Students Who Self Injure: Information, Implications,

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Students Who Self Injure Information,
Implications, Interventions for School
Counselors

• Presenter Holly Moore, Ed.D.
• Indiana University of Pennsylvania

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Myths

• People self-injure to manipulate others.
• True False

3
Myths

• Your answer is Incorrect.
• Research shows that physical pain is inflicted in
  an attempt to replace emotional rage. The
  victims attempts to conform to expectations of
  normal behavior lead to silence about the event.
  Victims go to great lengths to present themselves
  as uninjured and normal and rarely seek to
  manipulate others through self-injury (McLane,
  1996).

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Myths

• Your answer is Correct.
• Research shows that physical pain is inflicted in
  an attempt to replace emotional rage. The
  victims attempts to conform to expectations of
  normal behavior lead to silence about the event.
  Victims go to great lengths to present themselves
  as uninjured and normal and rarely seek to
  manipulate others through self-injury (McLane,
  1996).

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Myths

• Self-injury is synonymous with suicide.

True False
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Myths

• Your answer is Incorrect.
• Research shows that self-injury is a ritual
  performed for different reasons than suicide and
  should not be compared or confused with the
  latter. The self-injurer uses pain to mask
  emotional pain but does not intend to destroy the
  entire body (Levenkron, 1998 Zila Kiselica,
  2001).

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Myths

• Your answer is Correct.
• Research shows that self-injury is a ritual
  performed for different reasons than suicide and
  should not be compared or confused with the
  latter. The self-injurer uses pain to mask
  emotional pain but does not intend to destroy the
  entire body (Levenkron, 1998 Zila Kiselica,
  2001).

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Myths

• 3. Self-injurers are dangerous and will probably
  harm others.
• True False

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Myths

• Your answer is Incorrect.
• Research shows that self-injury is usually
  secretive and is most often performed in
  isolation. The behavior is not performed in an
  attempt to harm but rather to vanquish emotional
  pain. Violence is not directed toward others
  (McLane, 1996).

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Myths

• Your answer is Correct.
• Research shows that self-injury is usually
  secretive and is most often performed in
  isolation. The behavior is not performed in an
  attempt to harm but rather to vanquish emotional
  pain. Violence is not directed toward others
  (McLane, 1996).

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Myths

• 4. Self-injurers just want attention.
• True False

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Myths

• Your answer is Incorrect.
• Research shows that most self-injurers perform
  their ritual and symbolic acts in private. They
  are often humiliated about their scars and keep
  them private (Levenkron, 1998).

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Myths

• Your answer is Correct.
• Research shows that most self-injurers perform
  their ritual and symbolic acts in private. They
  are often humiliated about their scars and keep
  them private (Levenkron, 1998).

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Myths

• 5. Body piercing and tattooing are forms of
  self-injury.
• True False

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Myths

• Your answer is Incorrect.
• Research shows that although these practices have
  varying degrees of social acceptability, they are
  not typical of self-injury. The majority of these
  persons tolerate pain for the purpose of
  attaining a finished product, such as a piercing
  or tattoo. In self-injurers, the pain is sought
  in order to manage undesirable feelings (Coy
  Simpson, 2002).

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Myths

• Your answer is Correct.
• Research shows that although these practices have
  varying degrees of social acceptability, they are
  not typical of self-injury. The majority of these
  persons tolerate pain for the purpose of
  attaining a finished product, such as a piercing
  or tattoo. In self-injurers, the pain is sought
  in order to manage undesirable feelings (Coy
  Simpson, 2002).

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Definitions

• There is not a consistently used definition of
  self-injurious behavior (SIB)
• Recent attempts to add to DSM
• Self-injury is defined as a volitional act to
  harm ones body without any intention to die as a
  result of the behavior (Simeon Favazza, 2001).

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Prevalence

• Upward trend in the incidence of SIB
• In the 1970s, approximately 1 of the
  non-clinical population 3 to 5 of clinical
  populations engaged in SIB
• In the late 1990s, approximately 4 of the
  non-clinical population and 21 of the clinical
  populations engaged in SIB

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Prevalence

• In a non-clinical, all age population, estimates
  of SIB have ranged from 400 to 1,400 cases per
  100,000 annually (Favazza, 1998 Pattison
  Kahan, 1983).
• Among a non-clinical sample of adolescents,
  estimates of SIB have ranged from 2.4 to 20
  (Ross Heath, 2002).

