rolling eyes, walking away,
  saying whatever).
• 3. Observe what the other person is feeling in
  the moment. Try to see the situation from their
  point of view even if you dont approve of the
  behavior, emotion, or action itself.
• 4. Reflect the feeling back to them without
  judgment. Use just the facts. The goal is to
  communicate that you understand how the other
  person feels.
• 5. Respond in a way that shows you are taking
  the other person seriously.

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Helping Parents Regulate Their Emotions When in
Conflict with Teen

• Teach strategies for changing the timing and
  process of confrontations.
• Important to educate parents that when teen
  attacks and parent becomes dysregulated then
  parent can no longer be effective in enforcing
  rules and consequences.

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We acknowledge with gratitude the Pennsylvania
Legislature for its support of the STAR-Center
and our outreach efforts.This presentation may
not be reproduced without written permission
from STAR-Center Outreach, Western Psychiatric
Institute and Clinic, 3811 OHara Street,
Pittsburgh, PA 15213. [phone]All Rights
Reserved, 2009