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Prevalence

• All of he prevalence estimates must be
  interpreted with caution because of the limited
  number of studies. It is also likely that these
  estimates are low, because SIB produces wounds
  most individuals can care for by themselves
  (Muehlenkamp, 2005).

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Categories of Self Injurious Behavior (SIB)

• Socially Sanctioned
• Rituals
• Practices (Body Piercing and Tattooing)
• Pathological
• Suicidal
• Self-Mutilation/Self-Injury
• Unhealthy Behavior
• Favazza, 1996

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Four Types

• Self Mutilation/Injury can be divided into four
  different types
• Stereotypic
• Major
• Compulsive
• Impulsive

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STEREOTYPIC SIB

• Behaviors in this category include
• head banging
• self-hitting and face slapping
• lip and hand chewing
• self-biting
• hair pulling

• School counselors may see this type of SIB in
  relation to
• Individuals with organic mental disorders such as
  mental retardation and developmental delay.

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MAJOR SIB

• Behaviors in this category include severe or
  potentially life-threatening injuries such as
• castration
• eye enucleation
• limb amputation.

• School counselors would rarely see this type of
  SIB as it tends to accompany severe psychosis,
  intoxication, or a severe character disorder.

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COMPULSIVE SIB

• Behaviors in this category include
• repetitive hair pulling
• skin picking
• nail biting of a mild to moderate severity

• School counselors may see students who are
  diagnosed with trichotillomania or who engage in
  compulsive SIB in relation to an anxiety
  condition. It is similar to OCD.

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IMPULSIVE SIB

• Behaviors in this category include
• skin cutting
• burning
• self-hitting of a mild to moderate severity.

• 2 TYPES
• Episodic self-injury that occurs only a limited
  number of times throughout a persons life.
• Repetitive are more associated with reoccurring
  self-injury that has an almost addictive quality
  and is incorporated into a persons life and
  personality and should be classified under the
  impulse-control disorders NOS category of the
  DSM-IV-TR (Favazza Simeon, 1995).

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Impulsive SIB

• School counselors are in a unique position to
  intervene in impulsive SIB, as these behaviors
  typically begin in middle adolescence (Herpertz,
  1995), with the freshman year of high school
  being the average age of the first self-injurious
  behaviors (Ross Heath, 2002 Favazza
  Conterio, 1989). It can be seen as early as 11 or
  12 (Conterio, 2005)
• One study found that mental health professionals
  identified 18 as the average age their clients
  last engaged in self-cutting behaviors (Suyemoto
  MacDonald, 1995).

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Demographics Gender Issues

• It is commonly stated that females are more
  likely to engage in self-injury than males.
• However, at least one study, Briere and Gil
  (1998), found no gender differences with regard
  to SIB in a community sample.

• The higher numbers of females identified as self
  injurers may be related to researchers use of
  samples including help-seeking clinical
  populations, hospitalized patients, and sexual
  abuse and incest survivor populations samples
  that are more likely to be comprised of females.

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Other Demographics

• Self-injurers come from all walks of life and all
  economic brackets. People who harm themselves may
  be male or female gay, straight, or bi Ph.D.s
  or high-school dropouts rich or poor and live
  in any country in the world.
• Their ages typically range from early teens to
  early 60s, although they may be older or younger.

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The Causes of SIB

• There is no evidence of a particular cause of
  SIB, but there are several theories
• Biological
• Psychological
• Social

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Biological

• Biologys role in SIB is fairly unclear due to
  the mixed outcomes of studies (Muehlenkamp,
  2005).
• There is evidence suggesting that low levels of
  serotonin are associated with SIB (Favazza, 1996
  Grossman Siever, 2001).

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Biological

• Self Injury as addiction
• Self-injury has been compared to opiate addiction
  in that it has a similar numbing effect and
  subsequent high following the SIB.
• Studies that used naloxene, a drug is used to
  treat opiate addiction, have shown mixed results
  in treating SIB (Grossman Siever, 2001).

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Psychological

• In a study of 240 self-injurers, Favazza and
  Conterio (1989) found that the majority of the
  individuals self-injured to control racing
  thoughts, to release tension and relax, to feel
  less depressed or lonely, to stop disassociation,
  and to punish themselves.
• For most individuals who engage in SIB, preceding
  the act of self-injury is a psychological
  experience of increasing tension, anger, anxiety,
  dysphoria, general distress, or
  depersonalization, which the person feels he or
  she cannot escape from or control (Kahan
  Pattison, 1984 Simeon Favazza, 2001).

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Social

• Contagion infliction of self injury by one
  individual and imitation by others in the
  immediate environment (Rosen Walsh, 1989)
• In a study by Favazza and Conterio (1989), 24 of
  240 female self injurers had close friends who
  also self injure
• School counselors do not address in group
  counseling for this reason.
• Watch as potential risk factor in cliques (Goth
  culture)

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Predictors of SIB

• School counselors should be aware of some risk
  factors for SIB
• History of sexual abuse
• Family violence/physical or marital abuse
• Sexual assault/rape
• Physical illness/surgery at a young age
• Perfectionism
• Eating disorders
• Dissatisfaction with the body

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Predictors of SIB

• Loss of a parent/recent loss
• Familial self injury
• Peer conflict and intimacy problems
• Impulse control problems
• Parental alcoholism or depression
• Anxiety and depression
• best predictors
• (Briere Gil, 1998 Favazza Rosenthal, 1993
  Walsh Rosen, 1988).

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Reasons Predictors

• Research suggests that the precipitants for SIB
  are multidetermined (Favazza Rosenthal, 1993)
  however, all tend to share a theme of real or
  perceived rejection or abandonment and include a
  stressful situation.
• Other common precipitants are situations that
  cause feelings of helplessness, anger, or guilt
  in the individual (Favazza Rosenthal, 1993).

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What to look for in SIB

• Individuals self-injure an average of 50 times,
  although some individuals report over 400
  independent acts of SIB
• (Favazza Conterio, 1989).
• Therefore, school counselors can look for
• Unexplained scars, burns or cuts
• Wearing long sleeves regardless of the weather
• Changes in grades, friends, etc.
• Drug and alcohol usage
• Eating disorders
• Situational Predictors

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How can SIB come to your attention?

• From the student, unsolicited by you.
• From the student, because you asked based on
  signs you have observed.
• From parents.
• From teachers, administrators, or staff.
• From the students peers.
• Things to say handout.

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Ethical and Legal Implications

• Mandated reporting of any child abuse
• Confidentiality

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Confidentiality

• According to the American School Counseling
  Association Code of Ethics (2004), a school
  counselor, keeps information confidential unless
  disclosure is required to prevent clear and
  imminent danger to the student (section A.2.b).
• In order to assess a student, consider
• Age
• Capability
• District Policies
• Consequences to the therapeutic relationship
• Risks to self or others
• Facilitate disclosures to parents/guardians

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Interventions

• According to the ASCA National Model (2003),
  there are 4 delivery systems by which school
  counselors implement a comprehensive program,
  addressing SIB occurs in 3 of those 4 systems.
• School Guidance Curriculum
• System Support
• Responsive Services

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School Guidance Curriculum

• Classroom Instruction make yourself known and
  available. Provide instruction in D/A, violence,
  self-esteem, communication skills, assertiveness,
  and health risks.
• Parent Workshops and Instruction- provide
  information and appropriate resources for parents

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System Support

• Professional Development- provide accurate
  information to administrators, faculty, and staff
  through in-service trainings.
• Consultation, Collaboration, and Teaming be
  available for those with questions.

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Responsive Services

• Crisis Counseling/Response- safety planning,
  including medical treatment, if necessary. A
  suicide assessment should always be done.
• Referral- make sure you know who you can use as a
  referral for treatment
• Consultation
• Individual Counseling create a supportive
  environment where feelings can be expressed (know
  your own reactions). The two main issues are
  verbalization and behavioral alternatives.
• Special Education- use of a 504 plan.

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Safety Planning Issues

• Triggers
• Physical Cues
• Reducers of SI (handout)
• Safe places and people
• Avoidance of SI objects
• This plan can be put in place until treatment can
  be started.

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Questions